Kerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201Health Promotion in an Age of Normative Equity and Rampant Inequality675682324310.15171/ijhpm.2016.95ENRonaldLabontéCanada Research Chair, Globalization and Health Equity, Faculty of Medicine, School of Epidemiology, Public Health and Preventive Medicine,
University of Ottawa, Ottawa, ON, Canada0000-0002-0615-740XJournal Article20160701The world was different when the <em>Ottawa Charter for Health Promotion </em>was released 30 years ago. Concerns over the environment and what we now call the ‘social determinants of health’ were prominent in 1986. But the acceleration of ecological crises and economic inequalities since then, in a more complex and multi-polar world, pose dramatically new challenges for those committed to the original vision of the Charter. Can the 2015 Sustainable Development Goals (SDGs), agreed to by all the world’s governments, offer a new advocacy and programmatic platform for a renewal of health promotion’s founding ethos? Critiqued from both the right and the left for, respectively, their aspirational idealism and lack of political analysis, the SDGs are an imperfect but still compelling normative statement of how much of the world thinks the world should look like. Many of the goals and targets provide signals for what we need to achieve, even if there remains a critical lacuna in articulating how this is to be done. The fundamental flaw in the SDGs is the implicit assumption that the same economic system, and its still-present neoliberal governing rules, that have created or accelerated our present era of rampaging inequality and environmental peril can somehow be harnessed to engineer the reverse. This flaw is not irrevocable, however, if health promoters – practitioners, researchers, advocates – focus their efforts on a few key SDGs that, with some additional critique, form a basic blueprint for a system of national and global regulation of capitalism (or even its transformation) that is desperately needed for social and ecological survival into the 22nd century. Whether or not these efforts succeed is a future unknown; but that the efforts are made is a present urgency.https://www.ijhpm.com/article_3243_f3a93d9bfe33c097fd463834e132cf0c.pdfKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201The Legal Strength of International Health Instruments - What It Brings to Global Health Governance?683685327010.15171/ijhpm.2016.122ENHaikNikogosianWorld Health Organization Regional Office for Europe, Copenhagen, DenmarkIlonaKickbuschGlobal Health Centre, Graduate Institute for International and Development
Studies, Geneva, SwitzerlandJournal Article20160707Public health instruments have been under constant development and renewal for decades. International legal instruments, with their binding character and strength, have a special place in this development. The start of the 21st century saw, in particular, the birth of the first World Health Organization (WHO)-era health treaties – the WHO Framework Convention on Tobacco Control (WHO FCTC) and its first Protocol. The authors analyze the potential impact of these instruments on global health governance and public health, beyond the traditional view of their impact on tobacco control. Overall, the very fact that globally binding treaties in modern-era health were feasible has accelerated the debate and expectations for an expanded role of international legal regimes in public health. The impact of treaties has also been notable in global health architecture as the novel instruments required novel institutions to govern their implementation. The legal power of the WHO FCTC has enabled rapid adoption of further instruments to promote its implementation, thus, enhancing the international instrumentarium for health, and it has also prompted stronger role for national legislation on health. Notably, the Convention has elevated several traditionally challenging public health features to the level of international legal obligations. It has also revealed how the legal power of the international health instrument can be utilized in safeguarding the interests of health in the face of competing agendas and legal disputes at both the domestic and international levels. Lastly, the legal power of health instruments is associated with their potential impact not only on health but also beyond; the recently adopted Protocol to Eliminate Illicit Trade in Tobacco Products may best exemplify this matter. The first treaty experiences of the 21st century may provide important lessons for the role of legal instruments in addressing the unfolding challenges in global health.https://www.ijhpm.com/article_3270_dfc7f91e0d1091e8c16da06b812ae436.pdfKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201Cost-Sharing Rates Increase During Deep Recession: Preliminary Data From Greece687692320910.15171/ijhpm.2016.62ENAthanasiosGouvalasPharmaceutical Association of Fthiotida Prefecture, Lamia, GreeceMichaelIgoumenidisTechnological Educational Institute of Western Greece, Faculty of Nursing,
Patra, GreeceMamasTheodorouOpen University of Cyprus, Latsia, CyprusKostasAthanasakisNational School of
