Blockchain Papers

Virginia Macdonald, Annette Verster, Andrew Seale, Rachel Baggaley · 5 authors

PURPOSE OF REVIEW: There is renewed focus at global and national level to adopt commitments to ensure universal access to health services. The present study highlights key considerations to ensure that the commitment to 'leave no one behind' includes key populations, recognizing the specific impact of marginalization, stigma, discrimination, and criminalization on their access to health. RECENT FINDINGS: Universal health coverage (UHC) means that all people can use the promotive, preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. Countries commit to UHC through Sustainable Development Goals (SDG Target 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to well tolerated, effective, quality, and affordable essential medicines). SUMMARY: UHC cannot be achieved without addressing the needs of key populations. At the same time, the goal of UHC provides new opportunities to improve health equity and the health of key populations. Political commitment, defining and including essential high-impact, evidence-based interventions for key populations, and their full integration into national health benefit packages; integrated, decentralized, and differentiated health services with involvement, ownership, and acceptance of communities to ensure equity and quality; ensuring financing for UHC provides coverage for key populations, including those who may be undocumented, are needed. Developing more effective interventions and service delivery approaches, providing a supportive policy and legal environment; and measuring progress against clear targets for accountability and programme adjustment will also be required for key populations to benefit fully from UHC.

Sergiu Chirilă, Beatrice Severin

Abstract Primary health care (PHC) represents one of the most important parts of any health system, and consists of first-contact medical services (preventive, curative and rehabilitation) for the patients. Our study analyses the family physicians' opinions related to a series of measures that could improve Romania's healthcare system through an online survey. We identified three components, first one related to control over spendings, increase of medicine market efficiency and transparency in using public funds, second one related to standardization of care processes, accreditation, implementation of guidelines and control over utilization of specialty services and component number three related to type of insurance houses, with competition among them, better decentralization and integrated provision of medical services. The conclusions of the survey emphasize the fac that primary care health is affected by sub optimal financing, with a need of better support for its development through investments in health promotion, services integragion and human resources as means of increasing general health status of the population.

Joshua C. Rubin

He rests his hand on a tree of knowledge as he points to a city in the distance. Here is the city on a high hill for all to see. This is a symbol of the Learning Health System… [The] patient is the great unknown variable as we climb the hill. He has not yet been activated and could do so much good… I guess [it] is kinda frightening trying something new. It is sort of chaordic. But that is the energy that we need to crest this hill.—Patient Activist and Artist Regina Holliday, 1 2012 (“Health Care's Rosa Parks”2) Welcome to Issue 3 of Learning Health Systems, focused on “Patient Empowerment and the Learning Health System.” As Guest Editor for this theme issue, I find this topic near and dear to my heart, as it would be to the heart of anyone who ever has been or will be a patient or caregiver. We all stand poised to benefit from a health system in which opportunities for learning engender empowerment of everyone. The contributing authors share perspectives from diverse backgrounds. Almost all of them are motivated in part by some personal experience as a patient or caregiver during which they learned something about themselves, about others, or about the health system that touched and changed their lives. Their efforts are driven by partnerships between patients themselves and other stakeholders, recognizing the paramount importance of putting people at the center of their collaborative work to protect and improve health, often driven through processes of learning. The papers illuminate how patient (as well as family and community) participation advances the vision for a Learning Health System (LHS)—and in turn how an LHS supports patient-empowering initiatives. Indeed, the National Academy of Medicine (NAM) sees “engaged, empowered patients” as a key characteristic of an LHS,3 and the multi-stakeholder consensus Core Values Underlying a National-Scale Person-Centered Continuous Learning Health System (endorsed by over 100 organizations globally4 and referenced in the United States Federal Health IT Strategic Planning5) begins with “Person-Focused” as the first shared LHS Core Value6 (see Table 1). The papers in this theme issue bring a participatory LHS vision to life and paint vivid pictures of what it could look like and be like. The distinct person-centered approach to transforming health embodied in each paper manifests itself as a use case for an LHS sociotechnical infrastructure. Many authors illuminate how an LHS will advance or transform their work. When Learning Health Systems issued a general call for papers, we received an overwhelming response from individuals and organizations spanning the health spectrum and sharing their interest in patient empowerment through learning. Several authors of papers in this issue bring years or decades of being a patient or caregiver as their expertise. Others bring professional training in varied professions that must collaborate to realize a person-centered LHS. Some have made careers as patient and caregiver activists. Others have built nonprofit organizations and for-profit startups aimed at advancing patient empowerment. Still, others serve as leaders within federal government regulatory agencies, public health organizations, health IT organizations, advocacy organizations, patient communities, and academia. All of these authors are extraordinary communicators; all have compelling research to share or powerful stories to tell. We are grateful they chose to share them with the world through our open access online journal. “Of all the forms of inequality, injustice in health is the most shocking and inhuman.”8 From seemingly unlikely places, such as a federal regulatory agency, a nonprofit association with many of large health IT vendors as members, and a global pharmaceutical/life sciences company, other authors exude comparable passion for empowering patients to protect and improve their health and the health of others. Recognized patient activist “e-Patient Dave” deBronkart, citing the half-century-old The Structure of Scientific Revolutions by Dr Thomas Kuhn, has been among the earliest advocates for envisioning a new science of patient engagement.9 His thinking on the subject points to a natural complementarity with the science of learning systems when one considers his proposed definition for empowerment. Referencing a 2002 World Bank definition, deBronkart states, “Empowerment is increasing the capacity of individuals and groups to make choices and transform those choices into effective actions and outcomes.”10 Consider the apparent synergy between an area of science anchored in increasing the capacity of individuals and groups to make decisions and a hallmark of an LHS that “health-related decisions by individual members of society, care providers, and managers and planners of health services” are themselves underpinned by timely, actionable, trustworthy, and routinely updated best practice knowledge of what works best gleaned from the study of “every patient's characteristics and experiences….”11 In realizing an LHS at a nationwide or at an international scale, the importance of this science of empowerment becomes even more paramount when one recognizes that an LHS is not only “human intensive” but also that, “The system as a whole – not just the digital infrastructure, but also networks of people and institutions – will have to be understood not just as users of a technological infrastructure, but also as parts of the information system itself.”12 … [When patients] participate more actively in the process of medical care, we can create a new healthcare system with higher quality services, better outcomes, lower costs, fewer medical mistakes, and happier, healthier patients. We must make this the new gold standard of healthcare quality and the ultimate goal of all our improvement efforts: Not better hospitals. Not better physician practices. Not more sophisticated electronic medical systems. Happier, healthier patients.13 In Issue 1 of Learning Health Systems, an allusion to the four system-level requirements of an LHS (including that an LHS be “trusted and valued by all stakeholders”) by Editor-in-Chief Dr Charles P. Friedman suggests that “Transcendent research challenges… may require new methods and new modes of thinking that evolve naturally from the admixture of (diverse social and technical sciences) disciplines.”11 In this issue, we evidence the importance of including among these research challenges those associated with the study and advancement of empowerment of patients, caregivers, families, communities, and other stakeholders, in part through learning. These papers show how the emerging research methodologies they share can and must contribute to the (sociotechnical) science of learning systems. There is a saying in policy circles that if one is not at the table, he/she is likely on the menu. Patient activist Sharon Terry of the Genetic Alliance (and PCORnet's Executive Committee) gave a speech on participant-driven research using a similar phrase in its title last year.14 Further investment in the development of the envisioned scientific components will contribute invaluably to giving a seat at the table and a powerful voice in the dialogue shaping the future of health to patients, families, and those who advocate for and benefit from patient empowerment. It will prepare us for a paradigm shift in which, as Dr Eric Topol writes (to patients), “The Future of Medicine is in Your Hands”.15 It will form the foundation underpinning a people-powered transformation of health care and health,16 and perhaps even a corresponding patient-driven health information economy.17 A web server is designed and engineered. The internet protocol, IP, and HTTP were designed and engineered. The World Wide Web (WWW) was not. Rather, it emerged from the decentralized and locally autonomous actions of many independent actors acting within the framework of the WWW architecture. A building is designed and engineered. A city is planned and governed, but it emerges largely outside the direct control of a designer or engineer. A garden plan is designed, but the garden emerges, without either the control or the need for actions by the gardener.18 As an ultra-large scale (cyber-social) system, an LHS, especially at a nationwide scale, will have the emergent characteristics of the aforementioned WWW and city (and garden). Realizing it in a way that engenders the qualities desired will require that patients, consumers, and individual citizens be a part of the system and invaluable contributors to it, not merely passive recipients of its envisioned benefits, however benevolent. Patient empowerment will be an outcome of a LHS, but also an important engine propelling it. Just as an LHS cannot simply be built from a blueprint,11 an LHS cannot simply be built by others for patients; it must be built with and by patients (and all other stakeholders). While the papers in this theme issue generally highlight positive paths to addressing challenges and advancing empowerment, there are myriad studies (and individuals and organizations) that highlight present failings in our health care system to empower patients. Hence, the papers in this issue also provide guidance toward a course correction. As the future of health care and health moves in the LHS direction, the importance of patients shaping the design of the system becomes paramount. Think for a moment, outside of health care, about your interactions as a consumer in any system that (often in the name of efficiency) was designed without considering the needs of (or input from) consumers and workers, rendering them cogs in a machine. One example would be a service experience where a person serving a consumer must use a tool or application that constrains any ability to utilize their own skill and judgment, necessitating a process that stands in the way of a human interaction with the consumer. To an observer, it appears that the worker serves the commands of the device he/she uses and that the consumer is merely a passenger lacking autonomy and “along for the ride.” Another example would be where both the consumer and the local worker must engage in a process involving another worker at a national call center; by design, the national worker lacks the local knowledge or engagement with the consumer to help meaningfully, the local worker lacks the authority to help, the consumer (and both workers) are disempowered, and knowledge fragmentation in the system results in a process lacking empathy. A key hallmark of any person-centered system is empathy: i.e., knowing what it is like to stand in the consumer's shoes based on personalized relevant data about that consumer and knowledge derived from the experiences of others. In these aforementioned examples, the key participants in the systems (consumers and workers) were very likely not involved in designing or shaping the systems, and best practices from the science of human-centered design principles were likely not applied. Beyond putting the patient in the driver's seat of his/her own health, empowering patients to shape the transformative future of health anchored in an LHS will be essential to realizing an LHS that embodies the LHS Core Values and delivers on the promise of the LHS vision. Together, we have moved the LHS from impossible to imperative to inevitable. A future of health that involves big data and analytics will happen; it is already happening. What I believe we're really fighting for is the soul of this future.19 While our open access journal is anchored in a science underpinning “both the cyber-social and ultra-large-scale systemic character of the LHS,”11 this theme issues serves to remind us that there is something distinctive about health. At that time of this issue's release in July 2017, many Americans will have already celebrated the anniversary of the adoption of the Declaration of Independence which is grounded in the notion that all people are endowed with certain unalienable rights including rights to life, liberty, and the pursuit of happiness.20 A principle underpinning the United States legal system is that, in theory, when a threat to one's exercise of these unalienable rights is triggered, an individual is afforded rights (and sometimes tools and capabilities) to vigorously advocate to protect these paramount human rights. It is easy to see how an individual's health is central to his/her ability to exercise his/her fundamental human rights to life, liberty, and the pursuit of happiness. Yet when disease threatens a person's liberty or life today, he/she is not regularly told that he/she has rights to the information and tools he/she needs to vigorously advocate to protect his/her health; in certain ways, a person-centered LHS takes important steps toward changing that dynamic by empowering people through learning. The papers in this theme issue showcase select mechanisms by which an LHS can empower patients—with information, health literacy, personalized tools, connections to communities, and more—to be, in collaboration with their caregivers and care teams (and other stakeholders), strong advocates and activists to leverage learning to protect and promote their health as well as the health of others. Learning Health Systems serves as a gathering point (and perhaps an infrastructure component) for the community interested in the science of cyber-social learning systems as applied to health. It can also be a catalyst for advancing the science that will be foundational in driving this change in the way individuals and society relate to safeguarding and advancing health. Hence, these themes are interwoven into people's exercising of their human rights. Many of the authors in this issue have not only been engaged in conducting rigorous research and in pioneering initiatives, but they have also fought courageously and sacrificed greatly to advance patient empowerment. Some have accumulated scars on their extensive journeys championing patient empowerment and the LHS. I hope that the thoughts I have shared with you in this commentary and especially the papers featured in this first theme issue of Learning Health Systems will help to illuminate how and why these contributors were so willing to work steadfastly to advance this urgently important cause, endeavoring to disruptively transform the future of health. I wish to close by recognizing the late Jerry Matczak, a co-author of the paper entitled “Patient-centered drug development and the Learning Health System,”21 who passed away earlier this year. A champion of patient empowerment who worked as a social media guru and leader of a Clinical Open Innovation team at a global pharmaceutical/life sciences company, Jerry was widely lauded for actively listening to and communicating with patients, to advance clinical research and drug development.22 A vocal advocate for open sharing to advance human health, he was personally recognized for sharing his “unique perspective among geek-minded people,” harnessing humanity to draw the types of connections in science that will be at the heart of advancing the science of learning systems.23 Jerry Matczak's commitment to open innovation and community provides a powerful lens from which to view the papers in this issue as well as the emerging science that will underpin the development and advancement of the fabric weaving together a patient-empowering LHS. With motivation stemming from deeply personal family health experience, Jerry stated in a 2012 interview: “[By] acting openly, with honesty, transparency and integrity we intend to foster a community that will make a difference in people's lives. When you think about it that way, it's easy to commit.” 22

