[Vaccines: producers in countries of the Southern hemisphere]

Vaccine producers in southern hemisphere countries now contribute significantly to global output. In 2006 southern hemisphere countries accounted for more than 10% of the total worldwide production with a progression approximately 70% greater than all producers combined in the two-year period between 2004 and 2006. Though difficult to measure, production in volume is higher due to lower prices practiced in most of these countries. For many years before the 1980s, production was scattered among numerous limited-scale companies. Most were founded at the initiative of governments striving to cover the needs of the population for essential vaccines. A number of institutions and private structures such as Institut Pasteur Production, Connaught Laboratories, and Institut Merieux have also set up production facilities. Today's producers can be divided into two categories, i.e., local producers that produce mainly monovalent vaccines and worldwide producers with strong R&D investment programs. Local producers are located mainly in large southern hemisphere countries such as China, India, Brazil, and Indonesia as well as in eastern countries. For the most dynamic companies, international development is focused on southern hemisphere countries excluding North America and Europe. With the support international organization such as WHO, UNICEF and GAVI, alliances are now being formed and networks are being organized in an effort to ensure reliable supplies of high quality vaccines at affordable prices in developing countries. The contribution of these producers will increase for the greater benefit of the people living in the southern hemisphere.

Evaluating the potential impact of the new Global Plan to Stop TB: Thailand, 2004-2005

OBJECTIVE

WHO's new Global Plan to Stop TB 2006-2015 advises countries with a high burden of tuberculosis (TB) to expand case-finding in the private sector as well as services for patients with HIV and multidrug-resistant TB (MDR-TB). The objective of this study was to evaluate these strategies in Thailand using data from the Thailand TB Active Surveillance Network, a demonstration project begun in 2004.

METHODS

In October 2004, we began contacting public and private health-care facilities monthly to record data about people diagnosed with TB, assist with patient care, provide HIV counselling and testing, and obtain sputum samples for culture and susceptibility testing. The catchment area included 3.6 million people in four provinces. We compared results from October 2004-September 2005 (referred to as 2005) to baseline data from October 2002-September 2003 (referred to as 2003).

FINDINGS

In 2005, we ascertained 5841 TB cases (164/100 000), including 2320 new smear-positive cases (65/100 000). Compared with routine passive surveillance in 2003, active surveillance increased reporting of all TB cases by 19% and of new smear-positive cases by 13%. Private facilities diagnosed 634 (11%) of all TB cases. In 2005, 1392 (24%) cases were known to be HIV positive. The proportion of cases with an unknown HIV status decreased from 66% (3226/4904) in 2003 to 23% (1329/5841) in 2005 (P< 0.01). Of 4656 pulmonary cases, mycobacterial culture was performed in 3024 (65%) and MDR-TB diagnosed in 60 (1%).

CONCLUSION

In Thailand, piloting the new WHO strategy increased case-finding and collaboration with the private sector, and improved HIV services for TB patients and the diagnosis of MDR-TB. Further analysis of treatment outcomes and costs is needed to assess this programme's impact and cost effectiveness.

[Spatial analysis of leprosy cases treated at public health care facilities in Brazil]

Hansen disease or leprosy is a major endemic disease in Brazil. Well-designed strategies, including decentralization of basic care, are needed to reduce its prevalence. The article begins by describing the structure and supply of services for treating leprosy cases in the country, after which it analyzes the trends in epidemiological and operational indicators, comparing the periods before and after decentralization of services to the municipal (local) level. Finally, spatial analysis allowed identifying the territorial distribution of this endemic and analyzing the pattern of geographic areas according to care provided by health facilities and its evolution. Based on the location of the geographic centers in the census tracts by place of residence, and using spatial smoothing technique based on Kernel estimation, the study constructed domain areas of care for each health facility or unit. Following municipalization of care, there was an increase in the detection and treatment by the municipalities themselves, reducing patient evasion to neighboring counties and causing changes in demand trends, with an increase in use of services by the clientele and important alterations in the epidemiological and operational indicators.

