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The article discusses the various concerns that exist regarding the data regarding regional variations in health care spending documented by the Dartmouth Atlas of Health Care. The viewpoints expressed by different individuals highlight discrepancies in the methods used to analyze the data and the need to establish an 'industry standard' of hospital-level health care cost measures for the Medicare population.

Changes in the United Kingdom National Health Service's (NHS) budget are seen to adversely affect patient services. The NHS has recovered from financial instability. Large reductions in health services in some areas are seen.

The significane of cash transfer strategies in the improvement of health care outcomes is analyzed. The use of health care is increased due to these strategies.

Disruption caused by decades of war and civil strife in Afghanistan has led many international and national nongovernmental organizations (NGOs) to assume responsibility for the delivery of health services through contracts with donor agencies. Recently the Afghan Government has pursued the policy of contracting for a basic package of health services (BPHS) supported by funds from three major donors--the World Bank, the United States Agency for International Development (USAID) and the European Commission. With the gradual strengthening of the public health ministry, options for the future include pursuing the contracting option or increasing public provision of health services. Should contracting with NGOs be pursued, a clear strategy is required that includes developing accreditation instruments, better contracting mechanisms and a system for monitoring and evaluating the entire process. Should the government opt for an increasing role, problems to be solved include securing the transition to public provision, obtaining guarantees that appropriate financing will be provided and reconfiguration of the public health delivery system. Large-scale contracting with the private for-profit sector cannot be recommended at this stage, although this option could be explored via subcontracting by larger NGOs or small-scale trial contracts initiated by the public health ministry. Irrespective of the option chosen, an important challenge remaining is the recalcitrant problem of high out-of-pocket payments. Sustainable delivery of health services in Afghanistan can only be achieved with a clear national strategy in which all stakeholders have roles to play in the financing, regulation and delivery of services. La desorganisation provoquee par des decennies de conflits armes et de guerre civile en Afghanistan a conduit de nombreuses organisations non gouvernementales (ONG)internationales et nationales a assumer la delivrance de prestations de sante par le biais de contrats avec les agences donatrices. Recemment, le gouvernement afghan a prolonge cette politique contractuelle par un ensemble de prestations de sante de base, beneficiant du soutien financier des trois principaux donateurs :la Banque mondiale, l'AID des Etats-Unis d'Amerique (USAID) et la Commission europeenne. A mesure que le ministere de la sante publique se renforce, on peut envisager de poursuivre l'option contractuelle ou de developper la prestation de services de sante par le secteur public. Si l'on continue de passer des contrats avec des ONG, il faudra disposer d'une strategie claire, prevoyant la mise au point d'instruments d'accreditation, de meilleurs mecanismes contractuels et d'un systeme de suivi et d'evaluation du processus dans son ensemble. Si les pouvoirs publics optent pour un accroissement de leur role, il faudra assurer la transition vers une delivrance par le secteur public des prestations, obtenir des garanties quant a la disponibilite de fonds suffisants et reconfigurer de maniere appropriee le systeme public de prestations de sante. Nous ne recommandons pas a ce stade de passer de grands contrats a visees lucratives avec le secteur prive, bien qu'il soit possible d'envisager cette option en sous-traitant aupres d'ONG plus importantes ou en passant de petits contrats pilote a l'initiative du ministere de la sante. Quelle que soit l'option choisie, il reste a resoudre le probleme epineux du paiement des prestations par l'usager. La delivrance durable de prestations de sante n'est possible en Afghanistan que si l'on definit une strategie claire dans laquelle toutes les parties prenantes ont un role a jouer dans le financement, la reglementation et la delivrance des prestations. Las perturbaciones causadas por decadas de guerra y contiendas civiles en el Afganistan han llevado a muchas organizaciones no gubernamentales (ONG) internacionales y nacionales a asumir la responsabilidad de proveer los servicios de salud mediante la concertacion de contratos con organismos donantes. Recientemente el Gobierno del Afganistan ha aplicado la politica de contratar un paquete basico de servicios de salud con el respaldo de los fondos facilitados por tres importantes donantes, a saber, el Banco Mundial, la Agencia de los Estados Unidos para el Desarrollo Internacional y la Comision Europea. Con el gradual fortalecimiento del Ministerio de Salud Publica, las opciones con miras al futuro son el mantenimiento de la politica de subcontratacion o la ampliacion de la prestacion publica de servicios de salud. Si se opta por los contratos con ONG, se requiere una estrategia clara que abarque el desarrollo de instrumentos de acreditacion, mejores mecanismos de contratacion y un sistema de seguimiento y evaluacion de todo el proceso. Si el gobierno decide desempenar un papel mas importante, habra que resolver problemas como la necesidad de asegurar la transicion a la prestacion publica de servicios, la obtencion de garantias de que se contara con la suficiente financiacion y la reconfiguracion del sistema de prestacion de servicios de salud publica. La subcontratacion a gran escala con el sector privado con fines de lucro no es una opcion recomendable en esta etapa, aunque se podria explorar esa posibilidad subcontratando servicios a grandes ONG u organizando ensayos a escala reducida desde el Ministerio de Salud Publica. Con independencia de la opcion elegida, un problema arduo que se resiste es la elevada cuantia de los pagos directos. Para que la prestacion de servicios de salud en el Afganistan sea sostenible, habra que adoptar una estrategia nacional clara en la que todos los interesados directos tengan funciones que desempenar en materia de financiacion, reglamentacion y prestacion de servicios., Introduction Decades of war and civil strife have adversely affected the delivery of health services to the population of Afghanistan. Until recently, the network of public service delivery had been [...]