Alan Maynard, Stuart H. Altman, Sally C. Stearns

Like many countries, the health care industries of England 1 and the United States consume large amounts of resources and struggle to achieve equity and efficiency. They attempt to reach these goals in quite different ways, exhibiting common challenges familiar to reformers throughout the world. Recent activities in England and the United States suggest that significant changes being discussed in the United States or implemented in the United Kingdom could upset previously accepted policies and threaten some or many of the gains made to provide more equal and timely accessible care to all individuals. Policy makers in both countries wrestle with similar problems of redistribution and system design. Although in the United States, the issues of equity and expenditure controls do not have the same importance as in England, both countries seek the “Holy Grail” of limiting spending both by government and the private sector by redesigning institutions that manifest inefficiency and contribute to inflationary pressures. Yet competing value systems permeate the political debate about how to accomplish these aims. These value systems underlie political preferences for regulation and markets. Although a minority in the United States advocates for universal care funded by a single payer, private employer-based insurance remains the bedrock mechanism. Unlike the United Kingdom and most Organisation for Economic Cooperation and Development (OECD) countries, the United States has never shown a political willingness to have government responsible for financial protection for all inhabitants against the cost of medical care. The United States has, however, accepted this responsibility for major components of society, namely, the aged, disabled, and low-income families and children (e.g., via Medicare, Medicaid, and the State Children's Health Insurance Program). This commitment was expanded with the Affordable Care Act (ACA) in 2010, commonly known as Obamacare. The outcomes of the two health care systems reflect a preference for collectivism in funding and access in the United Kingdom and for pluralism in funding (less third-party coverage) and a greater role for privately delivered care in the United States. But the battle continues in both countries as important groups advocate for the reversal of these preferences. Policy makers continually try to change their health care systems. Some of these changes seek to develop greater efficiency in how care is delivered as a means of controlling the burdens imposed on society by ever-increasing public and private expenditure. Both countries face common problems that have been well identified for decades but have proven difficult to resolve. Reformers face three common problems. First, unwarranted variations in clinical practice (Wennberg, 2008, Wennberg, 2012) are produced by price variations in insurance systems and volume variations elsewhere (Institute of Medicine, 2013). Second, both systems have been slow to develop measures of the value of health care outcomes, that is, improvements in the length and quality of life. Third, both health care systems have perverse incentives that inhibit efficiency-inducing change; for example, they use hospital pricing or tariff systems that incentivise activity with little regard to patient value. Inadequate evaluation and political resistance to change continue to produce inefficiency. The end result is unnecessary spending and unethical deprivation of beneficial care for some populations. The English single payer system is characterised by frugality and cycles of famine and plenty, with attendant bouts of supply side reform (Street & Maynard, 2007). Constrained funding in the 1980s led to the Thatcher reforms and the creation of the “quasimarket” of purchaser and providers contracting for public and private care. These structural reforms received increased funding in the early 1990s. By the end of the 1990s, financial parsimony was creating renewed performance problems, for example, increased waiting times for elective surgery. As a consequence, the Blair government financed a large increase in funding. Since 2010, the Coalition and now Conservative government has exerted extreme expenditure controls, and current plans will result in real per capita funding falling by 2018. Since the Thatcher era, the often violent fluctuations in NHS funding have been accompanied by the “redisorganisation” of structures and processes of care whilst maintaining universal cover age free at the point of use. The purchaser side of the National Health Service (NHS) market has evolved from health authorities to primary care trusts and now to clinical commissioning groups, all with similar functions and uncertain impact. The provider side of the market remains dominated by public institutions as private providers have made only marginal inroads to public funding. The current chronic underfunding of the NHS and social care, manifested currently by increased waiting times for elective procedures, has produced inevitable pursuit of the “Holy Grail” of increased productivity. The Five Year Forward View (NHS, 2014) involved the acceptance of government parsimony and for the 2015–2020 period. Its authors argued that the NHS would require £30 billion to meet demographic and technological demands, of which only £8 billion was to be provided from tax revenues. The additional £22 billion was to be funded from productivity increases. Current NHS spending is £110 billion. Currently, a frenzy of structural reform proposals range from integration of currently fragmented hospital, primary and social care systems to hospital mergers to the abolition of the purchaser-provider “market” with the creation of accountable care organisations. These proposals involve unevidenced merger plans and deskilling of nursing and other workforce changes. The Sustainability and Transformation Plans (https://www.england.nhs.uk/stps/) are radical but unlikely to yield £22 billion of productivity gains in 5 years. There is little available funding to finance the change process, and its duration is likely to take many years to free up resources. Both options assume that healthcare is much more expensive in the United States than in any OECD country because American patients use too much medical care. Yet the evidence does not support this assumption. Americans are less likely to be admitted to a hospital and have a lower length of stay once in a hospital than many OECD countries. Americans also are less likely to see a doctor or use fewer pharmaceuticals than patients in OECD countries. U.S. patients do use more very expensive medical devices such as MRIs or new and expensive drugs, but on net, the pluses and minus may cancel out. What separates United States spending from that in OECD countries are the prices charged for all medical activities. The reasons for the higher prices are complicated and due to a myriad of factors including the higher wages paid to most participants in the healthcare system (not only physicians); the much higher prices Americans pay for drugs and medical devices; and the fact that the complexity of the U.S. system has evolved in a way that requires the use of many more lawyers, consultants, and administrators, all of whom are well paid. The latter consideration is possibly more central because some key providers such as primary care physicians receive relatively low compensation relative to education costs and work conditions. Additional efforts within the United States that are sometimes related to the ACA include a broad interest in insurance redesign, emphasis on value from services provided, and a focus on patient-centred outcomes. Value-based cost-sharing approaches are being implemented in the United States as well as other OECD countries (Thomson, Schang, & Chernew, 2013), though these approaches are more easily implemented for certain services such as pharmaceuticals. The Medicare program is testing a number of value-based payment innovations and incentive payments. The Patient-Centered Outcomes Research Institute is a nongovernmental institute created under ACA that was charged with assessing the effectiveness and appropriateness of medical treatments. However, the Patient-Centered Outcomes Research Institute is not able to mandate coverage or reimbursement for any treatments and infamously is prohibited from considering cost per quality-adjusted life years in its recommendations despite widespread interest in this measure in many other countries. The American and the English health and social care systems differ greatly, but they are surprisingly similar in some dimensions. Key differences pertain to who pays for care and how it is delivered, with the United States having a more decentralized and fragmented system leading to inequalities in the provision of care and its funding. The English system is universal and largely free at the point of consumption system but constrained by limited funding (which also generates inequalities in access to timely care). The supply side problems are more similar for both countries. Increasingly, U.S. reform in terms of payment mechanisms is being emulated by the English. Both systems seek better measurement and management of “value,” that is, the effects of health care on the length and quality of patients' lives. The hospital systems of both countries are attempting to integrate care function and move away from “fee for service” to bundled or incentive payments. The American system is the product of producer incentives producing grossly inflated costs. Concomitantly, a growing proportion of the U.S. population has a limited view about who should be eligible for government-supported health care services and the types of services that should be supported. Despite greater underlying consensus in favour of universal coverage, the English system's crisis is a product of parsimony and fragmentation of funding and provision. Both systems are permeated by organisational inertia and the defence of political values and self-interest. The United States is grappling with more than a sea change given political restructuring and the very uncertain future of most expansions of insurance or medical cost coverage under the ACA. England faces potentially revolutionary structural changes in supply and a real political challenge in its single payment system. Although current trends are not positive, the authors maintain hope that both countries will prevent further deterioration in health care coverage and return towards more progressive policies to protect their inhabitants' access to care when subjected to the misfortunes of medical illness.

Willy De Geyndt

No abstract is available for this record.

Adam Fusheini, John Eyles

BACKGROUND: Universal Health Coverage (UHC) has emerged as a major goal for health care delivery in the post-2015 development agenda. It is viewed as a solution to health care needs in low and middle countries with growing enthusiasm at both national and global levels. Throughout the world, however, the paths of countries to UHC have differed. South Africa is currently reforming its health system with UHC through developing a national health insurance (NHI) program. This will be practically achieved through a decentralized approach, the district health system, the main vehicle for delivering services since democracy. METHODS: We utilize a review of relevant documents, conducted between September 2014 and December 2015 of district health systems (DHS) and UHC and their ideological underpinnings, to explore the opportunities and challenges, of the district health system in achieving UHC in South Africa. RESULTS: Review of data from the NHI pilot districts suggests that as South Africa embarks on reforms toward UHC, there is a need for a minimal universal coverage and emphasis on district particularity and positive discrimination so as to bridge health inequities. The disparities across districts in relation to health profiles/demographics, health delivery performance, management of health institutions or district management capacity, income levels/socio-economic status and social determinants of health, compliance with quality standards and above all the burden of disease can only be minimised through positive discrimination by paying more attention to underserved and disadavantaged communities. CONCLUSIONS: We conclude that in South Africa the DHS is pivotal to health reform and UHC may be best achieved through minimal universal coverage with positive discrimination to ensure disparities across districts in relation to disease burden, human resources, financing and investment, administration and management capacity, service readiness and availability and the health access inequalities are consciously implicated. Yet ideological and practical issues make its achievement problematic.

Cristianne Maria Famer Rocha, Silvia Helena De Bortoli Cassiani

In recent decades, health care networks in diff erent parts of the world have incorporated new forms of social organization that involve extensive use of technology to produce and disseminate information and are based on the autonomous, non-hierarchical and decentralized cooperation and collaboration of those within these networks. In Latin American countries, Nursing Networks were created in the 2000s on the initiative of professionals seeking to exchange knowledge and experiences. Over time this initiative gained ground with the support and leadership of the Regional Council for Nursing and Health Technicians of the Pan American Health Organization (PAHO) and, in 2007 and, in 2007, the 1 st International Nursing Network Conference was held in Toledo (Spain), during the 9 th Ibero-American Conference of the Latin American Association of Nursing Schools (ALADEFE). These networks operate as a communication strategy, stimulating cohesion and cooperation between nurses interested in developing nursing care, management, research, information and education with a view to supporting the advancement of the profession and help countries achieve universal health care coverage and access to health services. There are currently around 25 International Nursing Networks in the Americas, which together form Rede EnfAmericas and consist of more than 3000 nurses in Latin America. Information on each of these networks is available at: http://www.