The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries

OBJECTIVE

To assess the availability and affordability of medicines used to treat cardiovascular disease, diabetes, chronic respiratory disease and glaucoma and to provide palliative cancer care in six low- and middle-income countries.

METHODS

A survey of the availability and price of 32 medicines was conducted in a representative sample of public and private medicine outlets in four geographically defined areas in Bangladesh, Brazil, Malawi, Nepal, Pakistan and Sri Lanka. We analysed the percentage of these medicines available, the median price versus the international reference price (expressed as the median price ratio) and affordability in terms of the number of days wages it would cost the lowest-paid government worker to purchase one month of treatment.

FINDINGS

In all countries<or=7.5% of these 32 medicines were available in the public sector, except in Brazil, where 30% were available, and Sri Lanka, where 28% were available. Median price ratios varied substantially, from 0.09 for losartan in Sri Lanka to 30.44 for aspirin in Brazil. In the private sector in Malawi and Sri Lanka, the cost of innovator products (the pharmaceutical product first given marketing authorization) was three times more than generic medicines. One month of combination treatment for coronary heart disease cost 18.4 days wages in Malawi, 6.1 days wages in Nepal, 5.4 in Pakistan and 5.1 in Brazil; in Bangladesh the cost was 1.6 days wages and in Sri Lanka it was 1.5. The cost of one month of combination treatment for asthma ranged from 1.3 days wages in Bangladesh to 9.2 days wages in Malawi. The cost of a one-month course of intermediate-acting insulin ranged from 2.8 days wages in Brazil to 19.6 in Malawi.

CONCLUSION

Context-specific policies are required to improve access to essential medicines. Generic products should be promoted by educating professionals and consumers, by implementing appropriate policies and incentives, and by introducing market competition and/or price regulation. Improving governance and management efficiency, and assessing local supply options, may improve availability. Prices could be reduced by improving purchasing efficiency, eliminating taxes and regulating mark-ups.

A call for greater flexibility in the use of public transport

This article, brought to you in association with Help the Aged, looks at the difficulties involved in using public transport for the older person. Help the Aged is calling for a flexible transport system which provides a free bus pass or travel tokens depending on what works for individuals.

'Where is the public health sector?' Public and private sector healthcare provision in Madhya Pradesh, India

OBJECTIVE

This paper aims to empirically demonstrate the size and composition of the private health care sector in one of India's largest provinces, Madhya Pradesh.

METHODOLOGY

It is based on a field survey of all health care providers in Madhya Pradesh (60.4 million in 52,117 villages and 394 towns). Seventy-five percent of the population is rural and 37% live below poverty line. This survey was done as part of the development of a health management information system.

FINDINGS

The distribution of health care providers in the province with regard to sector of work (public/private), rural-urban location, qualification, commercial orientation and institutional set-up are described. Of the 24,807 qualified doctors mapped in the survey, 18,757 (75.6%) work in the private sector. Fifteen thousand one hundred forty-two (80%) of these private physicians work in urban areas. The 72.1% (67793) of all qualified paramedical staff work in the private sector, mostly in rural areas.

CONCLUSION

The paper empirically demonstrates the dominant heterogeneous private health sector and the overall the disparity in healthcare provision in rural and urban areas. It argues for a new role for the public health sector, one of constructive oversight over the entire health sector (public and private) balanced with direct provision of services where necessary. It emphasizes the need to build strong public private partnerships to ensure equitable access to healthcare for all.

Customer orientation among employees in public administration: a transnational, longitudinal study

The relation between ergonomic principles and quality management initiatives, both, in the private and public sector, has received increasing attention in the recent years. Customer orientation among employees is not only an important quality principle, but also an essential prerequisite for customer satisfaction, especially in service organizations. In this context, the objective of introducing new public management (NPM) in public-service organizations is to increase customer orientation among employees who are at the forefront of service providing. In this study, we developed a short scale to measure perceived customer orientation. In two separate longitudinal studies carried out in Austria and the US, we analyzed changes in customer orientation resulting from the introduction of NPM. In both organizations, we observed a significant increase in customer orientation. Perceived customer orientation was related to job characteristics, organizational characteristics and employee quality of working life. Creating positive influences on these characteristics within the framework of an organizational change process has positive effects on employee customer orientation.