Public Health, Open University of Cyprus, Latsia, CyprusJournal Article20150608Background <br />Measures taken over the past four years in Greece to reduce pharmaceutical expenditure have led to significant price reductions for medicines, but have also changed patient cost-sharing rates for prescription drugs. This study attempts to capture the resulting increase in patients’ out-of-pocket (OOP) expenses for prescription drugs during the 2011-2014 period. <br /> <br />Methods <br />The authors conducted a retrospective review of financial data derived from 39 883 prescriptions, dispensed at three randomly chosen pharmacies located in Lamia, central Greece. <br /> <br />Results <br />The study recorded an average contribution rate per prescription as follows: 11.28% for 2011 (95% CI: 10.76-11.80), 14.10% for 2012, 19.97% for 2013, and 29.08% for 2014. Correspondingly, the mean patient charge per prescription for 2011 was €6.58 (95% CI: 6.22-6.94), €8.28 for 2012, €8.35 for 2013, and €10.87 for 2014. During the 2011-2014 period, mean percentage rate of patient contribution increased by 157.75%, while average patient charge per prescription in current prices increased by 65.22%. The use of a newly introduced internal reference price (IRP) system increased the level of prescription charge at a rate of 2.41% for 2012 (100% surcharge on patients), 26.24% for 2013 (49.95% on patients and 50.04% on the appropriate health insurance funds), and 47.72% for 2014 (85.06% on patients and 14.94% on funds). <br /> <br />Conclusion <br />Increased cost-sharing rates for prescription drugs can reduce public pharmaceutical expenditure, but international experience shows that rising OOP expenses can compromise patients’ ability to pay, particularly when it comes to chronic diseases and vulnerable populations. Various suggestions could be effective in refining the costsharing approach by giving greater consideration to chronic patients, and to the poor and elderly.https://www.ijhpm.com/article_3209_638f107287eca045869d93508f2a0204.pdfKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201Determinants of Healthcare Utilisation and Out-of-Pocket Payments in the Context of Free Public Primary Healthcare in Zambia693703321310.15171/ijhpm.2016.65ENFelixMasiyeDepartment of Economics, University of Zambia, Lusaka, ZambiaOliverKaongaDepartment of Economics, University of Zambia, Lusaka, ZambiaJournal Article20150602Background <br />Access to appropriate and affordable healthcare is needed to achieve better health outcomes in Africa. However, access to healthcare remains low, especially among the poor. In Zambia, poor access exists despite the policy by the government to remove user fees in all primary healthcare facilities in the public sector. The paper has two main objectives: (i) to examine the factors associated with healthcare choices among sick people, and (ii) to assess the determinants of the magnitude of out-of-pocket (OOP) payments related to a visit to a health provider. <br /> <br />Methods <br />This paper employs a multilevel multinomial logistic regression to model the determinants of an individual’s choice of healthcare options following an illness. Further, the study analyses the drivers of the magnitude of OOP expenditure related to a visit to a health provider using a two-part generalised linear model. The analysis is based on a nationally representative healthcare utilisation and expenditure survey that was conducted in 2014. <br /> <br />Results <br />Household per capita consumption expenditure is significantly associated with increased odds of seeking formal care (odds ratio [OR] = 1.12, P = .000). Living in a household in which the head has a higher level of education is associated with increased odds of seeking formal healthcare (OR = 1.54, P = .000) and (OR = 1.55, P = .01), for secondary and tertiary education, respectively. Rural residence is associated with reduced odds of seeking formal care (OR = 0.706, P = .002). The magnitude of OOP expenditure during a visit is significantly dependent on household economic wellbeing, distance from a health facility, among other factors. A 10% increase in per capita consumption expenditure was associated with a 0.2% increase in OOP health expenditure while every kilometre travelled was associated with a K0.51 increase in OOP health expenditure. <br /> <br />Conclusion <br />Despite the removal of user fees on public primary healthcare in Zambia, access to healthcare is highly dependent on an individual’s socio-economic status, illness type and region of residence. These findings also suggest that the benefits of free public healthcare may not reach the poorest proportionately, which raise implications for increasing access in Zambia and other countries in sub-Saharan Africa.https://www.ijhpm.com/article_3213_38cdc238df8674b79e5755ad6863242f.pdfKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201Analysing the Stewardship Function in Botswana’s Health System: Reflecting on the Past, Looking to the Future705713321410.15171/ijhpm.2016.67ENOnalennaSeitio-KgokgweMinistry of Health, Gaborone, BotswanaInstitute of Development
Management, Gaborone, BotswanaRobin DCGauldDepartment of Preventive and Social
Medicine, University of Otago, Dunedin, New Zealand0000-0001-5401-1192Philip C.HillDepartment of Preventive and Social
Medicine, University of Otago, Dunedin, New ZealandPaulineBarnettSchool of Health