Bounsathien Phimmasenh, Khamlusa Nouansavanh

The Government of Lao PDR has formulated a National Growth and Poverty Eradication Strategy (NGPES) that links sustainable economic growth, human development, reduced vulnerability and poverty alleviation; and addresses the key issues of public sector governance and public sector management. Implementation of the overall strategy focuses on rural Districts and relies on decentralized authority and beneficiary participation. Health services are a vital component of the NGPES, which reiterates the Government’s commitment to achieving the Millennium Development Goals (MDGs) and identifies improved access, equity, quality and strengthening the health workforce as key goals. Ministry of Health (MOH) supported by the World Bank (WB) is implementing the Health Services Improvement Project-Additional Financing (HSIP-AF) with the objective to increase utilization and quality of health services, particularly for the poor women and children in rural areas. The consultations with ethnic groups during project implementation is necessary in order to assess whether the design of the HSIP-AF is succeeding in responding to the needs for MNCH services of ethnic groups in project provinces, understand the extent to which free delivery, and outreach activities impact health seeking behaviour of pregnant women and new-born children from ethnic groups and ascertain based on the result of such consultations, broad community support to project activities. The principle of SWOT Analysis was adapted in the consultation methodology. The Consultations however, indicated that ethnic communities were not fully informed of and understood project benefits available to them and requirements for participation. Communication is often particular problematic in areas with language barriers. A higher degree of inclusion in terms of community participation in the identification of problems and ways of solving them would demand bottomup implementation mechanisms and more flexibility to adapt project activities and supplied resources to local needs. The health service providers should preferably be female and members of local communities in order to overcome cultural and language barriers.

Gregory P. Marchildon

No abstract is available for this record.

Paul Kuehnert, Herminia Palacio

For decades, governmental public health in the united States has been relegated to operating at the margins of the country's massive healthcare system that drives nearly 20% of the uS economy.1 Further buffeted in recent years by a variety of external forces (including the 2008 economic recession, shifting demographics, a high and complex population burden of chronic disease, and a rapidly changing health care delivery system), public health leaders and policymakers increasingly recognize that the existing practice models are no longer adequate for the task of protecting and promoting the public's health.2 put simply, uS public health risks moving from being marginalized to becoming irrelevant if public health practice is not transformed.the challenges embedded in changing public health practice are multiple, and are made more complex by the decentralized structure of public health in the united States. public health here is a federated enterprise that includes national entities such as the Center for Disease Control and prevention, the Food and Drug Administration, and others; state and local governmental health departments; non-governmental organizations at the national, state, and community levels that are organized around single or multiple health-related issues; and public and private colleges and universities that provide education and training to the multiple disciplines making up the public health workforce. National study committees convened by the National Academy of Science's institute of Medicine over the past 30 years3-5 have consistently found the uS public health system to be in a state of disarray: misunderstood by elected policymakers and the general public; under-resourced in financial, technological, and workforce spheres; and highly variable in practice and services provided by over 2500 state and local governmental public health departments.For more than 20 years, the robert Wood Johnson Foundation (rWJF) has made significant investments in advancing public health in the united States. this includes multi-million dollar, flagship investments in public health accreditation and in public health systems and services research, with both efforts broadly directed toward improving the quality and impact of public health practice. it also includes more recent, and more narrowly concentrated, investments in engaging public health leaders in focused dialogues on critical operational issues as well as on more aspirational strategic thinking about how to catalyze and support transformational change in public health practice. three current examples of these strategic investments include:1. Building consensus around a set of core and foundational public health capabilities and services;2. developing an aspirational vision for uS public health in 2030; and3. identifying leadership and educational preparation needed to prepare the public health workforce of the future.Foundational Capabilitiesrecognition of the significant variability in the type, amount and financing of public health services led the institute of Medicine in 2012 to call for a '... minimum package of public health services, which includes the foundational capabilities and an array of basic programs no health department can be without...'.5 through funding a public Health Leadership Forum (pHLF), rWJF convened a diverse group of federal, state, and local public health leaders and stakeholders in April 2013 to review this recommendation and operationalize it. over the course of the next nine months, the group developed consensus around a foundational capabilities and services framework6 (see Figure 1) and operationalized them with enough specificity that a costing model is now being developed. the framework is being systematically vetted with the broader uS public health community by way of presentations at multiple conferences, webinars, and social media. once vetted, it is hoped that the foundational capabilities and services framework will be utilized by state, local, and federal policymakers and result in increased resources for public health while decreasing variability in practice and, ultimately, improve population health outcomes. …

Heiner Grosskurth, Ruari Brugha, Benson Droti, Susan D. Foster

Levels of care Peripheral health units, such as health centres, dispensaries or community health posts, are the first places where patients meet the formal public health care system in most rural African districts. People also consult private clinics, pharmacies, formal or informal drug retailers and traditional providers, who are popular for psychosocial and mental health problems, when people suspect spiritual factors, in AIDS, tuberculosis and epilepsy or when orthodox medicine does not meet their needs. Together, these providers represent primary medical care; better district care must involve all of them. In most countries health care is decentralized and largely devolved to district health services. The Ministry of Health formulates policy, sets standards and ensures quality assurance and is responsible for mobilizing resources and monitoring and evaluation nationally. It oversees and sometimes manages nationally co-ordinated services such as epidemic control. However, the district health management team (DHMT), led by the district medical officer and the district hospital form the backbone of the health services. The health care system, especially in Anglophone African countries, is organized around the district health service. The district hospital provides secondary level medical care; whilst regional (provincial) and national hospitals provide tertiary specialist care. A referral chain, up which patients move, is thus established but, in reality, most district and tertiary hospitals have busy outpatient departments that give primary care to their community. As urbanization accelerates, urban polyclinics function like district hospitals and provide an intermediate tier between smaller urban clinics and specialist hospitals.

Ingrid Sperre Saunes, Anna Sagan, Ingrid Sperre Saunes

Norways five million inhabitants are spread over nearly four hundred thousand square kilometres, making it one of the most sparsely populated countries in Europe. It has enjoyed several decades of high growth, following the start of oil production in early 1970s, and is now one of the richest countries per head in the world. Overall, Norways population enjoys good health status; life expectancy of 81.53 years is above the EU average of 80.14, and the gap between overall life expectancy and healthy life years is around half the of EU average. The health care system is semi decentralized. The responsibility for specialist care lies with the state (administered by four Regional Health Authorities) and the municipalities are responsible for primary care. Although health care expenditure is only 9.4% of Norways GDP (placing it on the 16th place in the WHO European region), given Norways very high value of GDP per capita, its health expenditure per head is higher than in most countries. Public sources account for over 85% of total health expenditure; the majority of private health financing comes from households out-of-pocket payments.The number of practitioners in most health personnel groups, including physicians and nurses, has been increasing in the last few decades and the number of health care personnel per 100 000 inhabitants is high compared to other EU countries. However, long waiting times for elective care continue to be a problem and are cause of dissatisfaction among the patients. The focus of health care reforms has seen shifts over the past four decades. During the 1970s the focus was on equality and increasing geographical access to health care services; during the 1980s reforms aimed at achieving cost containment and decentralizing health care services; during the 1990s the focus was on efficiency. Since the beginning of the millennium the emphasis has been given to structural changes in the delivery and organization of health care and to policies intended to empower patients and users. The past few years have seen efforts to improve coordination between health care providers, as well as an increased attention towards quality of care and patient safety issues. Overall, comparing mortality rates amenable to medical intervention suggests that Norway is among the better performing European countries. Despite having one of the highest densities of physicians in Europe, though, Norway still struggles to ensure geographical and social equity in access to health care.

Fabrizio Carinci, Gianni Caracci, Francesco Di Stanislao, F Moirano

No abstract is available for this record.

Tom Miller, James C. Capretta, Grace-Marie Turner

No abstract is available for this record.