There have been significant increases in development finance since 2000, particularly for health [1,2]. As country programs put this money to work, important lessons and challenges on how to make [...]

The number of children worldwide with hearing impairment is increasing, and these children face a number of obstacles and burdens, given that spoken language is the predominant medium of communication [...]

A study examines the impact of medical advances and funding on longevity of living and economic growth.

Distribution of health aid and public health and heterogeneity aspects associated with this are evaluated.

A model for developing optimal finance method for health care systems in which user charges add to the fixed health care budgets, is presented. Such a method ensures equity and efficiency of the health care systems.

Informal payments are known to be widespread in the post-communist health care systems of Central and Eastern Europe. However, their role and nature remains contentious with the debate characterized by much polemic. This paper aims to make sense of this debate by reviewing and summarizing the main arguments of the theoretical debate in Hungary. The review examines the possible causes of informal payment, the motivation of the actors involved and the impact of informal payment on system performance, focusing on efficiency and equity. The lines of arguments are summarized in two contrasting hypotheses, which envisage informal payment as either a donation or a fee-for-service. Evidence pertaining to the scale of informal payments and the motivation of patients are reviewed, but found to be inconclusive to verify the hypotheses. Although focused on Hungary, accounts from oilier countries facing informal payments show similar threads of discussion and dilemmas. These theories should be tested further using evidence from existing studies and new empirical research, since the validity of the gratitude payment concept is a central dilemma of effective policy making in the area. To orient future research, a possible agenda is outlined, which links evidence to be obtained to the defining features of gratitude payments. Keywords: Informal payment; Hungary; Governance; Health care financing

The urgent need for reforming the health care system of Ukraine is examined. The program planning and central financing that are suggested reduces overcentralization of decision making and increases local accountability and responsibility for health care performance.

Health financing reform in Bulgaria has been characterised by lack of political consensus on reform direction, economic shocks, and, since 1998, steps towards social insurance. As in other eastern European countries, the reform has been driven by an imperative to embrace new ideas modelled on systems elsewhere, but with little attention to whether these reflect popular values. This study explores underlying values, such as views on the role of the state and solidarity, attitudes to, and understanding of compulsory and voluntary insurance, and co-payments. The study identifies general principles (equity, transparency) considered important by the population and practical aspects of implementation of reform. Data were obtained from a representative survey (n = 1547) and from 58 in-depth interviews and 6 focus groups with users and health professionals, conducted in 1997 before the actual reform of the health financing system in Bulgaria. A majority supports significant state involvement in health care financing, ranging from providing safety net for the poor, through co-subsidising or regulating the social insurance system, to providing state-financed universal free care (hall of all respondents). Collectivist values in Bulgaria remain strong, with support for free access to services regardless of income, age, of health status and progressive funding. There is strong support (especially among the well off) for a social insurance system based on the principle of solidarity and accountability rather than the former tax-based model. The preferred health insurance fund was autonomous, state regulated, financing only health care, and offering optional membership. Voluntary insurance and, less so, co-payments were acceptable if limited to selected services and better off groups. In conclusion, a health financing system under public control that fits well with values and population preferences is likely to improve compliance and be more sustainable. Universal health insurance appears to attract most support, but a broader public debate involving less empowered people is needed to resolve misunderstandings and create realistic expectations. Keywords: Bulgaria; Reform; Values; Attitudes; Population

