International Journal of Health Policy and Management
Volume:4 Issue: 9, Sep 2015

The role of competition in healthcare is much debated. Despite a wealth of international experience in relation to competition, evidence is mixed and contested and the debate about the potential role for competition is often polarised. This paper considers briefly some of the reasons for this, focusing on what is meant by “competition in healthcare” and why it is more valuable to think about the circumstances in which competition is more and less likely to be a good tool to achieve benefits, rather than whether or not it is “good” or “bad,” per se.

In modern decentralised health systems, district and local managers are increasingly responsible for financing, managing, and delivering healthcare. However, their lack of adequate skills and competencies are a critical barrier to improved performance of health systems. Given the financial and human resource, constraints of relying on traditional face-to-face training to upskill a large and dispersed number of health managers, governments, and donors must look to exploit advances in the education sector. In recent years, education providers around the world have been experimenting with blended learning; that is, amalgamating traditional face-to-face education with web-based learning to reduce costs and enrol larger numbers of students. Access to improved information and communication technology (ICT) has been the major catalyst for such pedagogical innovations. We argue that with many developing countries already improving their ICT systems, the question is not whether but how to employ technology to facilitate the continuous professional development of district and local health managers in decentralised settings.

National oral health policy was conscripted by the Indian Dental Association (IDA) in 1986 and was accepted as an integral part of National Health Policy (NHP) by the Central Council of Health and Family Welfare in one of its conferences in the year 1995. Objectives of this paper were to find out the efforts made or going on towards its execution, its current status and recent oral health-related affairs or programs, if any. Literature search was done using the institutional library, web-based search engines like ‘Google’ and ‘PubMed’ and also by cross referencing. It yielded 108 articles, of which 50 were excluded as they were not pertinent to the topic. Twenty-four were of global perspective rather than Indian and hence were not taken into account and finally 34 articles were considered for analyses. Documents related to central and state governments of India were also considered. All the articles considered for analysis were published within the past 10 years with gradual increase in number which depicts the researchers’ increasing focus towards oral health policy. Criticisms, suggestions and recommendations regarding national oral health programs, dental manpower issues, geriatric dentistry, public health dentistry, dental insurance, oral health inequality, and public-private partnerships have taken major occupancies in the articles. Proposals like “model for infant and child oral health promotion” and “oral health policy phase 1 for Karnataka” were among the initiatives towards national oral health policy. The need for implementation of the drafted oral health policy with modification that suits the rapidly changing oral health system of this country is inevitable.

As one of the most important components of harm reduction strategy for high-risk groups, following the HIV epidemics, Methadone Maintenance Treatment (MMT) has been initiated in prisoners since 2003. In this paper, we aimed to assess the advantages and shortcomings of the MMT program from the perspective of people who were involved with the delivery of prison healthcare in Iran. On the basis of grounded theory and through conducting 14 Focus Group Discussions (FGDs), 7 FGDs among physicians, consultants, experts, and 7 FGDs among directors and managers of prisons (n= 140) have been performed. The respondents were asked about positive and negative elements of the MMT program in Iranian prisons. This study included a total of 48 themes, of which 22 themes were related to advantages and the other 26 were about shortcomings of MMT programs in the prisons. According to participants’ views “reduction of illegal drug use and high-risk injection”, “reduction of potentially high-risk behaviors” and “making positive attitudes” were the main advantages of MMT in prisons, while issues such as “inaccurate implementation”, “lack of skilled manpower” and “poor care after release from prison” were among the main shortcomings of MMT program. MMT program in Iran’s prisons has achieved remarkable success in the field of harm reduction, but to obtain much more significant results, its shortcomings and weaknesses must be also taken into account by policy-makers.