Alain C. Enthoven

In a wide-ranging look at many aspects of health care financing and delivery, the concepts of glasnost and perestroika are used as a framework for presenting ideas from the American system that may have value for European health care planners. These include more uniform approaches to data collection and cost reporting, patient outcome studies, evaluation of service and access standards, publication of information, quality assurance review, decentralization and independent institutions, prepaid group practice, demonstrations and experiments, and managed competition. Suggestions are offered for making health care systems on both sides of the Atlantic more manageable, efficient, and responsive.

Uldis Mitenbergs, Maris Taube, Janis Misins, Eriks Mikitis · 7 authors

This analysis of the Latvian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. After regaining independence in 1991, Latvia experimented with a social health insurance type system. However, to overcome decentralization and fragmentation of the system, the National Health Service (NHS) was established in 2011 with universal population coverage. More recently, reforms in 2017 proposed the introduction of a Compulsory Health Insurance System, with the objective of increasing revenues for health, which links access to different health care services to the payment of social health insurance contributions. In June 2019 the implementation of this proposal was postponed to 2021. Latvia has recovered from the severe economic recession of 2008, which resulted in the adoption of austerity measures that significantly affected the health care system. The recovery has created fiscal space to focus on policy challenges neglected in the past, especially regarding health. Despite recent increases in spending, the health system remains underfunded and resources have to be allocated wisely. Latvia's health outcomes should be considered within this context of limited health system resources. While life expectancy at birth in Latvia has increased since 2000, reaching 74.9 years in 2017, it remains among the lowest in the EU. Recent reforms have focused on improving access to services in rural/remote areas, increasing funding for health care services, and tougher regulation of tobacco and alcohol. However, a number of longstanding unresolved problems still need to be addressed, including financial sustainability and low public funding, high levels of unmet need, high rates of preventable and treatable mortality, and challenges in both communicable and noncommunicable diseases.

Hans Okkels Birk, Karsten Vrangbæk, Andreas Rudkjøbing, Allan Krasnik · 7 authors

Denmark has a tradition of a decentralized health system. However, during recent years, reforms and policy initiatives have gradually centralized the health system in different ways. The structural reform of 2007 merged the old counties into fewer bigger regions, and the old municipalities likewise. The hospital structure is undergoing similar reforms, with fewer, bigger and more specialized hospitals. Furthermore, a more centralized approach to planning and regulation has been taking place over recent years. This is evident in the new national planning of medical specialties as well as the establishment of a nationwide accreditation system, the Danish Healthcare Quality Programme, which sets national standards for health system providers in Denmark. Efforts have also been made to ensure coherent patient pathways - at the moment for cancer and heart disease - that are similar nationwide. These efforts also aim at improving intersectoral cooperation. Financially, recent years have seen the introduction of a higher degree of activity-based financing in the public health sector, combined with the traditional global budgeting.A number of challenges remain in the Danish health care system. The consequences of the recent reforms and centralization initiatives are yet to be fully evaluated. Before this happens, a full overview of what future reforms should target is not possible. Denmark continues to lag behind the other Nordic countries in regards to some health indicators, such as life expectancy. A number of risk factors may be the cause of this: alcohol intake and obesity continue to be problems, whereas smoking habits are improving. The level of socioeconomic inequalities in health also continues to be a challenge. The organization of the Danish health care system will have to take a number of challenges into account in the future. These include changes in disease patterns, with an ageing population with chronic and long-term diseases; ensuring sufficient staffing; and deciding how to improve public health initiatives that target prevention of diseases and favour health improvements.

Vaida Bankauskaitė, Christina M. Novinskey

Along with resource generation, financing, and health service delivery, stewardship is a key health system function. However, very little empirical analysis has been carried out on it. This paper aims to fill this gap in the literature by assessing the Ministry of Health's (MoHs) role as a steward of the Spanish National Health System (NHS) after the 2001 decentralization reform of health care management to the Autonomous Communities. We use the following stewardship framework with six sub-functions for the analysis, looking at the MoH's ability to: (1) formulate strategic policy framework; 2) ensure a fit between policy objectives and organizational structure and culture; (3) ensure tools for implementation; (4) build coalitions and partnerships; (5) generate intelligence, and (6) ensure accountability. We describe the stewardship function, identify existing challenges and issues in the Spanish case, and reflect upon methodological aspects of this exercise. We use reports, documents, articles, and official statistics to complete the analysis. Overall, we find the MoH to give an average performance in its role as the steward of the health system. The MoH has progressed particularly well in generating intelligence as well as formulating a strategic policy framework over recent years. However, it lacks the appropriate authority to efficiently coordinate the health system and to ensure that the Autonomous Communities implement policies that are in-line with overall NHS objectives.

Alice Ghent

year as Switzerland's Federal Office of Public Health (FOPH) announces the annual round of health insurance premium increases, this nation of 7.5 million people lets out a collective groan. Last year, the pain was greater than usual. Concerned about the depletion of cash reserves insurers' coffers, the FOPH allowed rises of up to 14.6% for basic insurance premiums depending on the canton. That hurt. Since 1999 the Swiss have seen health insurance costs rise by 50%, according to the FOPH. From 2008-2009, the price hike was significant enough to cut 0.1% from rising household disposable income. Nadia Bouchardy does not need an announcement to know that a sizeable portion of her family's income is being spent on health. Married to an ambulance driver with two young daughters, the family has an annual income of 90 000 Swiss francs (US$ 83 000) before taxes and insurances. year around 10 500 Swiss francs (US$ 9700) or 12.5% of their income goes on health insurance and extra expenses such as dental care. Last year, Bouchardy, who is aged 41, had an operation and had to pay 10% of the costs of the operation, medicine and her stay hospital. (In out-of-pocket expenses are capped to ensure families do not suffer what is termed catastrophic expenses). We are not very happy with the health insurance system Switzerland, she says. Every year we pay more and we get less. The lists with items that are not covered anymore by the health insurance gets longer. Some items like glasses or basic medicine are not fully covered, so we have to pay these costs out of our non-health budget. So far we are lucky we have not been forced to borrow money order to pay the health bill. The Bouchardy family represents how middle-income Switzerland is being squeezed financially. They earn too much to benefit from the health subsidy received by households that spend more than about 8% of their income on premiums (the level of subsidy depends on the canton). Some 40% of households receive the subsidy--either through a lower premium or tax rebate--which is the government's mechanism for preventing the cost of insurance from unfairly disadvantaging low-income families. Professor Alberto Holly, of the University of Lausanne, is an expert Switzerland's health financing system. He points to a system that is envied for its universal coverage, its equity, standard of care and lack of waiting lists. of the strengths of the Swiss system is equity with respect to health risk and patient ratio. No one is penalized for age, gender or medical history. However, it is not totally equitable and is regressive respect to income, he says. Under the Swiss constitution, the Federal Government is responsible for managing the health insurance but has limited responsibility terms of health policy. Instead, this energetically democratic country has a decentralized system which the 26 cantons are autonomous and choose how to organize their own health care. results a wide disparity terms of insurance premiums, which are usually paid by householders, not employers. [ILLUSTRATION OMITTED] Since 1996, it has been illegal not to have basic health insurance Switzerland. There are 82 not-for-profit insurers that offer policies costing around 350 Swiss francs (US$ 325) a month per adult. No one can be turned away under this scheme, known as LAMal. Further, some 44 companies offer complementary forms of insurance, which allow benefits such as dental treatment and access to luxurious hospitals, and these companies are free to choose clients according to their risk profile. One characteristic of Switzerland's health-financing system is its expense. This is not an efficient system, says Holly, in that it has not been possible to control costs. The result is that Switzerland has the third most expensive medical system the world. …

Kristian Bolin, Sören Höjgård, Björn Lindgren

No abstract is available for this record.

