International Journal of Health Policy and Management
Volume:11 Issue: 4, Apr 2022

Coronavirus disease 2019 (COVID-19) dramatically unveiled the fragile state of the world’s health and social systems – the lack of emergency health crisis preparedness (under-resourced, weak leadership, strategic plans without clear lines of authority), siloed policy frameworks (focus on individual diseases and the lack of integration of health into the whole of societal activity and its impact on individual as well as community well-being and prosperity), and unclear communication (misguided rationale of policies, inconsistent interpretation of data). The net result is fear – about the disease, about risks and survival, and about economic security. We discuss the interdependencies among these domains and their emergent dynamics and emphasise the need for a robust distributed health system and for transparent communication as the basis for trust in the system. We conclude that systems thinking and complexity sciences should inform the redesign of strong health systems urgently to respond to the current health crisis and over time to build healthy, resilient, and productive communities.

Taxation of tobacco, food, alcohol and other beverages has gained renewed attention in responding to non-communicable diseases (NCDs). While largely built on evidence from high-income countries (HICs), the projected economic and health benefits of these measures have increased calls for their use in price-sensitive low- and middle-income countries (LMICs). However, uptake has been sporadic and there remains little research on why and how LMICs utilise fiscal measures in response to NCDs. 

This scoping review analyses factors influencing the design and implementation of health-related fiscal measures in LMICs. Utilising Arksey and O’Malley’s scoping review methodology and Walt and Gilson’s policy triangle, we considered the contextual, procedural, content and stakeholder-related factors that influenced measures.

 Results

We identified 75 papers focussing on health-related fiscal measures, with 47 (63%) focused on tobacco, 5 on alcohol, 6 on soft drink and 4 studies on food-related fiscal regulation. Thirteen papers analysed multiple measures and most papers (n = 66, 88%) were less than a decade old. Key factors enabling the design and implementation of measures included localised health and economic evidence, policy championing, inter-ministerial support, and global or regional momentum. Impeding factors encompassed negative framing and retaliation by industry, vested interests and governmental policy disjuncture. Aligning with theoretic insights from the policy triangle, findings consistently demonstrated that the interplay between factors – rather than the presence or absence of particular factors – has the most profound impact on policy implementation. 

Given the growing urgency to address NCDs in LMICs, this review highlights the need for recognition and rigorous exploration of political economy factors influencing the design and implementation of fiscal measures. Broader LMIC-specific empirical research is needed to overcome an implication noted in much of the literature: that mechanisms used to enact tobacco taxation are universally applicable to measures targeting foods, alcohol and other beverages.

On February 26, 2020, the first case of coronavirus disease 2019 (COVID-19) was detected in Israel. The Ministry of Health (MoH) instructed people to take isolation measures and restrict their movement. Similarly, there was a gradual decrease in the number of visits to our emergency department (ED). ObjectivesTo describe the decline in the referrals to the ED and in-hospital beds occupancy during the COVID-19 pandemic and to compare it to the H1N1 2009 pandemic. 

Employing a cross-sectional epidemiologic study, the pattern of visits to the ED during the COVID-19 was compared with the pattern of visits during the 2009 H1N1 pandemic, as well as a year without a pandemic. The data was adjusted to consider changes in population size. The Welch t test for unpaired, unequal samples was used to analyze the data. 

Within 2 months of the COVID-19 outbreak, the average number of visits to the ED dropped by 30.2% and the hospital occupancy by 29.2% (a minimum of 57%), compared to the same period, the year before. In comparison to the same period during the H1N1 outbreak, we witnessed a significant decline in the number of visits to the ED during the COVID-19 outbreak. 

The behavior of people during the COVID-19 pandemic was different from their behavior during the H1N1 pandemic. People seemed to avoid visiting the ED. The boundary between precaution and panic in the generation of the media could be very thin. Decision-makers must take this into account.