Sciences, University of Canterbury, Christchurch, New ZealandJournal Article20150807Background <br />In many parts of the world, ongoing deficiencies in health systems compromise the delivery of health interventions. The World Health Organization (WHO) identified four functions that health systems need to perform to achieve their goals: Efforts to strengthen health systems focus on the way these functions are carried out. While a number of studies on health systems functions have been conducted, the stewardship function has received limited attention. In this article, we evaluate the extent to which the Botswana Ministry of Health (MoH) undertook its stewardship role. <br /> <br />Methods <br />We used the WHO Health Systems Performance Assessment Frame (HSPAF) to guide analysis of the stewardship function of the Botswana’s MoH focusing on formulation of national health policies, exerting influence through health regulation, and coalition building. Data were abstracted from published and unpublished documents. We interviewed 54 key informants comprising staff of the MoH (N = 40) and stakeholder organizations (N = 14). Data from documents was analyzed through content analysis. Interviews were transcribed and analyzed through thematic analysis. <br /> <br />Results <br />A lack of capacity for health policy development was identified. Significant policy gaps existed in some areas. Challenges were reported in policy implementation. While the MoH made efforts in developing various statutes that regulated different aspects of the health system, some gaps existed in the regulatory framework. Poor enforcement of legislation was a challenge. Although the MoH had a high number of stakeholders, the mechanisms for stakeholder engagement in the planning processes were weak. <br /> <br />Conclusion <br />Problems in the exercise of the stewardship function posed challenges in ensuring accountability and limited the health system’s ability to benefit from its stakeholders. Ongoing efforts to establish a District Health System under control of the MoH, attempts to improve service delivery at a national level and political will to strengthen public-private engagement mechanisms are some of the prospects that can improve the MoH’s stewardship function.https://www.ijhpm.com/article_3214_884f1b8504733e09bee5f3839a363a6d.pdfKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201Outcomes and Impact of Training and Development in Health Management and Leadership in Relation to Competence in Role: A Mixed-Methods Systematic Review Protocol715720328610.15171/ijhpm.2016.138ENReuben OlugbengaAyelekeHealth Systems Section, School of Population Health, University of Auckland,
Auckland, New ZealandNicolaNorthHealth Systems Section, School of Population Health, University of Auckland,
Auckland, New ZealandKatharine AnnWallisDepartment of General Practice and Primary Health
Care, School of Population Health, University of Auckland, Auckland, New
ZealandZhanmingLiangDepartment of Public Health, School of Psychology and Public
Health, La Trobe University, Melbourne, AustraliaAnnetteDunhamHealth Systems Section, School of Population Health, University of Auckland,
Auckland, New ZealandJournal Article20160321Background <br />The need for competence training and development in health management and leadership workforces has been emphasised. However, evidence of the outcomes and impact of such training and development has not been systematically assessed. The aim of this review is to synthesise the available evidence of the outcomes and impact of training and development in relation to the competence of health management and leadership workforces. This is with a view to enhancing the development of evidence-informed programmes to improve competence. <br /> <br />Methods and Analysis <br />A systematic review will be undertaken using a mixed-methods research synthesis to identify, assess and synthesise relevant empirical studies. We will search relevant electronic databases and other sources for eligible studies. The eligibility of studies for inclusion will be assessed independently by two review authors. Similarly, the methodological quality of the included studies will be assessed independently by two review authors using appropriate validated instruments. Data from qualitative studies will be synthesised using thematic analysis. For quantitative studies, appropriate effect size estimate will be calculated for each of the interventions. Where studies are sufficiently similar, their findings will be combined in meta-analyses or meta-syntheses. Findings from quantitative syntheses will be converted into textual descriptions (qualitative themes) using Bayesian method. Textual descriptions and results of the initial qualitative syntheses that are mutually compatible will be combined in mixed-methods syntheses. <br /> <br />Discussion <br />The outcome of data collection and analysis will lead, first, to a descriptive account of training and development programmes used to improve the competence of health management and leadership workforces and the acceptability of such programmes to participants. Secondly, the outcomes and impact of such programmes in relation to participants’ competence as well as individual and organisational performance will be identified. If possible, the relationship between health contexts and the interventions required to improve management and leadership competence will be examined.https://www.ijhpm.com/article_3286_fbfdf726c7ae4c80f643faff27a62beb.pdfKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201New Provider Models for Sweden and Spain: Public, Private or Non-profit?; Comment on “Governance, Government, and the Search for New Provider Models”721723323310.15171/ijhpm.2016.87ENPatrick P.T.JeurissenRadboud Institute for Health Sciences, Celsus Academy for Sustainable