IRS Reddy

Respected chair persons and members of the Indian Psychiatric Society (IPS), I am extremely happy and privileged to be here at the 59th Annual Conference, before an enlightened gathering to preside over the prestigious IPS. It is a rare honour and it shall be my endeavour to prove myself worthy of being chosen for this prestigious and highly coveted honour among the psychiatrists. I know my limitations but I am also aware of the great role that can be played by our society and I make bold to place before you many of my experiences in the field to exhort my fellow psychiatrists that we have a great responsibility ahead. From what I have observed during these years of my active practice, I have no doubt in my mind that the psychiatry as a profession is slowly gaining ground and in the years to come it will play an effective role in disabusing the minds of the public of their wrong and ill conceived notions. I shall endeavour my best with the cooperation and support of all my fellow psychiatrists. There were quite a few topics that I short listed for my presidential address. Finally, I zeroed in on this topic titled “MAKING PSYCHIATRY A HOUSEHOLD WORD” as I feel the art and science of psychiatry has a great deal to offer society apart from treating the “crazy people”. To make that contribution, psychiatrists must continue to tackle society's most pressing problems and also raise the visibility of psychiatry and its perceived relevance to solving a wide range of personal, social and family problems. The image of psychiatry has been tarnished in the eyes of common man, thanks to the battering that the profession has received at the hands of the media, not to mention the apathy of the policy makers. Here is an example to prove my point. At the recently held conference at Jaipur, I was walking outside the convention center when I heard two young women talking to each other. One said to the other: “My God!!!…. He's so weird! He really should see one of those psychiatrists who are walking around here.” “That's it!” I thought. “People think you have to be ‘weird’ to see a psychiatrist.” The public tends to view psychiatrists narrowly, associating us chiefly with our expertise in mental illness. In reality, psychiatrists can promote coping and wellness in addition to diagnosing and treating mental illness. Many people today have significant stress in their lives and we all undergo crises and life-stage transitions as a normal part of life. Psychiatrists can help people assess how they are coping with current stresses and develop new skills and strategies. A lot of people find that their stress levels have increased in this era of wars, terrorism and natural disasters. We, as psychiatrists, could do much more to prevent problems by helping people learn to cope and build their resilience. I wondered what it would take to normalize our public image, that set me thinking and I looked into dentistry, which changed the public image of its profession in the 1980s when it teamed up with Colgate toothpaste in a public education campaign that promoted the idea of the dental check-up. This campaign led to major changes not only in the public image of dentistry but also in the very nature and public impact of dental practice. Dentistry moved from a focus on restorative dentistry to an emphasis on preventive dentistry. We have all witnessed the success of this transition. People no longer wait for a toothache to visit the dentist and employers routinely include preventive examinations and cleanings as a dental benefit. I am envisaging a day when people similarly take appointments for a “psychological check-up” akin to a general health check -up and when that day comes one can rest assured that the community has truly embraced our profession. At these check-ups they could address such matters as their stress level, their relationships, how they are caring for their children and ageing parents and health basics such as diet, nutrition, sleep and exercise. In my 30 years of practising psychiatry, I have had a unique vantage point from which to both observe and reflect on, the process whereby psychiatry responds to urgent societal needs and how these needs thus influence the evolution of psychiatry. As I see it, the scope of psychiatric practice is expanding and diversifying into new areas. In short, the stage is set for the public's as well as policymakers and health care payers' full embrace of our field and for the true integration of psychiatry into health care, Only if we make them aware of our scientific knowledge and professional skills. DISABILITY AND MENTAL ILLNESS The burden of mental illness on health and productivity throughout the world has long been profoundly underestimated. Data developed by the massive Global Burden of Disease study conducted by the World Health Organization, the World Bank and Harvard University, reveal that mental illness, including suicide, accounts for over 15 percent of the burden of disease in established market economies, such as the United States. This is more than the disease burden caused by all cancers.[1] This Global Burden of Disease study developed a single measure to allow comparison of the burden of disease across many different disease conditions by including both death and disability. This measure was called Disability Adjusted Life Years (DALYs). DALYs measure lost years of healthy life regardless of whether the years were lost to premature death or disability. The disability component of this measure is weighted for severity of the disability. For example, disability caused by major depression was found to be equivalent to blindness or paraplegia whereas active psychosis seen in schizophrenia produces disability equal to quadriplegia. The World Health Organization's Global Burden of Disease study reported that mental disorders comprise four of the top five sources of premature death and disability in 15-44 year olds in the Western world. Using the DALYs measure, major depression ranked second only to ischemic heart disease in magnitude of disease burden in established market economies. Schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder and post-traumatic stress disorder also contributed significantly to the total burden of illness attributable to mental disorders. The projections show that with the aging of the world population and the conquest of infectious diseases, psychiatric and neurological conditions could increase their share of the total global disease burden by almost half, from 10.5 percent of the total burden to almost 15 percent in 2020. Major depression is the leading cause of disability (measured by the number of years lived with a disabling condition) worldwide among persons age 5 and older. For women throughout the world as well as those in established market economies, depression is the leading cause of DALYs. In established market economies, schizophrenia and bipolar disorder are also among the top 10 causes of DALYs for women. The above stated facts, hopefully will be an eye-opener for all the concerned parties. From our side, we should do all that we can in whichever small way to reduce this enormous disease burden. My presidential address, I hope, will serve as an initiative to formulate ways and means to achieve this objective. IMPEDIMENTS IN MAKING PSYCHIATRY A HOUSEHOLD WORD There have been a lot of impediments in making psychiatry a household word. The main culprits are the age old concept of mind-body dualism and lack of integration of mental health care into primary health care, stigma, psychiatrists themselves, the apathy of the policy makers, failure of Consultation - Liaison psychiatry and media. I will make an attempt to briefly detail what resulted in these hindrances and some plausible solutions to overcome them. MIND-BODY DUALISM The earlier concepts of health glorifying mind-body dualism are bankrupt now and mind-body dualism has an enormous negative impact on our health care system. Because of it, our health care system does not systematically attend to the many psychological risk factors for both morbidity and mortality and it virtually ignores the psychosocial pathways that lead to unnecessary utilization of medical and surgical services. In addition, the psychological impact of a medical illness is not well by the health care is the that many people from a illness have psychological illness. Finally, the share of mental health problems are by primary care take a at some of the of the top health risk factors are diet, suicide, and of the leading causes of death have significant At as much as of all to primary care medical are for problems with a psychological those who with mental health problems and those who or for problems with a psychological component those with such as those with and those with medical one study found that than of had and A number of have that health care the utilization of medical and surgical The of people mental health are for by medical with in mental is a of the of psychological in a wide range of health including both and disease system and and In addition to being these are than across a wide of and including and that mental health can be in primary health care with and on but it is whether this is true of for persons with and mental illness. There is a long of in for persons with mental disorders that would be a single system of care that to medical and mental health services. Many mental health problems are seen as and thus the general health is a natural point for and treating mental health problems. Many also continue to find care for psychiatric problems more when by their primary care The and mental health care in an system also a that common and mental disorders will be and that and among will reduce and common of of The concept of a number of that are at the of health care them are the and A significant is that not be in a highly system of As medical are to be more and they have to to each and to know the and to the of problems that Because with conditions are and to their and they will not be with disabling mental illness will have to with who more and to deal with by and of these problems has but they are not can be to and with mental but this is a and can be to increase the of health care to disabling illness, but this must with many in an of new and practice by of public and is but effective in this objective. the that mental health for ill can be into the general health a and that are on at for the The is for persons with more and disorders. - A Psychiatrists should have been seen as and as an as they are so few in In are only psychiatrists for a population of over of psychiatrists to the of is which is quite Psychiatrists are seen in negative by the of the have been are seen as disease and not are seen as being seen as are seen as a on the most in the are seen as the to as not in and thus could them of their and being a are seen as making a a to their view are seen as not scientific psychiatrists in and are seen as are seen as only and not the have been up over and mental health of of and of including have contributed to