Brent D. Fulton

Health workforce skill mix and task shifting in low income countries: a review of recent evidence.

BackgroundHealth workforce needs-based shortages and skill mix imbalances are significant health workforce challenges. Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address these challenges. This study uses an economics perspective to review the skill mix literature to determine its strength of the evidence, identify gaps in the evidence, and to propose a research agenda.MethodsStudies primarily from low-income countries published between 2006 and September 2010 were found using Google Scholar and PubMed. Keywords included terms such as skill mix, task shifting, assistant medical officer, assistant clinical officer, assistant nurse, assistant pharmacist, and community health worker. Thirty-one studies were selected to analyze, based on the strength of evidence.ResultsFirst, the studies provide substantial evidence that task shifting is an important policy option to help alleviate workforce shortages and skill mix imbalances. For example, in Mozambique, surgically trained assistant medical officers, who were the key providers in district hospitals, produced similar patient outcomes at a significantly lower cost as compared to physician obstetricians and gynaecologists. Second, although task shifting is promising, it can present its own challenges. For example, a study analyzing task shifting in HIV/AIDS in sub-Saharan Africa noted quality and safety concerns, professional and institutional resistance, and the need to sustain motivation and performance. Third, most task shifting studies compare the results of the new cadre with the traditional cadre. Studies also need to compare the new cadres results to the results from the care that would have been provided--if any care at all--had task shifting not occurred.ConclusionsTask shifting is a promising policy option to increase the productive efficiency of the delivery of health care services, increasing the number of services provided at a given quality and cost. Future studies should examine the development of new professional cadres that evolve with technology and country-specific labour markets. To strengthen the evidence, skill mix changes need to be evaluated with a rigorous research design to estimate the effect on patient health outcomes, quality of care, and costs.

The mental health workforce gap in low- and middle-income countries: a needs-based approach

OBJECTIVE To estimate the shortage of mental health professionals in low- and middle-income countries (LMICs). METHODS We used data from the World Health Organizations Assessment Instrument for Mental Health Systems (WHO-AIMS) from 58 LMICs, country-specific information on the burden of various mental disorders and a hypothetical core service delivery package to estimate how many psychiatrists, nurses and psychosocial care providers would be needed to provide mental health care to the total population of the countries studied. We focused on the following eight problems, to which WHO has attached priority: depression, schizophrenia, psychoses other than schizophrenia, suicide, epilepsy, dementia, disorders related to the use of alcohol and illicit drugs, and paediatric mental disorders. FINDINGS All low-income countries and 59% of the middle-income countries in our sample were found to have far fewer professionals than they need to deliver a core set of mental health interventions. The 58 LMICs sampled would need to increase their total mental health workforce by 239,000 full-time equivalent professionals to address the current shortage. CONCLUSION Country-specific policies are needed to overcome the large shortage of mental health-care staff and services throughout LMICs.

Positive Association Between Attention-Deficit/ Hyperactivity Disorder Medication Use and Academic Achievement During Elementary School

OBJECTIVE. Approximately 4.4 million (7.8%) children in the United States have been diagnosed with attention-deficit/hyperactivity disorder, and 56% of affected children take prescription medications to treat the disorder. Attention-deficit/hyperactivity disorder is strongly linked with low academic achievement, but the association between medication use and academic achievement in school settings is largely unknown. Our objective was to determine if reported medication use for attention-deficit/hyperactivity disorder is positively associated with academic achievement during elementary school. METHOD. To estimate the association between reported medication use and standardized mathematics and reading achievement scores for a US sample of 594 children with attention-deficit/hyperactivity disorder, we used 5 survey waves between kindergarten and fifth grade from the nationally representative Early Childhood Longitudinal Study—Kindergarten Class of 1998–1999 to estimate a first-differenced regression model, which controlled for time-invariant confounding variables. RESULTS. Medicated children had a mean mathematics score that was 2.9 points higher than the mean score of unmedicated peers with attention-deficit/hyperactivity disorder. Children who were medicated for a longer duration (at >2 waves) had a mean reading score that was 5.4 points higher than the mean score of unmedicated peers with attention-deficit/hyperactivity disorder. The medication-reading association was lower for children who had an individualized education program than for those without such educational accommodation. CONCLUSIONS. The finding of a positive association between medication use and standardized mathematics and reading test scores is important, given the high prevalence of attention-deficit/hyperactivity disorder and its association with low academic achievement. The 2.9-point mathematics and 5.4-point reading score differences are comparable with score gains of 0.19 and 0.29 school years, respectively, but these gains are insufficient to eliminate the test-score gap between children with attention-deficit/hyperactivity disorder and those without the disorder. Long-term trials are needed to better understand the relationship between medication use and academic achievement.