To determine whether population-adjusted rates of physical rehabilitation need (ie, disability-related epidemiological data) are associated with the workforce supply (ie, combined rates of practicing physical therapists (PTs) and occupational therapists (OTs) per 10 000 population) across high-income countries (HICs), adjusted for socio-demographic and economic covariates.

This is a cross-national ecological study. Hierarchical, multiple linear regressions analyzed current international data across 35 HICs using: current PTs and OTs supply data obtained from the international professional federations (outcome variable); needs data obtained from the Global Burden of Disease 2017 (GBD 2017); and finally relevant socio-demographic variables and supply-side covariates extracted from the World Bank, GBD 2017, the supply data sources, and the Global Health Expenditure Database.

The PTs and OTs per capita varied greatly across the 35 HICs, differing by as much as 40-fold. Denmark had the greatest supply per capita. Physical rehabilitation need was not a significant, independent predictor of workforce supply regardless of the multiple regression model used (P >.10). In the final model, after Bonferroni correction, 3 covariates were significant, independent predictors of the supply variable: gross national income (GNI) per capita and the current health expenditure in % of gross domestic product (GDP) were positive factors for workforce supply, while population size was a negative factor (all P <.01).

PT and OT workforce supply is highly variable across HICs. This variability is not accounted for by an indicator of population need but rather by financial indicators and population size.

Diabetes imposes an enormous burden on patients, families, societies, and healthcare systems. Determining the affordability of medications is an important complicated and vague task, especially in low- and middle-income countries (LMICs). This study aimed to assess the affordability of diabetes medication therapy in Iran’s health system.

This paper presents a scenario-based assessment of the affordability of all registered anti-diabetes medications in Iran in 2017. To this end, 4 medication therapy scenarios were defined as mono, dual, triple, and insulin therapy in accordance with the existing guidelines and clinicians’ opinions. Then the affordability ratio of each treatment scenario was determined for type 1 and type 2 diabetes drawing on the World Health Organization (WHO)/Health Action International (HAI) Methodology. If the affordability ratio for treatment schedules was more than 1, the patients’ out-of-pocket (OOP) expenses exceeded the lowest-paid unskilled government worker (LPGW)’ wage per day, and the treatment was labelled as non-affordable.

The results revealed that the mono, dual, and triple (non-insulin) medication therapies in type 2 diabetes were affordable, despite an increase in the dosage or a switch from the monotherapy to the combination therapy of oral medications. However, some treatment scenarios in the triple therapy, including oral plus insulin and some insulin only therapies, were proved to be non-affordable. In type 1 diabetes, only insulin glulisine, detemir, and lispro were nonaffordable in monotherapy. Regarding the combination therapy, only isophane insulin with aspart or regular insulin were affordable treatments.

Although oral medication therapies were documented to be affordable, insulin therapy, with current coverage conditions, for patients with lowest paid wages and those receiving even less is unaffordable and a major barrier to treatment; hence, policy-maker should consider targeting and more financial protection policies to improve the affordability of insulin therapies among this group of patients

Coronavirus disease 2019 (COVID-19) is a new viral disease and in a short period of time, the world has been affected in various economic, social, and health aspects. This disease has a high rate of transmission and mortality. The aim of this study is to investigate the factors affecting the survival of COVID-19 patients in Kurdistan province.

In this retrospective study, the data including demographic features and the patient’s clinical background in terms of co-morbidities such as diabetes, cancer, chronic lung disease (CLD), coronary heart disease (CHD), chronic kidney disease (CKD) and weak immune system (WIS) were extracted from electronic medical records. We use Cox’s regression proportional hazard (PH) to model.