these of by help has matters The of and of view has it from the the of psychiatrists themselves, the to formulate and not the focus from negative to and not our have it We of the of mental and disease in the but are not to prevent We of mental health but do not or we do not have or for mental health at the professional or We of well being and on The and do not have psychiatrists as the but are to our We would be to of and for but not in at the to preventive and health strategies. We can be if we are to The community of which is a part would be to allow us to lead if we have for and which are effective and We would have to hands with and community with to long solutions for the population than at a of only those who have extremely and We to be for the mental health needs of the and not only the for It is only that psychiatrists in and psychiatry in general would its place and a - PSYCHIATRY of the to with are and are for the cooperation and for effective is a on the part of some to the place of factors in the of the This be to and conditions that are to observe and or to is that mental health have long had a for The or at was in the many people the field in to their psychological problems. it and such an are to The that be and the of psychiatric The on of or at in many is with and One by many including psychiatrists, is that a will come in that the has a more disorder than the one and that the is on should the for psychiatric the the moved to this is not an the two care This is to the of if the psychiatric The should that lack expertise outside of and with psychiatrists is a that must be over a of the most here is to make but when called for an This reduce by the and allow to up in the psychiatrists have a for diagnosing as or the that they be to have some psychiatric problems of their The is not as many psychiatrists and mental health in make of fellow them or their A general way to many of these is for the to be in and to the of and medical and should that the is a in which the will have the The of with psychological problems in with should be and not The should not be or or that will be as very by the He should also be aware of the of the and than a take it or it I have found that with when I am by and does not medical the can find ways to make to the medical He should with and take the of these It is also to attend medical The of knowledge of one by psychiatrists and can during before such and can lead to the also the with an to the and of with their and AND MENTAL of people with mental disorders has throughout It is by to or or people with mental disorders such as It to and and to and It the public from and to In its most and in and it people of their and with their full in for in from the mind and by of in the of the mental health system in the United from the of an influence on and in the world. In the the public mental illness as a and an of mental illness. were not to as when with of who would have been said to be ill to the professional of the The public was not at mental illness from and and to see only of mental illness. illness great social stigma, with of and a that had scientific of mental illness. the in knowledge not social in comparison with the the public's of mental illness more This was true among those who mental illness to include psychosis view held by of the The also how of those with mental illness by The public was more to an with schizophrenia as mental illness than an with This people with mental disorders truly more some public but the of is The risk of is from those who have who have a mental disorder as well as a There is a small in risk of from with mental disorders if they are with their the risk of is much for a than for a family or who is to the with mental In is very risk of or to a from with an who has a mental Because the is to whether who is has of these or in the natural is to be to this all in the of mental disorders to the total of in society is Because most people should have to from those with mental illness, in its most is of so focus on and One of found that the public's and mental illness and people to from those with mental disorders. of the common with from psychiatric disorders are listed of mental illness of of It is not that psychiatry has a in its to mental illness, but that it has also to address its current of the psychiatry in their There is a of psychiatric on and and a to the are some in psychiatry, which are in minds and a great deal to the in psychiatry. A IN PSYCHIATRY and of and and for and help for mental disorders of all people with mental disorders do not the of mental health is among the many that people from to be in in to or and for mental disorder of is in the public's to for mental health services. to for mental health or has been public held in of the public a to for for with mental such as schizophrenia and than for conditions such as and the public to support for its support the that or would be In the of the to for mental illness is to be The public for mental disorders that for There is no or single to the with mental illness. was to with increased knowledge of mental illness, but the in some ways over the years of mental illness by to knowledge be to public is to that negative mental illness can be by on the and mental to of public education and with persons with mental illness and societal way to is to find causes and effective for mental disorders. this to be of and to are of mental disorders for which has The of an infectious and of led to the of when was to a and with was the was in the developed world. with had been in mental in the before its was no one has the of public these conditions over the and of this disease of its these also a more that the mental health field was when causes and were As were each was from the mental health field to medical For over of was moved to and in and over mental disorders was moved to The of this to is that mental health field over the years the for mental disorders was This the mental health field to by their medical that psychiatry was not part of and that psychiatric practice on and that for disorders them or the mental disorders not only but be by to mental health care only those conditions causes or To point this is not to that in mental health should be should be and The here is to some of the of the the general health and mental health that will continue to effective for mental disorders to be an effective people that mental disorders are not the of or will but are that are to much of the negative to to to be developed and science has much to to the and of As a in public should People should to should more to its most they should more to the that are the of this mental health and mental illness are part of the of health and they are a for all to would be the of the to who to mental illness regardless of from the of has been a in the success of on and AND MENTAL and medical profession have been in in the media. psychiatry and psychiatrists have not been so than the profession has been by media. illness has been the for and which the in the minds of the public mental illness and the the old some of the have psychiatry in extremely Psychiatrists are as who and for the most are not in their of mental illness. as as if is not in the minds of The is not in its of psychiatry and psychiatrists. I an by the which in the on the the no longer as a the Indian Psychiatric to do of that and it a measure of the of the profession of psychiatry in if you to a This of will the most from of psychiatric have been some of mental illness, the and both of which have been into the It is to that these have been well and psychiatrists are in a of will well for the mental health profession and for psychiatrists as a There are no to tackle this It is for all of as psychiatrists, to a to this It is our responsibility to more in the mental illness. For we should no as the of this can be of you must have seen in the and for public health causes you seen psychiatry in which I think of a when mental illness and the impact that will have on the common I feel that is a and we in are some to that I all members of to the and come more with a and the psychiatry and do all that you can to the image of psychiatry, which is for the public to embrace our IN PSYCHIATRY In this I would briefly some of the success in the field of mental The that come to my mind are the by the psychiatrists in the of the The has a lot of for psychiatry and psychiatrists. This is significant as this of will a long way in making the public more and in psychiatry. The by psychiatrists during the and and the so called in the Indian of and is a in point. a long way in the with the policy and the public I also the of and that is on in the and I also the of all the psychiatrists who have in the community mental illness and to the PSYCHIATRY IN must a with a as its more than psychiatry at the of a of has such a of as psychiatry This of both and is our and we must not up one for the of the other. health must more for Indian and psychiatry do not develop in a but they develop in a social psychiatric of and and to are all on This is not a very for a with its no has the of the and the of mental the way we have in we continue to concepts and these are in our We to on these and a truly to mental from such an will more with ground in of is its and psychological well being of the community for a and of the and we as mental health should that MENTAL I of this has a to a and an which to an of and family community and care or or in the that of mental health care with primary health care into the and of mental illness and into the of and effective and overcome the with mental illness public and Health to effective must be the for people with mental illness as for medical to mental health care should be across including the and to be with and should be to and to an of psychiatrists, to the current and needs of the population I psychiatry as my profession with a lot of and I am very happy I do feel to the way in which psychiatrists are in the society A day should come when we should be to that am a and in are psychiatrists and are psychiatry. This will if we to offer solutions to a wide range of personal, family and pressing social in and and the of in some of our role in We should make the that their health the to their should be on long solutions for the population than at a of only those who are extremely and We should make the community what we are is what our minds are the which the To this the with a the is a the mind is so to it is that we it to the is the medical profession to the with such emphasis on the In this who the of by in the is by and has to a to at the of the mind and all that it has I a day not in when people make appointments for general health check We to be for the mental health needs of the community and not only the for In these of I would to the the that you to see in the we play our role as psychiatrists, I a when psychiatry in general and psychiatrists in would their place and a household word. My to all of you is that each one of you needs to in this of a household one and all IPS.