Medicen Paris Région, pôle de compétitivité mondial et recherche en neuroscience

The French public-private partnerships known as "competitive clusters" [pôles de compétitivité (PdC)] are intended to be novel and ambitious engines of regional growth, employment and biomedical innovation. Partly funded by government and local councils, they aim to capitalize on regional expertise by bringing together basic scientists, clinicians, innovative entrepreneurs and local decision-makers around specific themes that have become too costly and complex for any of these actors to tackle alone. Clusters provide the critical mass required both to underpin innovation potential and to authenticate regional claims to international competitiveness. Medicen is a biomedicine and therapeutics cluster comprising 120 partners from four broad "colleges" in the greater Paris region: major industry, small and medium-sized businesses, teaching hospitals/State research bodies, and local councils. Chief among its cooperative R&D projects is the neuroscience subcluster, in which "TransAl" the neurodegenerative disease project, counts Sanofi-Aventis, Servier and the French Atomic Energy Commission [Commissariat à l'Energie Atomique (CEA)] as key partners. One main aim is to develop an experimental model in rhesus monkeys in which a putative cause of Alzheimer's disease, intracerebral accumulation of b-amyloid peptide, is generated by impairing the peptide's clearance. The other aim, in which the nuclear medicine expertise of the CEA will be crucial, is to identify, characterize and validate markers for magnetic resonance and positron emission tomography imaging, and to source biomarkers from cerebrospinal fluid proteomics. A human biological resource centre (DNA and tissue banks) project dedicated to neurological and psychiatric disease should be up and running in 2007. Only through fundamental restructuring of resources on such a large cooperative scale are solutions likely to be found to the major problems of modern medicine, bringing healthcare and regional socioeconomic benefits in its wake.

The changing face of voluntary welfare provision in New Zealand

This paper contributes a micro-level analysis of voluntary welfare providers, an under explored avenue of geographical research. It analyses the localised social impacts of the macroeconomic restructuring of the Welfare State in New Zealand in the 1980s and 1990s on the work of voluntary service organisations (VSOs) and drop-in centres (DICs) as spaces of care in Dunedin, a small South Island city. We document differences among VSOs and DICs in terms of funding, clientele, and adjustments to service provision to satisfy increasing numbers of patrons and the changing composition of demand. Our findings suggest policy recommendations which, we believe, would do much to enhance the ability of both DICs and smaller VSOs to meet client needs.

Public and private regulation of organ transplantation: liver allocation and the final rule

The allocation of cadaveric organs for transplantation in the United States is governed by a process of private regulation. Through the Organ Procurement and Transplantation Network (OPTN), stakeholders and public representatives determine the substantive content of allocation rules. Between 1994 and 2000 the U.S. Department of Health and Human Services conducted a rule making to define more clearly the public and private roles in the determination of organ allocation policy. Several prominent liver transplant centers that were losing market share as a result of the proliferation of transplant centers used the rule making as a vehicle for challenging the local priority for organ allocation inherent in the OPTN rules. The process leading to the final rule provides a window on the politics of organ allocation. It also facilitates an assessment of the strengths and weaknesses of private rule making. Overall, private rule making appears to be relatively effective in tapping the technical expertise and tacit knowledge of stakeholders to allow for the adaptation of rules in the face of changing technology and information. However, the particular system of representation employed may give less influence to some stakeholders than they would have in public regulatory arenas, giving them an incentive to seek public rule making as a remedy for their persistent losses within the framework of private rule making.

