Strategic emphases for tropical diseases research: a TDR perspective

Setting priorities for health research is a difficult task, especially for the neglected diseases of the poor. A new approach to priority setting for tropical diseases research has been adopted by the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (known as the TDR). Priorities are defined on the basis of a comprehensive analysis of research needs and research opportunities for each of the ten major tropical diseases in the TDR portfolio. The resulting strategic emphases matrix reflects the priorities for tropical diseases research from the perspective of the TDR. Its purpose is not to impose global research priorities, but we believe the results could be useful to other organizations.

Prioritizing care is an essential nursing skill

It is a tough world in nursing practice these days and the key to surviving is getting your priorities right. Top of the priority list, of course, are the patient's problems; sorting out which problem to deal with first is critical to achieving the right outcomes for the patient.

Developing cataract surgery priority criteria: results from the Western Canada Waiting List Project

BACKGROUND

The Western Canada Waiting List Project (WCWL) is a federally funded partnership of 19 organizations, including medical associations, health authorities, ministries of health and research organizations, that was created to develop tools to assist in the management of waiting lists. The WCWL cataract surgery panel, one of five panels constituted under this project, developed and tested a set of standardized clinical criteria for prioritizing among patients awaiting cataract surgery.

METHODS

The cataract surgery panel was composed of seven academic and community ophthalmologists, two family physicians, an optometrist, a health care services researcher and a health information specialist. The panel met three times between October 1999 and June 2000. The priority criteria were applied to 563 patients in the four western provinces. Regression analysis was used to determine the set of criteria weights that collectively best predicted clinicians' overall ratings of urgency. Interrater and test-retest reliability were assessed, based on clinicians' ratings of videotaped interviews with six hypothetical patients.

RESULTS

The resulting criteria accounted for about one-third of the observed variance in clinicians' ratings of overall clinical urgency (R2 = 31.2%). The panel modified the original criteria and weights based on empirical results and clinical judgement. Reliability of the revised criteria items was mixed, with the lowest reliability observed for items dealing with glare and social role.

INTERPRETATION

Participating clinicians considered the criteria easy to use and reasonably reflective of expert surgical judgement regarding clinical urgency. Further development and testing of the tool appear warranted.

Priorities for child safety in the European Union: agenda for action

STATEMENT OF THE PROBLEM

Children have a right to safety, but this is still not optimally implemented throughout Europe. Furthermore, no joint commitment to change has been undertaken by the European Parliament, European Commission, or collectively by the EU Member States. This paper summarizes a White Book presented to governments entitled 'Priorities for Child Safety in the European Union,' requesting concerted action.

METHODS

The report is based on statistics provided by the World Health Organization as well as by research centers in the European Union Member States. Original research was contracted to the Mori Social Research Institute in 2001 in order to obtain an update on parents' and leading government officials' views on child safety.

RESULTS

The leading causes of child injury deaths in the EU (road accidents, 48%, other unintentional 16%, intentional 13%, drowning 11%, fires 5%, falls 5%, and poisoning 2%) are the same in all Member States, but it is the distribution of injuries within each category that determines the unique profile of each. Adopting a number of best practices that have been identified for each injury area can reduce these injury deaths. Survey results show that the parents of children in Europe are concerned regarding child injuries, while government officials are still not making strong commitments to advance safety for children. A review of EU standards and legislation related to child safety shows that these are still incomplete and require changes.

CONCLUSIONS

A joint commitment to reduce child accidental injury deaths in the EU is advocated, with a clear set of recommendations to act upon.

Solving the surgical waiting list problem? New Zealand's 'booking system'

This article discusses the development and implementation of New Zealand's booking system for publicly funded non-urgent surgical and medical procedures. The 'booking system' emerged out of New Zealand's core services debate and the government's desire to remove waiting lists. It was targeted for implementation by mid-1998. However, the booking system remains in an unsatisfactory state and a variety of problems have plagued its introduction. These include a lack of national consistency in the priority access criteria, failure to pilot the system and a shortfall in the levels of funding available to treat the numbers of patients whose priority criteria 'scores' deem them clinically eligible for surgery. The article discusses endeavours to address these problems. In conclusion, based on the New Zealand experience, the article provides lessons for policy-makers interested in introducing surgical booking systems.

[Evaluating quality and effectiveness in the promotion of health: approaches and methods of public health and social sciences]