Armando Arredondo, Emanuel Orozco, Esteban de Icaza

OBJECTIVE: The main objective was to identify trends and evidence on health financing after health care decentralization. STUDY DESIGN: Evaluative research with a before-after design integrating qualitative and quantitative analysis. Taking into account feasibility, political and technical criteria, three Latin American countries were selected as study populations: Mexico, Nicaragua and Peru. DATA SOURCES: The methodology had two main phases. In the first phase, the study referred to secondary sources of data and documents to obtain information about the following variables: type of decentralization implemented, source of finance, funds of financing, providers, final use of resources and mechanisms for resource allocation. In the second phase, the study referred to primary data collected in a survey of key personnel from the health sectors of each country. FINDINGS: The trends and evidence reported in all five financing indicators may identify major weaknesses and strengths in health financing. CONCLUSIONS: Weaknesses: a lack of human resources trained in health economics who can implement changes, a lack of financial resource independence between the local and central levels, the negative behavior of the main macro-economic variables, and the difficulty in developing new financing alternatives. Strengths: the sharing between the central level and local levels of responsibility for financing health services, the implementation of new organizational structures for the follow-up of financial changes at the local level, the development and implementation of new financial allocation mechanisms taking as a basis the efficiency and equity principles, new technique of a per-capita adjustment factor corrected at the local health needs, and the increase of financing contributions from households and local levels of government.