Contracting but not without caution: experience with outsourcing of health services in countries of the Eastern Mediterranean Region

The public sector in developing countries is increasingly contracting with the non-state sector to improve access, efficiency and quality of health services. We conducted a multicountry study to assess the range of health services contracted out, the process of contracting and its influencing factors in ten countries of the Eastern Mediterranean Region: Afghanistan, Bahrain, Egypt, Islamic Republic of Iran, Jordan, Lebanon, Morocco, Pakistan, the Syrian Arab Republic and Tunisia. Our results showed that Afghanistan, Egypt, Islamic Republic of Iran and Pakistan had experience with outsourcing of primary care services; Jordan, Lebanon and Tunisia extensively contracted out hospital and ambulatory care services; while Bahrain, Morocco and the Syrian Arab Republic outsourced mainly non-clinical services. The interest of the non-state sector in contracting was to secure a regular source of revenue and gain enhanced recognition and credibility. While most countries promoted contracting with the private sector, the legal and bureaucratic support in countries varied with the duration of experience with contracting. The inherent risks evident in the contracting process were reliance on donor funds, limited number of providers in rural areas, parties with vested interests gaining control over the contracting process, as well as poor monitoring and evaluation mechanisms. Contracting provides the opportunity to have greater control over private providers in countries with poor regulatory capacity, and if used judiciously can improve health system performance.

Hard gains through soft contracts: productive engagement of private providers in tuberculosis control

Over the past decade, there has been a rapid increase in the number of initiatives involving "for-profit" private health care providers in national tuberculosis (TB) control efforts. We reviewed 15 such initiatives with respect to contractual arrangements, quality of care and success achieved in TB control. In seven initiatives, the National TB Programme (NTP) interacted directly with for-profit providers; while in the remaining eight, the NTP collaborated with for-profit providers through intermediary not-for-profit nongovernmental organizations. All but one of the initiatives used relational "drugs-for-performance contracts" to engage for-profit providers, i.e. drugs were provided free of charge by the NTP emphasizing that providers dispense them free of charge to patients and follow national guidelines for diagnosis and treatment. We found that 90% (range 61-96%) of new smear-positive pulmonary TB cases were successfully treated across all initiatives and TB case detection rates increased between 10% and 36%. We conclude that for-profit providers can be effectively involved in TB control through informal, but well defined drugs-for-performance contracts. The contracting party should be able to reach a common understanding concerning goals and role division with for-profit providers and monitor them for content and quality. Relational drugs-for-performance contracts minimize the need for handling the legal and financial aspects of classical contracting. We opine that further analysis is required to assess if such "soft" contracts are sufficient to scale up private for-profit provider involvement in TB control and other priority health interventions.

The benefits of setting the ground rules and regulating contracting practices

In recent years, health systems have increasingly made use of contracting practices; despite results that are often promising, there have also been failures and occasionally harsh criticism of such practices. This has made it even more necessary to regulate contracting practices. As part of its stewardship function, in other words its responsibility to protect the public interest, the ministry of health has the responsibility of introducing the tools needed for such regulation. Several tools are available to help it do this. Some of them, such as standard contracts or framework contracts, useful as they may be, are nevertheless specific and ad hoc. Contracting policies, when carefully linked to overall health policies, are undoubtedly the most comprehensive of these tools, since they enable contracting to be accommodated within the management of the health system as a whole and thus take into account its potential contribution to improving health system performance. However, the requirements for success are not present automatically and it has to be ensured that there are mechanisms for vitalizing these regulatory mechanisms and that the key actors make proper use of the framework laid down by the ministry of health. The first three authors of this article have participated in the preparation and implementation of national policies on contracting in their own countries, viz. Chad, Madagascar and Senegal.

The development of China's medical biotech industry needs to be driven by innovation

The Chinese biotech industry is going through a period of fast growth, and with its huge population, China is predicted to be the biggest single-country market in the world. However, the Chinese biotech industry has to tackle the critical issue of innovation, which should be the driving force for China's development into an advanced and responsible country. Here, in this article, the authors review the history of the Chinese biotech industry, exemplified by the development of genetically engineered drugs during the last 20 years, and also point out its the future.