In this study, out of 1831 patients, 1019 were males (55.7%) and 812 were females (44.3%) with an average age of 52.74 ± 22.16 years. For survival analysis, data from people infected with COVID-19 who died or were still being treated were used. According to Cox’s regression analysis, age variables (hazard ratio [HR]: 1.03, CI: 1.02-1.04), patients with a history of diabetes (HR: 2.16, CI: 1.38-3.38), cancer (HR: 3.57, CI: 1.82-7.02), CLD (HR: 2.21, CI: 1.22-4) and CHD (HR: 2.20, CI: 1.57-3.09) were significant and affected the hazard of death in patients with COVID-19 and assuming that the other variables in the model are constant, the hazard of death increases by 3% by increasing one unit (year), and the hazard of death in COVID-19 patients with CHD, diabetes, cancer, CLD is 2.16, 3.57, 2.2 and 2.21, respectively.

According to findings, it is necessary to evaluate the prevalence of COVID-19 in patients with CLD, diabetes, cancer, CHD, and elder, as patients with these characteristics may face a greater risk of death. Therefore, we suggest that elders and people with those underlying illnesses need to be under active surveillance and screened frequently.

The implications of competition among hospitals on care quality have been the subject of considerable debate. On one hand, economic theory suggests that when prices are regulated, quality will be increased in competitive markets. On the other hand, hospital mergers have been justified by the need to exploit cost advantages, and by evidence that hospital volume and care quality are related.

Based on patient-level data from two years (2005 and 2012) we track changes in market competition and treatment patterns in breast cancer surgery. We focus on technology adoption as a proxy of process quality and examine the likelihood of offering two innovative surgical procedures: immediate breast reconstruction (IBR), after mastectomy and sentinel lymph node biopsy (SLNB). We use an index of competition based on a multinomial logit model of hospital choice which is not subject to endogeneity bias, and estimate its impact on the propensity to receive IBR and SLNB by means of multilevel models taking into account both observable patient and hospital characteristics.

The likelihood of receiving these procedures is significantly higher in hospitals located in more competitive markets. Yet, hospital volume remains a significant indicator of quality, therefore benefits of competition appear to be sensitive to the estimates of the impact of volume on care process. In France, the centralisation policy, with minimum activity thresholds, have contributed to improving breast cancer treatment between 2005 and 2012.

Finding the right balance between costs and benefits of market competition versus concentration of hospital care supply is complex. We find that close to monopolistic markets do not encourage innovation and quality in cancer treatment, but highly competitive markets where many hospitals have very low activity volumes are also problematic because hospital quality is positively linked to patient volume

BackgroundSince 2011, Taiwan’s National Health Insurance Administration (NHIA) issued a regulation on the reimbursement to anti-osteoporosis medications (AOMs). This study aimed to evaluate the impact of this regulation in reimbursement on the utilization of AOMs, clinical outcomes and associated medical expenditures of patients with incident hip fractures. MethodsBy using the National Health Insurance Research Database (NHIRD), patients with incident hip fracture from 2006 to 2015 were identified as our study cohort. Patients younger than 50 years old or prescribed with AOMs within one year prior to incident fracture were excluded. Outcomes of interest were quarterly estimates of the proportion of patients who received bone mineral density (BMD) examination, who were prescribed AOMs, as well as who encountered subsequent osteoporotic fracture-related visits and associated medical expenditures. Particularly, age- and gender-specific estimates were reported. An interrupted time series study design with segmented regression model was used to quantitatively explore the impact of the changes of the reimbursement criteria on the level (immediate) and trend (long-term) changes of these outcomes. ResultsOur study enrolled 118 493 patients with incident hip fracture with those patients aged older than 80 years old accounting for the largest proportion. A significantly decreased trend of AOMs prescription rates was observed immediately post regulation except for female aged between 65 and 80, while the long-term pattern showed no significant difference. However, the percentage of patients encountered subsequent osteoporotic fracture-related visit was not statistically different between pre- and post-regulation periods. Noteworthy, the policy regulation was associated with an increasing trend of osteoporotic fracture associated medical expenditures, especially for patients older than 80 years old. ConclusionThe regulation on the reimbursement for AOMs decreased the prescribing rate of AOMs immediately although the effect did not sustain thereafter. However, higher subsequent osteoporotic fracture-related medical expenditures were introduced, especially among those very old population.