People Living with HIV (PLHIV) are highly stigmatized and consequently hard-to-access by researchers and importantly, public health outreach in Iran, possibly due to the existing socio-cultural situation in this country. The present study aimed to evaluate the sexual and reproductive health needs of PLHIV in Tehran, the capital of Iran. As a mixed-method descriptive study, this project was conducted in 2012 in Tehran, Iran. In this study, we evaluated and discussed socio-demographic characteristics, family and social support, sexual behaviors, fertility desires and needs, PMTCT services, contraceptive methods, unintended pregnancy and safe abortion, and Pap smear tests among 400 participants referring to the behavioral disorders consulting centers. Of the sample 240 (60%) were male and 160 (40%) were female. About 50% of women and 40% of men were 25-34 years old. More than 60% of men and 96% of women were married, while more than 50% of the participants had HIV-positive spouses at the time of study. According to the results, fertility desire was observed among more than 30% of female and 40% of male participants. Results of the in-depth interviews indicate that the participants are not satisfied with most of the existing services offered to address their sexual and reproductive health needs. Despite the availability of services, most of sexual and reproductive health needs of the PLHIV are overlooked by the health system in Iran. Paying attention to sexual and reproductive health needs of PLHIV in Iran not only protects their right to live long and healthy lives, but also may prevent the transmission of HIV from the patients to others within the community.

The lack of effective use of research evidence in policy-making is a major challenge in most low- and middle-income countries (LMICs). There is need to package research data into effective policy tools that will help policy-makers to make evidence-informed policy regarding infectious diseases of poverty (IDP). The objective of this study was to assess the usefulness of training workshops and mentoring to enhance the capacity of Nigerian health policy-makers to develop evidence-informed policy brief on the control of IDP. A modified “before and after” intervention study design was used in which outcomes were measured on the target participants both before the intervention is implemented and after. A 4-point Likert scale according to the degree of adequacy; 1 = “grossly inadequate,” 4 = “very adequate” was employed. The main parameter measured was participants’ perceptions of their own knowledge/understanding. This study was conducted at subnational level and the participants were the career health policy-makers drawn from Ebonyi State in the South-Eastern Nigeria. A oneday evidence-to-policy workshop was organized to enhance the participants’ capacity to develop evidence-informed policy brief on IDP in Ebonyi State. Topics covered included collaborative initiative; preparation and use of policy briefs; policy dialogue; ethics in health policy-making; and health policy and politics. The preworkshop mean of knowledge and capacity ranged from 2.49-3.03, while the postworkshop mean ranged from 3.42–3.78 on 4-point scale. The percentage increase in mean of knowledge and capacity at the end of the workshop ranged from 20.10%–45%. Participants were divided into 3 IDP mentorship groups (malaria, schistosomiasis, lymphatic filariasis [LF]) and were mentored to identify potential policy options/recommendations for control of the diseases for the policy briefs. These policy options were subjected to research evidence synthesis by each group to identify the options that have the support of research evidence (mostly systematic reviews) from PubMed, Cochrane database and Google Scholar. After the evidence synthesis, five policy options were selected out of 13 for malaria, 3 out of 10 for schistosomiasis and 5 out of 11 for LF. The outcome suggests that an evidence-to-policy capacity enhancement workshop combined with a mentorship programme can improve policy-makers’ capacity for evidence-informed policy-making (EIP).

Professor Naoki Ikegami’s “Fee-for-service payment – an evil practice that must be stamped out” summarizes many of the failings of alternatives to fee-for-service (FFS) payment systems. His article also offers several suggestions for improving FFS systems. However, even powerful arguments against many of the alternatives to FFS, does not make a convincing argument for FFS systems. In addition, there are significant misunderstandings in Professor Ikegami’s presentation of and use of United States payment methods, the role of private vs. public insurance systems, and the increasing role of “accountable care organizations.”

Compassion is a complex process that is innate, determined in part by individual traits, and modulated by a myriad of conscious and unconscious factors, immediate context, social structures and expectations, and organizational “culture.” Compassion is an ethical foundation of healthcare and a widely shared value; it is not an optional luxury in the healing process. While the interrelations between individual motivation and social structure are complex, we can choose to act individually and collectively to remove barriers to the innate compassion that most healthcare professionals bring to their work. Doing so will reduce professional burnout, improve the well-being of the healthcare workforce, and facilitate our efforts to achieve the triple aim of improving patients’ experiences of care and health while lowering costs.