Teaching Spiritual Care in a Public Institution: Legal Implications, Standards of Practice, and Ethical Obligations

This article reviews the status of teaching spiritual care in a public institution of higher education. The resurgence of interest in spiritual care across the United States has spurred interest and expanded theories of spirituality within the nursing profession. Nursing education rose to the challenge of teaching spiritual care theories and interventions to students, despite the absence of policy to guide educators. However, differences between public and private educational institutions have led to variations in the teaching of spiritual care. In addition to the legal implications stemming from the need for separation of church and state, nurses must also be aware of their ethical obligations in order to teach spiritual care concepts appropriately. The accrediting agencies for nursing education programs and hospitals, as well as state licensure boards, foster high expectations for nurses to provide spiritual care. A call for research and policy development to guide nurse educators is also addressed in this article.

Differences in public and private sector adoption of telemedicine: Indian case study for sectoral adoption

Telemedicine is the use of communication networks to exchange medical information for providing healthcare services and medical education from one site to another. The application of telemedicine is more promising in economically developing countries with agrarian societies. The American Telemedicine Association (ATA) identifies three healthcare services: clinical medical services, health and medical education, and consumer health information. However, it is not clear how these services can be adopted by different sectors: public and private. This paper looks at four Indian case studies, two each in public and private sectors to understand two research questions: Are there differences in telemedicine adoption between public and private hospitals. If there are differences: What are the differences in telemedicine adoption between public and private sectors? Authors have used the extant literature in telemedicine and healthcare to frame theoretical background, describe the research setting, present the case studies, and provide discussion and conclusions about their findings. Authors believe that as India continues to develop its telemedicine infrastructures, especially with continued government support through subsidies to private telemedicine initiatives, its upward trend in healthcare will continue. This is expected to put India on the path to increase its life expectancy rates, especially for it rural community which constitute over 70% of its populace.

The Gateway Paper--proposed health reforms in Pakistan--interface considerations

The Gateway Paper recognizes three system interfaces as being critical to the delivery of healthcare within Pakistan. These include the federal/provincial interface, the provincial-district interface and the public-private interface. A number of gaps in each area have been highlighted. At the federal-provincial interface lack of provincial ownership of federal initiatives, gaps in provincial counterpart arrangements, ambiguities about federal and provincial roles and responsibilities, conflicts over sharing of resources and gaps in understanding provincial requirements and poor coordination have been articulated as core issues. It is envisaged that the development of a broad based mechanism to develop a consensus on national policy positions, incorporation of appropriate guidance from the provinces, giving provinces an active participatory role in decision-making, garnering their support and clearly demarcating roles and responsibilities will obviate some of these issues as would the institutionalization of a federal-provincial coordinating mechanism to review actions at both levels with regards to progress on meeting stipulating goals. At a district level poor governance, limited capacity within the system, lag in granting full district level financial and administrative autonomy, and lack of operational clarity in the rules of business have contributed to the challenge. This is compounded by inadvertent centralization of some functions within the district, which political and administrative decentralization has paradoxically created and impediments to harnessing the role of communities. The clear delineation of these issues provides a substrate, which need to be at the heart of strategic reform within the context of the recent devolution initiative. At the public-private interface the absence of locally established principles, legislative frameworks, policies and operational strategies have been contributing to the adhoc nature of public-private engagement within the country, which leads to skewed powered relationships and lack of clarity in combined models of governance. Within this context the Gateway Paper makes a strong case for developing a set of norms and ethical principles, developing legislative and policy frameworks, and specific guidelines to steer such relationships with careful attention to accountability and sustainability related parameters.

Ethics in public health research: a research protocol to evaluate the effectiveness of public-private partnerships as a means to improve health and welfare systems worldwide

Public-private partnerships have become a common approach to health care problems worldwide. Many public-private partnerships were created during the late 1990s, but most were focused on specific diseases such as HIV/AIDS, tuberculosis, and malaria. Recently there has been enthusiasm for using public-private partnerships to improve the delivery of health and welfare services for a wider range of health problems, especially in developing countries. The success of public-private partnerships in this context appears to be mixed, and few data are available to evaluate their effectiveness. This analysis provides an overview of the history of health-related public-private partnerships during the past 20 years and describes a research protocol commissioned by the World Health Organization to evaluate the effectiveness of public-private partnerships in a research context.

