Is the United States an outlier in health care and health outcomes? A preliminary analysis

Does decentralization influence efficiency of health units? A study of opinion and perception of health workers in Odisha

Background

Health systems in low and middle income countries are struggling to improve efficiency in the functioning of health units of which workforce is one of the most critical building blocks. In India, Rogi Kalyan Samiti (RKS) was established at every health unit as institutions of local decision making in order to improve productive efficiency and quality. Measuring efficiency of health units is a complex task. This study aimed at assessing the perception (opinion and satisfaction) of health workers about influence of RKS on improving efficiency of peripheral decision making health units (DMHU); examining differences between priority and non-priority set-ups; identifying predictors of satisfaction at work; and discussing suggestions to improve performance.

Methods

Following a cross-sectional, comparative study design, 130 health workers from 30 institutions were selected through a multi-stage stratified random sampling. A semi-structured questionnaire was administered to assess perception and opinion of health workers about influence of RKS on efficiency of decision making at local level, motivation and performance of staff, and availability of funds; improvement of quality of services, and coordination among co-workers; and participation of community in local decision making. Three districts with highest infant mortality rate (IMR), one each, from 3 zones of Odisha and 3 with lowest IMR were selected on the basis of IMR estimates of 2011. The former constituted priority districts (PD) and the latter, non-priority districts (NPD). Composite scores were developed and compared between PD and NPD. Adjusted linear regression was conducted to identify predictors of satisfaction at work.

Results

A majority of respondents felt that RKS was efficient in decision making that resulted in improvement of all critical parameters of health service delivery, including quality; this was significantly higher in PD. Further, higher proportion of respondents from PD was highly satisfied with the current set of provisions and manners of functioning of the sample health units. Active community engagement, participation of elected representatives, selection of a pro-active Chairman, and training to RKS members were suggested as the immediate priority action points for the state government. Mean scores differed significantly between PD and NPD with regard to: influence of RKS on individual-centric, organizational-centric and patient-centric performance, and the responsibilities to be entrusted with RKS. Absenteeism was strongly associated with satisfaction and local self-governance. Work-related factors, systemic factors, local accountability and patients’ involvement were found to be the key predictors of satisfaction of health workforce.

Conclusion

The understanding on quality improvement strategies was found to be very poor among the health workers. Tailor-made capacity building measures at district and sub-district levels could be critical to equip the peripheral health units to achieve the universal health coverage goals. Work environment, systemic factors and accountability need to be addressed on priority for retention of health workforce. The hypothesized link between efficient local decision making, perception of health workers about efficiency of health units and the health status of population needs further investigation.

Comparing efficiency of health systems across industrialized countries: a panel analysis

Background

Rankings from the World Health Organization (WHO) place the US health care system as one of the least efficient among Organization for Economic Cooperation and Development (OECD) countries. Researchers have questioned this, noting simplistic or inappropriate methodologies, poor measurement choice, and poor control variables. Our objective is to re-visit this question by using newer modeling techniques and a large panel of OECD data.

Methods

We primarily use the OECD Health Data for 25 OECD countries. We compare results from stochastic frontier analysis (SFA) and fixed effects models. We estimate total life expectancy as well as life expectancy at age 60. We explore a combination of control variables reflecting health care resources, health behaviors, and economic and environmental factors.

Results

The US never ranks higher than fifth out of all 36 models, but is also never the very last ranked country though it was close in several models. The SFA estimation approach produces the most consistent lead country, but the remaining countries did not maintain a steady rank.

Discussion

Our study sheds light on the fragility of health system rankings by using a large panel and applying the latest efficiency modeling techniques. The rankings are not robust to different statistical approaches, nor to variable inclusion decisions.

Conclusions

Future international comparisons should employ a range of methodologies to generate a more nuanced portrait of health care system efficiency.

Socialized medicine and mortality

Over the last century life expectancy has increased substantially and so has the share of health care expenditures financed by governments. In cross-country comparisons, the US, which has the lowest government health expenditure share, often has the poorest health outcomes. Is there a plausible connection between health outcomes and government financing of health care? This paper addresses this question with panel data from 20 developed countries from 1950 to 2010. I review the history of government involvement in health care financing over this period. Then I use panel regression methods to examine whether a variety of mortality based outcome measures are correlated with the extent of government involvement. The answers are robustly negative.

Improving life expectancy: how many years behind has the USA fallen? A cross-national comparison among high-income countries from 1958 to 2007

OBJECTIVE

Many studies have documented higher mortality levels in the USA compared to other high-income nations. We add to this discussion by quantifying how many years behind comparison countries the USA has fallen and by identifying when US mortality rates began to diverge.