Armando Arredondo, Irene Parada

OBJECTIVE: The results of an evaluative longitudinal study, which identified the effects of health care decentralization on health financing in Mexico, Nicaragua and Peru are presented in this article. METHODS: The methodology had two main phases. In the first, secondary sources of data and documents were analyzed with the following variables: type of decentralization implemented, source of financing, funds for financing, providers, final use of resources, mechanisms for resource allocation. In the second phase, primary data were collected by a survey of key personnel in the health sector. RESULTS: Results of the comparative analysis are presented, showing the changes implemented in the three countries, as well as the strengths and weaknesses of each country in matters of financing and decentralization. CONCLUSIONS: The main financing changes implemented and quantitative trends with respect to the five financing indicators are presented as a methodological tool to implement corrections and adjustments in health financing.

Walter J. Jones

From an international perspective, U.S. health policymaking is quite distinctive. Other economically advanced nations face the same problems of cost, access, and quality, but none use policymaking structures that resemble ours. To a great extent, the same American “exceptionalism” is evident when analyzing the values that motivate health policymakers. The American people have never truly resolved for themselves the fundamental question that must be considered when directing the objectives of health policies: Is American healthcare a business, a public service, or something in between? Most other wealthy nations have concluded that healthcare is primarily a public function, and have established systems with objectives directly or indirectly set by government and primarily paid for with tax dollars. In contrast, the United States maintains a mixed public-private sector system with no centralized policymaking or financing organization.1 Certainly, the resulting decentralization and flexibility in American health services has its advantages. On the other hand, many important financing and service questions are never resolved, since their solution would require ultimate priority setting by policymakers and, more broadly, by the American people. Irresolution as to whether healthcare is first and foremost a business or a public service is at the heart of major contemporary public policy problems. The following are two important examples. Academic health centers (AMCs) and the public goods of health education and research. Since the beginning of the 1980s, federal policymakers have generally encouraged competition between health providers, with the reasonable expectation that such competition would limit cost increases, encourage the development of a customer (or at least payer) service orientation, and lead to innovations in service delivery. This approach has had positive results in terms of reduced cost inflation and innovative service delivery methods. However, most health industry reform and innovation relies on certain “public goods” being present in the system as a whole. Just as all of us assume that we will have clean air and water as we live and do business, healthcare providers, when engaging in marketplace competition, assume that adequate numbers of trained health professionals will be available to staff their organizations. They also assume that a steady stream of technological advances will make state-of-the-art health services possible. Finally, since society seems to feel that all of its citizens deserve at least a survival level of health services, they have further assumed that other institutions, primarily public facilities, will provide services to those who cannot pay for them. But nongovernmental healthcare providers are not willing to directly pay much for these “public goods.” By and large, they simply expect that public institutions, particularly academic medical centers (AMCs), will provide these goods while they engage in the more lucrative business of market-based health services. However, AMCs have not been provided immunity from the cost pressures resulting from treating healthcare like a “business.” They are told to shape up and compete like other health providers in the marketplace, but they are also told to provide educated health professionals and research products to their competitors, and to take nonpaying patients off their competitors' hands. The funding that they need to do this cannot come primarily from their patients (customers), since a high proportion of them are uninsured and pay little or nothing for the health services. Other traditional sources of funding, including state appropriations, a “disproportionate share” from Medicare, and cost-shifting of uninsured care services to paying patients, are rapidly drying up. Employers paying for the care of their workforce will not pay for others who have no money, nor will they pay more for services because those providing them are also doing research and educating future health professionals. Therefore, most AMCs simply cannot compete in the marketplace. Even if the centers were run at peak efficiency (which they are not), they could not provide services at the prices offered by non-AMC hospitals, clinics, and physician group practices. Are AMCs businesses? If so, they probably cannot succeed as currently structured, because they are forced to provide unprofitable products like education, research, and “free” care. Are AMCs public services, providing unreimbursed health services, education, and research for the healthcare sector as a whole? If so, they cannot properly do their job if they are forced to compete with non-AMCs for survival, because they cannot meet marketplace prices without seriously damaging their educational, research, or service outreach missions. Medicare—A public institution to guarantee health equity for seniors, or a funding mechanism to provide marketplace choice for seniors? Viewed in terms of its original objectives—to reduce medical poverty for seniors—Medicare has been a major public policy success. In some ways it has been too successful. The open-ended commitment to services, along with the “graying of America” and healthcare technological advances, have led to major financing problems for Medicare. Quite properly, the federal government has begun to tighten Medicare's financial spigots. European nations, with publicly run and financed health systems, face the same problems, and can respond quite decisively. To elderly pensioners and their health service providers, European policymakers usually claim that they are doing as well as they can, and will provide more funding in the future, but must balance current public needs with available resources. No European would argue that this is ideal, but most would agree that public policymakers do have to make difficult tradeoffs.2 In the United States, however, healthcare providers are not charged with serving the national interest in carefully providing a public good. Rather, they are called upon to meet consumer demands in an evolving marketplace. Medicare is not a national health service. It is a complex system of writing and disbursing checks to providers for specified services to defined clients. On the one hand, the program is supposed to provide healthcare equality to seniors, so it has nationally defined benefits and prohibits balance billing. On the other hand, it does not take responsibility for providing the services themselves—that would be interfering with the marketplace. In fact, in recent years, Medicare Part C has been created to enhance the role of consumer choice in the marketplace. As Medicare has developed, this conflict—fulfilling a national mandate through the “business” of healthcare—has resulted in the creation of incredibly complicated payment guidelines. Providers have to devote large portions of their resources not to health services, but to Medicare “compliance.” They are also subject to progressively expansive federal mandates (such as the adoption of computerized patient records suitable for uploading into national databases for research purposes) that force them to restructure their organizations. Their consumers now supposedly have greater flexibility and choice, but that choice cannot entail paying more for any particular service; healthcare providers must follow detailed reimbursement schedules. At least, one supposes, U.S. providers can be thankful that they are in the “private” sector, unlike their unfortunate European counterparts, who have lost their independence to “big government” and “socialized medicine.” Is Medicare supposed to be a public commitment to healthcare equality for seniors? Then, as currently designed, it cannot guarantee equal services, since it lacks the direct controls over service provision found in (say) the National Health Service in the United Kingdom. Or is Medicare supposed to be a generous subsidy to the elderly so that they can obtain their healthcare in the marketplace? Then it is extremely inefficient, for it gives the money to the providers (along with damaging and cumbersome regulatory oversight) rather than empowering the senior “customers” to buy their own services (at whatever prices they negotiate) through direct cash payments or vouchers. The United States is now muddling through the unresolved conflict of health services as a business or as a public service. If AMCs are threatened with bankruptcy because of their divided missions, national and state governments will respond with arbitrary relaxation of the equally arbitrary cuts in disproportionate share, or provide some additional health research funding and student loans, which may tide the AMCs over until the next crisis. If Medicare rules (to preserve public control) lead to numerous federal indictments for reimbursement fraud (the providers trying to eke out every possible payment dollar to keep afloat in the competitive market), the larger providers will complain, and the federal government will relax its enforcement efforts, until another highly publicized crackdown is launched, and the cycle begins again. Perhaps the United States, with its wealth, will be able to keep muddling through indefinitely. If we keep slathering money around the healthcare system, taking it away here and putting it back there, perhaps we can keep believing that our healthcare system is both a business and a public service at the same time. We can avoid making fundamental decisions about the nature of healthcare. As long as we are willing to keep our wallets wide open, that is, and are not too fussy about the resulting disorder that keeps our healthcare managers in, as the Chinese would say, “interesting times.”