[A paradigm change in German academic medicine. Merger and privatization as exemplified with the university hospitals in Marburg and Giessen]

1. The intended fusion of the university hospitals Marburg and Giessen in the state of Hessia is "a marriage under pressure with uncalculated risk" (Spiegel 2005). In the present political and financial situation it hardly appears to be avoidable. From the point of the view of the faculty of medicine in Marburg it is difficult to understand, that the profits of this well guided university hospital with a positive yearly budget should go to the neighboring university hospital which still had a fair amount of deficit spending in the last years.2. Both medical faculties suffer from a very low budget from the state of Hessia for research and teaching. Giessen much more than Marburg, have a substantial need for investments in buildings and infrastructure. Both institutions have a similar need for investments in costly medical apparatuses. This is a problem, which many university hospitals face nowadays.3. The intended privatisation of one or both university hospitals will need sound answers to several fundamental questions and problems:a) A privatisation potentially endangers the freedom of research and teaching garanteed by the German constitution. A private company will undoubtedly influence by active or missing additional support the direction of research in the respective academic institution. An example is the priorisation of clinical in contrast to basic research.b) With the privatisation practical absurdities in the separation of research and teaching on one side and hospital care on the other will become obvious with respect to the status of the academic employees, the obligatory taxation (16%) when a transfer of labor from one institution to the other is taken into account. The use of rooms for seminars, lectures and bedside with a double function for both teaching, research and hospital care has to be clarified with a convincing solution in everyday practice.c) The potential additional acquisition of patients, which has been advocated by the Hessian state government, may be unrealistic, when the 4th biggest university hospital in Germany will be created by the merger. University hospitals recrute the patients for high end medicine beyond their region because of the specialized academic competence and advanced technical possibilities. Additional recruitment of patients for routine hospital can hardly be expected.d) A private management will have to consider primarily the "shareholder value", even when investing in infrastructure and buildings, as it can be expected for one partner. On the longterm this will not be possible without a substantial reduction of employees in both institutions. There are, however, also substantial efforts of some private hospital chains in clinical research, e. g. by Helios in Berlin and Rhön Gmbh at the Leipzig Heart Center.e) There is a yet underestimated but very substantial risk because of the taxation for the private owner when academic staff is transferred from the university to hospital care in their dual function as academic teachers and doctors. This risk also applies for the university if the transfer should come from hospital to the university. These costs would add to the financial burden, which has to be carried in addition to the DRGs.

Different approaches to contracting in health systems

Contracting is one of the tools increasingly being used to enhance the performance of health systems in both developed and developing countries; it takes different forms and cannot be limited to the mere purchase of services. Actors adopt contracting to formalize all kinds of relations established between them. A typology for this approach will demonstrate its diversity and provide a better understanding of the various issues raised by contracting. In recent years the way health systems are organized has changed significantly. To remedy the under-performance of their health systems, most countries have undertaken reforms that have resulted in major institutional overhaul, including decentralization of health and administrative services, autonomy for public service providers, separation of funding bodies and service providers, expansion of health financing options and the development of the profit or nonprofit private sector. These institutional reshuffles lead not only to multiplication and diversification of the actors involved, but also to greater separation of the service provision and administrative functions. Health systems are becoming more complex and can no longer operate in isolation. Actors are gradually realizing that they need to forge relations. The simplest way to do that is through dialogue, although some prefer a more formal commitment. Interaction between actors may take various forms and be on different scales. There are several types of contractual relations: some are based on the nature of the contract (public or private), others on the parties involved and yet others on the scope of the contract. Here they are classified into three categories according to the object of the contract: delegation of responsibility, act of purchase of services, or cooperation.