Health promotion and health education have often been limited to evaluation of the effectiveness of actions and programmes. However, since 1996 with the Third European Conference on Health Promotion and Education Effectiveness, many researchers have become interested in "quality assessment" and new ways of thinking have emerged. Quality assurance is a concept and activity developed in industry with the objective of increasing production efficiency. There are two distinct approaches: External Standard Inspection (ESI) and Continuous Quality Improvement (CQI). ESI involves establishing criteria of quality, evaluating them and improving whatever needs improvement. CQI views the activity or service as a process and includes the quality assessment as part of the process. This article attempts to answer the questions of whether these methods are sufficient and suitable for operationalising the concepts of evaluation, effectiveness and quality in health promotion and education, whether it is necessary to complement them with other methods, and whether the ESI approach is appropriate. The first section of the article explains that health promotion is based on various paradigms from epidemiology to psychology and anthropology. Many authors warn against the exclusive use of public health disciplines for understanding, implementing and evaluating health promotion. The author argues that in practice, health promotion: -integrates preventive actions with those aiming to maintain and improve health, a characteristic which widens the actions of health promotion from those of classic public health which include essentially an epidemiological or "risk" focus; -aims to replace vertical approaches to prevention with a global approach based on educational sciences; -involves a community approach which includes the individual in a "central position of power" as much in the definition of needs as in the evaluation of services; -includes the participation and socio-political actions which necessitate the use of varied and specific instruments for action and evaluation. With the choice of health promotion ideology, there exist corresponding theories, concepts of quality, and therefore methods and techniques that differ from those used until now. The educational sciences have led to a widening of the definition of process to include both "throughput and input", which has meant that the methods of needs analysis, objective and priority setting and project development in health promotion have become objects of quality assessment. Also, the modes of action and interaction among actors are included, which has led to evaluation of ethical and ideological aspects of projects. The second section of the article discusses quality assessment versus evaluation of effectiveness. Different paradigms of evaluation such as the public health approach based on the measurement of (epidemiological) effectiveness, social marketing and communication, and the anthropological approach are briefly discussed, pointing out that there are many approaches which can both complement and contradict one another. The author explains the difference between impact (the intermediate effects, direct or indirect, planned or not planned, changes in practical or theoretical knowledge, perceptions, and attitudes) and results (final effects of mid to long term changes such as changes in morbidity, mortality, or access to services or cost of health care). He argues that by being too concerned with results of programmes, we have often ignored the issue of impact. Also, by limiting ourselves to evaluating effectiveness (i.e. that the expected effects were obtained), we ignore other possible unexpected, unplanned and positive and negative secondary effects. There are therefore many reasons to: -evaluate all possible effects rather than only those lined to objectives; -evaluate the entire process rather than only the resources, procedures and costs; -evaluate the impact rather than results; -evalu

Value judgment in the Oregon Medicaid experiment

Oregon proposed a unique social experiment in which combinations of medical conditions and treatments were prioritized. Under the proposed program, providers would not be reimbursed for services relevant to 17% of the condition-treatment pairs. The program was designed to expand access and allow significantly more residents to qualify for Medicaid. The original Oregon proposal used four levels of human judgment: community values assessed in town meetings; ratings of the desirability of health states; medical judgment of treatment efficacy; and subjective reordering of the list by Oregon Health Services Commissioners. In August 1992, the Department of Health and Human Services rejected Oregon's application to proceed with the experiment, objecting to the use of one of the four types of subjective data: ratings of the desirability of health states. A revised application that eliminated this one subjective component was approved in March 1993. This paper demonstrates that among the four levels of judgment, the ratings of health states were supported by the most evidence of reliability and validity. Implications for future prioritization experiments are discussed.

Explorations in consultation of the public and health professionals on priority setting in an inner London health district

The methodology for eliciting the public's priorities for health services is in its infancy. This paper presents the results from a series of exploratory exercises on priorities in City and Hackney. The authors surveyed the opinions of members of community groups and tenants' associations, and compared their responses with those of a random sample of the public as well as general practitioners, consultants and public health doctors. This revealed some disagreement on priorities between these groups. The public, in consistency with the results from other studies, prioritised perceived life saving technologies as high, in contrast to community services and services for people with mental illnesses, which they prioritised as medium to low, in contrast to all the samples of doctors; the public also prioritised health education and family planning as fairly low, as did the GPs and consultants, in contrast to the public health doctors who prioritised them as high. Before DHAs embark on these studies as part of priority setting, they must answer the question: "what will they do if they disagree with the results?"

Oregon's experiment

Oregon's systematic design for universal access to health care, known as the Oregon Basic Health Services Act, has provoked heated debate over its rationale, plan and process. It is a novel attempt to address inequities in the distribution of health care for those below the federal poverty level. Its controversial nature compels more informed discussion to guide further analysis. Accordingly, this report is primarily descriptive, aiming to provide a clear synopsis of the Oregon project's history, complex methodology, and strengths and weaknesses.

Communitarian illusions: or why the Dutch proposal for setting priorities in health care must fail

This article accounts for the failure of the Dutch Government Committee on Choices in Health Care to develop useful criteria of necessary care by which to set health care priorities and ration resources. The Government Committee has been inspired by philosophers who think that allocation problems cannot be solved without placing broad moral questions about the good life, and about the place of health and illness in our lives on the public agenda. The fruitless attempts of the Committee to formulate an effective notion of essential care, based upon a community-oriented perspective of health, shows why the communitarian approach is bound to fail. Questions about essential health care cannot be answered on a macro-level. The only way to get some reasonable control over day-to-day health care allocation decisions in hospitals and institutions is by trying to understand the history, laws, habits and contingencies of what is going on between doctors and patients. Such an understanding can be gained by developing a relational and biographical view on the doctor-patient relationship.

Methods to establish priorities for health care

There is no right way to rank health care projects or patients requiring treatment. Different people or interests, either explicitly or implicitly, adopt different criteria: medical, economic, ethical, or political. This paper discusses the nature of these criteria and presents some strategies for improving our processes for setting priorities for health care expenditure.