Estimates Of Health Care Professional Shortages In Sub-Saharan Africa By 2015

This paper uses a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in thirty-nine African countries for 2015, the target date of the United Nations Millennium Development Goals. We forecast that thirty-one countries will experience needs-based shortages of doctors, nurses, and midwives, totaling approximately 800,000 health professionals. We estimate the additional annual wage bill required to eliminate the shortage at about

International Variation in Treatment Procedures for ADHD: Social Context and Recent Trends

2.6 billion (2007

Health care supply and county-level variation in attention-deficit hyperactivity disorder prescription medications

US)-more than 2.5 times current wage-bill projections for 2015. We illustrate how changes in workforce mix can reduce this cost, and we discuss policy implications of our results.

Review of Medicare, Medicaid, and Commercial Quality of Care Measures: Considerations for Assessing Accountable Care Organizations

OBJECTIVE Scientific and clinical interest in attention-deficit hyperactivity disorder (ADHD) is increasing worldwide. This article presents data from a cross-national workshop and survey related to questions of variability in diagnostic and, particularly, treatment procedures. METHODS Representatives of nine nations (Australia, Brazil, Canada, China, Germany, Israel, the Netherlands, Norway, and the United Kingdom), plus the United States, who attended a 2010 workshop on ADHD, responded to a survey that addressed diagnostic procedures for ADHD; treated prevalence of medication approaches, as well as psychosocial interventions; types of medications and psychosocial treatments in use; payment systems; beliefs and values of the education system; trends related to adult ADHD; and cultural and historical attitudes and influences related to treatment. RESULTS Use of both medication and psychosocial treatment for ADHD varies widely within and across nations. More expensive long-acting formulations of medications are becoming more widespread. Nations with socialized medical care provide a wide array of evidence-based interventions. Economic, historical, and political forces and cultural values are related to predominant attitudes and practices. Strong antipsychiatry and antimedication voices remain influential in many nations. CONCLUSIONS There is considerable variation in implementation of care for ADHD. Recognition of the social context of ADHD is an important step in ensuring access to evidence-based interventions for this prevalent, chronic, and impairing condition.

Differing Impacts Of Market Concentration On Affordable Care Act Marketplace Premiums

Although much literature reports small‐area variation in medication prescriptions used to treat attention‐deficit hyperactivity disorder (ADHD), scant research has examined factors that may drive this variation. We examine, across counties in the USA, whether the use of prescription medications to treat ADHD varies positively with supply‐side healthcare characteristics.

A New Vision for California’s Healthcare System: Integrated Care with Aligned Financial Incentives

Accountable care organizations (ACOs) have proliferated under the Affordable Care Act (ACA). If ACOs are to improve health care quality and lower costs, quality measures will be increasingly important in determining if provider consolidations associated with the development of ACOs are achieving their intended purpose. This article assesses quality measurement across public and private sectors. We reviewed available quality measures for a subset of programs in six organizations and assessed the number and domain of measures (structure, process, outcomes, and patient experience). Two-thirds of all quality measures were categorized as process measures. Outcome measures made up nearly 20 percent of measures. Patient experience and structure measures made up approximately 8 percent and 7 percent, respectively. We propose further improvements to quality measurement initiatives. For example, programs that reward providers should consider reward size and distribution within the organization. Quality improvement initiatives should consider what encourages provider buy-in and participation and the effects on populations with disproportionate health care needs. As the focus of quality initiatives may change from year to year, measures should be periodically revisited to ensure continued improvement and sustainability. Finally, we suggest quality measures that regulators could use prior to ACO formation or in the year or two following formation.

State Variation in Increased ADHD Prevalence: Links to NCLB School Accountability and State Medication Laws.

Recent increases in market concentration among health plans, hospitals, and medical groups raise questions about what impact such mergers are having on costs to consumers. We examined the impact of market concentration on the growth of health insurance premiums between 2014 and 2015 in two Affordable Care Act state-based Marketplaces: Covered California and NY State of Health. We measured health plan, hospital, and medical group market concentration using the well-known Herfindahl-Hirschman Index (HHI) and used a multivariate regression model to relate these measures to premium growth. Both states exhibited a positive association between hospital concentration and premium growth and a positive (but not statistically significant) association between medical group concentration and premium growth. Our results for health plan concentration differed between the two states: It was positively associated with premium growth in New York but negatively associated with premium growth in California. The health plan concentration finding in Covered California may be the result of its selectively contracting with health plans.