There is an increasing emphasis on the importance of comprehensive primary healthcare (CPHC) in improving population health and health equity. There is, therefore, a need for a practical means to determine how comprehensive regional primary healthcare organisations (RPHCOs) are in their approach. This paper proposes a framework to provide such a means. The framework is then applied to assess the comprehensiveness of Australian RPHCOs.

Drawing on a narrative review of the broader literature on CPHC versus selective primary healthcare (SPHC) and examples of international models of RPHCOs, we developed a framework consisting of the key criteria and a continuum from comprehensive to selective interventions. We applied this framework to Australian RPHCOs using data from the review of their planning documents, and survey and interviews with executive staff, managers, and board members. We used a spidergram as a means to visualise how comprehensive they are against each of these criteria, to provide a practical way of presenting the assessment and an easy way to compare progress over time.

Key criteria for comprehensiveness included (1) focus on population health; (2) focus on equity of access and outcomes; (3) community participation and control; (4) integration within the broader health system; (5) intersectoral collaboration; and (6) local responsiveness. An examination of Australian RPHCOs using the framework suggests their approach is far from comprehensive and has become more selective over time.

The framework and spidergram offer a practical means of gauging and presenting the comprehensiveness of RPHCOs, and to identify gaps in comprehensiveness, and changes over time.

The cost-sharing impact on hospital service utilization of different services is a critical issue that has not been well addressed worldwide. This study aimed to investigate the cost-sharing effects based on income status on hospital service utilization of different services among elderly people in Japan and provide a comprehensive examination and discussion for the reasonability of a cost-sharing system.

The data were extracted from the Latter-Stage Elderly Healthcare Insurance database in the fiscal year 2016. A total of 610 182 insured people aged ≥75 years old, with 155 773 hospitalization patients, were identified. Hospitalization rate, length of stay (LOS), and total hospitalization cost were used to test the statistical significance among patients categorized by income levels. Generalized linear models for total hospitalization cost were constructed based on bed types to further assess different hospital service utilization.

For medical chronic care and psychiatric beds, which both required long-term care treatment, much higher hospitalization rates were observed in the patients with low- and middle-income levels than patients with high-income level. The LOS and total hospitalization cost of the patients with low- and middle-income levels were significantly higher than the patients with high-income level treated in medical chronic care and psychiatric beds. For psychiatric beds, the total hospitalization cost for patients with low-income level was significantly higher than that for patients with highincome level.

The cost-sharing policy in Japan, especially the cap for out-of-pocket needs further determination. The importance of community-based care services needs to be emphasized, and the collaboration between hospitals and community-based care facilities should be enhanced.

Uptake of social distancing behaviors may be determined by a combination of individual perceptions and social values. The study investigated (1) the associations between individual perception of perceived response efficacy and social distancing behaviors, (2) the association between social value of perceived freedom infringement and social distancing behaviors, and (3) whether perceived freedom infringement would moderate the association between perceived response efficacy and social distancing behaviors.

A cross-sectional telephone survey interviewed 300 adults in the Hong Kong adult general population during April 21-28, 2020. The instruments of social distancing behaviors, perceived response efficacy, and perceived freedom infringement assessed the frequencies of practicing seven types of social distancing behaviors in the past week, perceived response efficacy of four types of governmental social distancing measures/instructions, and a 5-point Likert scale item on perceived infringement on personal freedom regarding a governmental social distancing measure of banning gatherings of >4 people in public areas. Linear regression adjusted for background factors was performed; the interaction term of perceived response efficacy × perceived freedom infringement was tested.