Although the English NHS has been described as a world leader in pioneering methods of distributing expenditure in relation to population needs, concerns about the legitimacy of using the current utilisation-based model to allocate health service resources are mounting. In this paper, we present a critical review of NHS resource allocation in England and demonstrate the feasibility and impact of using direct health estimates as a basis for setting health care capitations. Comparing target allocations for the inpatient treatment of coronary heart disease in a sample of 34 primary care trusts in contrasting locations in England, we find that a morbidity-based model would result in a significant shift in hospital resources away from deprived areas, towards areas with older demographic profiles and towards rural areas. Discussing the findings in relation to a wider policy context that is generally concerned to direct more health care resources towards the poor, the paper concludes by calling for greater clarity between the goals of health care equity and health equity. Whilst the former demands that the legitimate needs of demographically older populations for more health care resources are acknowledged, the goal of health equity requires real political commitment to resource broader social policy initiatives. Keywords: NHS resource allocation; Health and equity; Urban and rural health needs; Morbidity-based capitation; England

Most countries of the Former Soviet Union (FSU) have either initiated or are contemplating reform of the health sector. With negative real income growth and falling government revenues, a key concern of many governments is to secure additional finance through non-budgetary sources such as hypothecated payroll taxes, voluntary insurance, and increased private finance through patient cost-sharing. However, before such reforms can be considered, information is needed both on the current levels and distribution of household expenditures on health care, and the extent to which increased charges may affect access to health services, especially amongst the poor. This paper uses the Tajikistan Livings Standard Survey to investigate the level and distribution of out-of-pocket payments for health care in Tajikistan and to examine the extent to which such payments act as barriers to health-care access. The data show that there are significant differences in health-care utilisation rates across socio-economic groups and that these differences are related to ability to pay. Official and informal payments are acting both to deter people from seeking medical assistance and once advice has been sought, from receiving the most appropriate treatment. Despite informal exemptions, out-of-pocket payments for health care are exacting a high toll on household welfare with households being forced to sell assets or go into debt to meet the costs of care. Urgent action is needed to ensure equity in access to health care. Keywords: Health financing; Informal payments: Poverty; Tajikistan

There is considerable evidence that unofficial payments are deeply embedded in the markets for health care in transition countries. Numerous surveys indicate that these payments provide a significant but possibly distorting contribution to health care financing. Unofficial payments can be characterised into three groups: cost contributions, including supplies and salaries, misuse of market position and payments for additional services. There is evidence from across the region on the presence of payment in each category although it is often difficult to distinguish between payment types. Regulatory policy must address a number of issues. Imposing penalties may help to reduce some payments but if the system is simply unable to provide services, such sanctions will drive workers into the private sector. There appears to be some support for formalising payments in order to reduce unofficial charges although the impact must be monitored and the danger is that formal fees add to the burden of payment. Regulation might also attempt to increase the amount of competition, provide information on good performing facilities and develop the legal basis of patient rights. Ultimately, unless governments address the endemic nature of payments across all sectors, policy interventions are unlikely to be fully effective. Keywords: Informal payments; Corruption; Unofficial Health Care Markets; Rent Seeking

Severity and probability of occurrence of comorbidities increases the willingness to pay(WTP) for health improvements. Old people are more likely to develop comorbidities, the effect of comorbidities on WTP tends to compensate for the fall in WTP associated with increased age.

Objective. Both acute and chronic complications of diabetes account for a disproportionate percentage of US health care expenditures. Despite improvements in diabetes care, the incidence of adverse events in children with type 1 diabetes remains high, particularly for youths with poor glycemic control. Cost-effective intervention programs designed to reduce complications are needed. This study evaluated a low-intensity, non-medical intervention using a case manager (called a "Care Ambassador"), with and without the supplementation of psychoeducational modules, designed to monitor and encourage routine diabetes care visits to reduce short-term adverse outcomes and improve glycemic control in youths with type 1 diabetes. Methods. We performed a 2-year prospective, randomized clinical trial in 299 youths with type I diabetes, aged 7 to 16 years, comparing 3 treatment programs (Care Ambassador [CA], Care Ambassador plus psychoeducational modules [CA+], and standard multidisciplinary diabetes care [SC]). The study was conducted in a large metropolitan US city from April 1997 through April 2000. Number of medical visits, frequency of hypoglycemic events, hospital/emergency department (ED) utilization, and glycosylated hemoglobin A1c were assessed during follow-up. Results. During the 2-year study period, both the CA and CA+ groups had significantly more routine visits (mean [standard deviation]: 7.3 [2.06] and 7.5 [2.02], respectively) compared with the SC group (5.4 [2.62]). The CA+ intervention group had significantly reduced rates of short-term adverse outcomes compared with the other 2 groups; 25% fewer total hypoglycemic events, 60% fewer severe hypoglycemic events, and 40% fewer hospitalizations and ED visits. "High-risk" youths in the CA+ group (baseline glycosylated hemoglobin A1c [greater than or equal to] 28.7%) were 3.4-fold (1.57-7.41) more likely to improve their glycemic control compared with those at high risk in the other 2 groups. Conclusions. For youths with type 1 diabetes, the CA and CA+ interventions increased visit frequency. Youths in the CA+ intervention had reduced rates of hypoglycemia and hospital/ED utilization with estimated annual cost savings of $80 000 to $90 000. The CA+ intervention compared with the other 2 groups improved glycemic control in "high-risk" youths. Nonmedical case management incorporating psychoeducational modules seems to be a cost-effective approach to improving outcomes in youths with diabetes. Pediatrics 2003;112:914-922; type 1 diabetes, pediatrics, case management, HbA1c, adverse outcomes., ABBREVIATIONS. DCCT, Diabetes Control and Complications Trial; HbA1c, glycosylated hemoglobin A1c; CA, Care Ambassador; ED, emergency department; CA+, Care Ambassador plus psychoeducational modules; SC, standard care. Diabetes is a common [...]