Healthcare, and Scientific Institute for Quality of Healthcare, Radboud University
Medical Center, Nijmegen, The Netherlands0000-0002-4198-2448HansMaarseMaastricht University, Maastricht,
The NetherlandsJournal Article20160511Sweden and Spain experiment with different provider models to reform healthcare provision. Both models have in common that they extend the role of the for-profit sector in healthcare. As the analysis of Saltman and Duran demonstrates, privatisation is an ambiguous and contested strategy that is used for quite different purposes. In our comment, we emphasize that their analysis leaves questions open on the consequences of privatisation for the performance of healthcare and the role of the public sector in healthcare provision. Furthermore, we briefly address the absence of the option of healthcare provision by not-for-profit providers in the privatisation strategy of Sweden and Spain.https://www.ijhpm.com/article_3233_f03268389ec5796af85fb4109e5e572e.pdfKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201Is the Role of Physicians Really Evolving Due to Non-physician Clinicians Predominance in Staff Makeup in Sub-Saharan African Health Systems?; Comment on “Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians”725727323410.15171/ijhpm.2016.80ENMohsin M.SidatFaculty of Medicine, University Eduardo Mondlane, Maputo, MozambiqueJournal Article20160503Health workforce shortages in Sub-Saharan Africa are widely recognized, particularly of physicians, leading the training and deployment of Non-physician clinicians (NPCs). The paper by Eyal et al provides interesting and legitimate viewpoints on evolving role of physicians in context of decisive increase of NPCss in Sub-Saharan Africa. Certainly, in short or mid-term, NPCs will continue to be a proxy solution and a valuable alternative to overcome physicians’ shortages in sub-Saharan Africa. Indeed, NPCs have an important role at primary healthcare (PHC) level. Physicians at PHC level can certainly have all different roles that were suggested by Eyal et al, including those not directly related to healthcare provision. However, at secondary and higher levels of healthcare, physicians would assume other roles that are mainly related to patient clinical care. Thus, attempting to generalize the role of physicians without taking into account the context where they will work would be not entirely appropriate. It is true that often physicians start the professional carriers at PHC level and progress to other levels of healthcare particularly after clinical post-graduation training. Nevertheless, the training programs offered by medical institutions in sub-Saharan Africa need to be periodically reviewed and take into account professional and occupational roles physicians would take in context of evolving health systems in sub-Saharan Africa.https://www.ijhpm.com/article_3234_a20a7d3e769fff72362f9b754e69a2af.pdfKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201Decentralisation – A Portmanteau Concept That Promises Much but Fails to Deliver?; Comment on “Decentralisation of Health Services in Fiji: A Decision Space Analysis”729732323510.15171/ijhpm.2016.88ENStephenPeckhamCentre for Health Services Studies, University of Kent, Canterbury, UKDepartment of Health Services Research and Policy, London School of
Hygiene and Tropical Medicine, London, UK0000-0002-7002-2614Journal Article20160423Decentralisation has been described as an empty concept that lacks clarity. Yet there is an enduring interest in the process of decentralisation within health systems and public services more generally. Many claims about the benefits of decentralisation are not supported by evidence. It may be useful as an organising framework for analysis of health systems but in this context it lacks conceptual clarity and particularly often ignores level context issues given the focus on a principal-agent/vertical centre/local axis or other aspects of limits on autonomy such as standards for professional practice. Both these aspects are relevant in discussing the establishment of “decentralised” health centres in Fiji. In the end decentralisation may be nothing more than a useful descriptive label that can be used in an increasingly wide range of ways but actually have little meaning in practice as an analytical concept.https://www.ijhpm.com/article_3235_d9909956f72ea39e75bceb09374bdbdb.pdfKerman University of Medical SciencesInternational Journal of Health Policy and Management2322-593951220161201Provider Governance; A Basic Blackbox Seldom Looked at Properly: A Response to Recent Commentaries733734327610.15171/ijhpm.2016.128ENRichard B.SaltmanDepartment of Health Policy and Management, Rollins School of Public Health,
Emory University, Atlanta, GA, USAAntonioDuranAllDMHealth, Seville, Spain0000-0002-8765-1468Journal Article20160908https://www.ijhpm.com/article_3276_52a7467a4666cd3ed95fd9d93cb460f5.pdf