About 40.4%-83.0% of the respondents practiced various types of social distancing behaviors; 57.3%-75.0% perceived response efficacies of related governmental measures; about 20% showed perceived freedom infringement. Perceived response efficacy, but not perceived freedom infringement, was independently and positively associated with social distancing behaviors. Perceived freedom infringement significantly moderated the association between perceived response efficacy and social distancing behaviors; such a positive association was significant at higher (those scored “extremely agree”), but not lower (those scored “extremely disagree”), levels of perceived freedom infringement.

Perceived response efficacy is a potential determinant of social distancing. However, the strength of such an association may be modified by opposing social values about personal freedom. Future studies are warranted to verify above findings and explore other potential determinants.

As health systems across the world respond to the coronavirus disease 2019 (COVID-19), there is rising concern that patients without COVID-19 are not receiving timely emergency care, resulting in avoidable deaths. This study examined patterns of self-reported health service utilization, their socio-demographic determinants and association with avoidable deaths during the COVID-19 outbreak.

A cross-sectional telephone survey was conducted between March 22 and April 1, 2020, during the peak rise in confirmed COVID-19 cases in Hong Kong. Cantonese-speaking Hong Kong residents over 18-years-old were recruited using a computerised random digital dialling (RDD) system. The RDD method used stratified random sampling to ensure a representative sample of the target population by age, gender, and residential district. A structured self-reported questionnaire was used.

Out of 1738 placed calls, 765 subjects responded to the questionnaire (44.0% response rate). The factors associated with avoiding medical consultation included being female (37.2% vs. 22.5%, P<.001), married (32.8% vs. 27%, P=.044), completing tertiary education (35.3% vs. 27.7% (secondary) vs. 14.8% (primary), P=.005), and those who reported a “large/very large” impact of COVID-19 on their mental health (36.1% vs 30.5% (neutral) vs. 19.7% (very small/small), P=.047) using logistic regression analysis.

Married females with both higher educational attainment and concern about COVID-19 were associated with avoiding healthcare services. Timely public communication to encourage and promote early health seeking treatment even during extreme events such as pandemics are needed.

The province of Ontario, Canada has made major investments in interdisciplinary primary care teams. There is interest in both demonstrating and improving the quality of care they provide. Challenges include lack of consensus on the definition of quality and evidence that the process of measuring quality can be counter-productive to actually achieving it. This study describes how primary care teams in Ontario voluntarily measured quality at the team level.

Data for this 4-year observational study came from electronic medical records (EMRs), patient surveys and administrative reports. Descriptive statistics were calculated for individual measures (eg, access, preventive interventions) and composite indicators of quality and healthcare system costs. Repeated measures identified patient and practice characteristics related to quality and cost outcomes.

Teams participated in an average of 5 of 8 possible iterations of the reporting process. There was variation between teams. For example, cervical cancer screening rates ranged from 21 to 86% of eligible patients. Rural teams had significantly better performance on some indicators (eg, continuity) and worse on others (eg, cancer screening). There were some statistical but small changes in performance over time.

High, sustained voluntary participation suggests that the initiative served a need for the primary care teams involved. The absence of robust data standards suggests that these standards were not crucial to achieve participation. The constant level of performance might mean that measurement has not yet led to improvement or that measures used might not accurately reflect improvement. The data reinforce the need to consider differences between rural and urban settings. They also suggest that further analysis is needed to identify characteristics that teams can change to improve the quality of care their patients experience. The study describes a practical, sustainable real-world approach to performance measurement in primary care that was attractive to interdisciplinary teams.

It is increasingly recognised within public health scholarship that policy change depends on the nature of the power relations surrounding and embedded within decision-making spaces. It is only through sustained shifts in power in all its forms (visible, hidden and invisible) that previously excluded perspectives have influence in policy decisions. Further, consideration of the underlying neoliberal paradigm is essential for understanding how existing power dynamics and relations have emerged and are sustained. In their analysis of political and governance factors, Townsend et al have provided critical insight into future potential strategies for increasing attention to health concerns in trade policy. In this commentary we explore how incorporating theories of power more rigorously into similar political analyses, as well as more explicit critical consideration of the neoliberal political paradigm, can assist in analysing if and how strategies can effectively challenge existing power relations in ways that are necessary for transformative policy change.