The concept of quaternary prevention (P4) refers to the idea that medicine has acquired the ability to damage through the proper exercise. Family medicine or general practice has the duty of recovering the ethical values and the exercise of a profession with the doctor-patient relationship serving to people’s humanity. In the fourth Congress of Family and Community Medicine, held in Montevideo (Uruguay) last March 18-21, 2015, it was established the Working Group P4 WONCA-CIMF with communication tools included as constitutive part of P4. It was also remarked that we should be wary of attempts to denature the P4, diminishing its ethic value and limiting it to a reason for cost control.

The absence of compassion, argues the author, is not the cause of healthcare failures but rather a symptom of deeper systemic failures. The clinical encounter arouses strong emotions of anxiety, fear, and anger in patients which are often projected onto the clinicians. Attempts to protect clinicians through various bureaucratic devices and depersonalization of the patient, constitute as Menzies noted in her classic work, social defences, aimed at containing the anxieties of clinicians but ending up in reinforcing these anxieties. Instead of placing additional burdens on clinicians by bureaucratizing and benchmarking compassion, the author argues that proper emotional management and support is a precondition for a healthcare system that offers humane and effective treatment to patients and a humane working environment for those who work in it.

Despite fiscal stress, public confidence in the National Health Service (NHS) remains strong; privatisation has not hollowed out the service. But if long term challenges are to be overcome, pragmatism not rhetoric should be the guide.

The article takes its cue from models of quantitative research applied to complementary/alternative medicine (CAM) and pinpoints some innovative features in the case at issue (Portugal). It goes on to outline new research scenarios moving beyond the either biomedical or CAM framework.

How to instill compassion in a healthcare organization? In this article, I respond to Marianna Fotaki’s proposals in her piece, ‘Why and how is compassion necessary to provide good quality healthcare?’ by drawing on insights from organization studies. Following Fotaki, I argue that to instill targets and formal measures for assessing compassion would be problematic. I conclude by drawing on psychoanalytic and feminist theories to introduce alternatives, specifically proposing an approach that is grounded in a shared sense of a common, embodied precarity, which necessitates our commitment to preserving the conditions in which life might flourish.

Health reforms that emphasize public health and improvements in primary care can be cost-effective measures to achieve health improvements, especially in developing countries that face severe resource constraints. In their paper “Shanghai rising: health improvements as measured by avoidable mortality since 2000,” Gusmano et al suggest that Shanghai’s health policy-makers have been successful in reducing avoidable mortality among Shanghai’s 14.9 million (2010) registered residents through these policy measures. It is a plausible hypothesis, but the data the authors cite also would be compatible with alternative hypotheses, as the comparison they make with trends in amenable mortality-rate (AM) in large cities in other parts of the world suggests.

This comment on Professor Fotaki’s Editorial agrees with her arguments that training health professionals in more compassionate, caring and ethically sound care will have little value unless the system in which they work changes. It argues that for system change to occur, senior management, government members and civil servants themselves need training so that they learn to understand the effects that their policies have on health professionals. It argues that these people are complicit in the delivery of unethical care, because they impose requirements that contradict health professionals’ desire to deliver compassionate and ethical forms of care.

In health policy, magic bullet answers tend to have more appeal than incremental adjustments. Politicians faced with the daunting issues in healthcare are eager to embrace new ideas promoted by academics and think tanks. However, in implementation, intrinsic flaws in design, such as the difficulty of finding physicians willing to be at risk for the costs of care, tend to be ignored. Once launched, inconvenient data about cost savings and quality tend to be downplayed or ignored until intrinsic flaws become manifest,1 which would be the signal to embrace a new idea. Such is likely to be the fate of the latest fix-all from the United States: the Accountable Care Organizations (ACOs).