DESIGN

We use full life tables, for men and women, for 17 high-income countries including the USA. We extract the life expectancy at birth and compute the mortality rates for each 5-year age group from birth up to age 80. Using the metric of how many 'years behind' a country has fallen, we compare US mortality levels with those in other high-income countries ('comparators').

RESULTS

We report life expectancy for 17 high-income countries, for the period 1958-2007. Up to the late 1970s, US men and especially women closely tracked comparators in life expectancy. In the late 1970s in the USA, most strikingly women began to diverge from comparators so that the US female life expectancy in 2007 corresponded to that of the comparators' average 10 years earlier. Mortality rates also began to diverge from the late 1970s, and the largest mortality gap was in the 15-49 age group, for both men and women, where the USA had fallen about 40 years behind the comparators by 2007.

CONCLUSIONS

Some causes proposed for the relatively high US mortality today-racial differences, lack of universal health insurance, US exceptionalism-changed little while the mortality gap emerged and grew. This suggests that explanations for the growing gap lie elsewhere. Quantification of how many years behind the USA has fallen can help provide clues about where to look for potential causes and remedies.

A second look at pharmaceutical spending as determinants of health outcomes in Canada

Per capita spending on pharmaceutical products has increased substantially in recent decades in Canada. Recent Canadian research by Crémieux et al. concludes that there is a strong statistical relationship between pharmaceutical spending and health outcomes (Health Econ. 2005a; 14: 117, Health Econ. 2005b; 14(2): 107-116). This paper takes a second look at pharmaceutical spending as determinants of health outcomes in Canada. In doing so, it examines the robustness of the findings of Crémieux et al. by considering the appropriateness of the data used and statistical approach utilized. Particular attention is given to the potential for non-stationarity and spurious regression, issues related to unit heterogeneity and the choice of estimators. In contrast with earlier findings, on the whole, no discernable relationship between spending on private or public pharmaceutical products and infant mortality or life expectancy at 65 is observed.

Lessons for a national pharmaceuticals strategy in Canada from Australia and New Zealand

BACKGROUND

The provincial formulary review processes in Canada lead to the slow and inequitable availability of new products. In 2004, the exploration of a national pharmaceuticals strategy (NPS) was announced. The pricing policies of New Zealand and Australia have been suggested as possible models for the NPS.

OBJECTIVE

To compare health care indexes and health care use information from Canada, Australia and New Zealand.

METHODS

The 2006 Organisation for Economic Co-operation and Development health data were used to compare health and health care indexes from Canada, Australia and New Zealand between 1994 and 2002 to 2004. The principal focus of the evaluation was cardiovascular and respiratory disorders.

RESULTS

Although the mortality rate from acute myocardial infarction decreased in each country from 1994, it levelled off in New Zealand in 1997, 1998 and 1999. Between 1994 and 2003, the average length of hospital stay for any cause and for cardiovascular disorders was stable in Australia and Canada, but increased in New Zealand, while the rate of hospital discharges for cardiovascular diseases decreased in Canada and Australia, but strongly increased in New Zealand. Over the same period, sales of cardiovascular drugs decreased in New Zealand, while sharply increasing in Canada and Australia.

CONCLUSIONS

Although only circumstantial, our results suggest an association between decreasing cardiovascular drug sales and markers of declining cardiovascular health in New Zealand. Careful consideration must be given to the potential consequences of any model for an NPS in Canada, as well as to opportunities provided for discussion and input from health care professionals and patients.

Pay-for-performance: considerations in application to the management of spinal disorders

STUDY DESIGN

Descriptive review.

OBJECTIVES

To describe the role of pay-for-performance as a health care policy that has a significant influence on the management of spinal disorders, and to consider parameters of quality measure that are likely to optimize the efficacy of a pay-for-performance system as applied to spine care.

SUMMARY OF BACKGROUND DATA

Pay-for-performance arrangements have been adopted in many areas of medicine with limited evidence for improvement in quality of care. There is an important role for a system that will improve quality of care in the management of spinal disorders. The absence of accepted evidence-based approaches to the management of spinal disorders makes the choice of parameters to measure for quality difficult.

RESULTS

Performance parameters to consider include a continuum of measures from process variables that focus on a discrete component of the health care experience, to outcome variables that encompass the end result of care. There are advantages and limitations to each parameter discussed.

CONCLUSION

A pay-for-performance system in the management of spinal disorders should include both process variables that measure safety and outcome variables that reflect the end result of care.