Townsend and colleagues highlighted the myriad political forces which fostered attention to health issues during negotiations to establish a new trans-pacific trade deal in Australia (the CP-TPP [Comprehensive and Progressive Agreement for Trans-Pacific Partnership], formerly known as TPP). Among the factors they identify, exporter interests and exogenous events helped to generate attention to trade-related concerns about tobacco and access medicines, and limited attention to nutrition and alcohol. These are important considerations as the United Kingdom negotiates a trade deal with the United States in haste, whilst at the same time attempting to manage the ongoing coronavirus disease 2019 (COVID-19) pandemic. In this commentary, I reflect on changing attention to trade and nutrition during the COVID-19 pandemic in light of Townsend and colleagues’ analysis. I explore scope for greater attention to nutrition in US-UK trade negotiations, and the challenges created by the vested interests of major UK and US processed food exporters. I further discuss the utility of the theoretical tools employed by Townsend and colleagues for wider debates in the political economy of health.

The power of the alcohol industry pervades the global governance of alcohol. The influence of the industry is seen in trade and investment treaty negotiations, operating through direct and indirect means. Curbing the influence of the industry is vital to improving the treatment of health issues generally and in trade and investment policy particularly. The World Health Organization (WHO) has an opportunity to start to rein in the power of the industry with its current work on drafting an ‘action plan’ for 2022-2030 to implement the Global Strategy to Reduce the Harmful Use of Alcohol. The WHO working paper, however, proposes inadequate controls on alcohol industry influence. The WHO proposes ‘dialogue’ with the industry and allows the industry to take a role with government in public health labelling of alcohol. The public’s health will suffer if the WHO does not take a firmer stand against the industry in the ‘action plan.’

The burden of registrations for professionals should be more firmly on the policy agenda. In a rigorous study, Marieke Zegers and colleagues make a compelling argument why that should be the case. In Dutch hospitals, the average professional spends 52.3 minutes a day on quality registries and monitoring instruments. Many more administrative duties exist. These represent substantial resources and ultimately could become a drag on the intrinsic motivation of the care professions. We agree with Zegers et al that we are in need for more operational efficiency. However, the issue at hand is very complex and also intensely connected to the entire healthcare system and its different levels. More operational efficiency alone will not solve this problem. We are also in need for better governance of data-issues at the macro-system level.

Countries around the world have implemented programs to help monitor and enhance the quality of health services provided. Inherent in these programs and internal process improvement initiatives are an array of reporting requirements which often place a burden on clinicians and the organizations in which they function. Zegers and colleagues performed a mixed methods study on the perceived burden which these reporting requirements place on doctors, nurses, and other clinicians within three hospitals in the Netherlands. Like all studies, theirs has some minor limitations; most notably possible limits on generalizability from a limited sample. Nonetheless, their project makes a valuable contribution to the growing body of research which suggests that the burden has deleterious effects on clinicians and may well have an erosive impact on patient care.

Zegers and colleagues’ study codifies the perceived burden of quality monitoring and improvement stemming from the work by clinicians of registering (documenting) quality information in the medical record. We agree with Zegers and colleagues’ recommendation that a smaller, more effective and curated set of measures is needed to reduce burden, confusion, and expense. We further note that focusing on validity of clinical evidence behind individual measures is critical, but insufficient. We therefore extend Zegers and colleagues’ work through a pragmatic, tripartite heuristic. To assess the value of and curate a targeted set of performance measures, we propose concentrating on the relationships among three factors: (1) The purpose of the performance measure, (2) the subject being evaluated, and (3) the consumer using information for decision-making. Our proposed tripartite framework lays the groundwork for executing the evidence-based recommendations proposed by Zegers et al, and provides a path forward for more effective healthcare performance-measurement systems.