Background. The prevalence of repeated otitis media (OM) increased during the 1980s, but it is unknown if the increase has continued. Objectives. To determine trends in the prevalence of OM, early-onset OM, and repeated OM among US children from 1988 to 1994 and to identify factors that may explain any observed changes. Methods. The Third National Health and Nutrition Examination Survey was administered in 2 phases: phase I (1988-1991) and phase II (1991-1994), each comprising a national probability sample. OM (ever having had OM), early-onset OM (first episode at Results. After controlling for risk factors for OM, the prevalence of OM from phase I to phase II increased from 66.7% to 69.7% (odds ratio [OR] = 1.1; 95% confidence interval [CI] = .99, 1.1), early-onset OM increased from 41.1% to 45.8% (OR = 1.1; 95% CI = 1.03, 1.2), and repeated OM increased from 34.8% to 41.1% (OR = 1.2; 95% CI = 1.1, 1.4). This observed increase corresponds to 561 000 and 720 000 more children having early-onset OM and repeated OM, respectively. Child care use, early breastfeeding termination, asthma, and access to health care did not significantly increase from phase I to phase II. The prevalence of early-onset OM and repeated OM was higher for affluent children, but the greatest increase in prevalence was among impoverished children. There was an increase in allergic conditions from phase I to phase II for poor children (22.6% to 30.2%). Conclusions. The prevalence of early-onset OM and repeated OM continued to increase among preschool children in the United States. Further research to investigate this increasing prevalence should explore changes in management practice and an increase in prevalence of allergic conditions among poor children. Pediatrics 2003; 112:514-520; otitis media, early-onset otitis media, National Health and Nutrition Examination Survey, allergy, epidemiology, pediatric, children., Otitis media (OM) is the most common reason for an illness-related medical visit in pre-school age children. In 1990, OM accounted for 24.5 million clinical visits in the United States, [...]

From a normative perspective, conventional economic analysis is often used to establish a framework in which social objectives can be built into the decision-making process. The health economics literature, however, tends to overlook the positive analysis of decision making--often assuming particular social objectives that may or may not correspond with reality. This perhaps explains why exercises in health economics priority setting on occasions break down. This study is a positive analysis of group decision making. It examines the process of deliberating upon proposed changes to funding arrangements across Divisions of General Practice in Queensland, Australia. Existing levels of funding had, for a number of years, largely been determined by an allocation formula. The motivation for this study was a perceived inequity created by the long-term under-funding of smaller (resource poor or 'marginal') Divisions. The challenge in this project was that any change in funding arrangements required the support of all the Divisions but also would potentially create 'winners' and 'losers'. Decision making within such an institutional context was rendered a zero sum game. This paper documents a consultative process whereby the relevant stakeholders, with clear interests in any decision, were asked to participate in deliberations as to how such a problem should be tackled. The objective was, in the face of adverse incentives, to derive recommendations for addressing existing shortfalls experienced by some of these Divisions. The process involved encouraging relevant players to take into consideration the global allocation issues and to move beyond their localised interests. The results indicate that such a process can be effective in not only generating the necessary goodwill to enable such group decision making, but also in establishing a more realistic set of policy recommendations. Keywords: Institutions; Priority setting: Decision making; Political economy; Health policy; Australia