David Legge

Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance

OBJECTIVE To assess the degree to which the Chinese people are protected from catastrophic household expenditure and impoverishment from medical expenses and to explore the health system and structural factors influencing the first of these outcomes. METHODS Data were derived from the Fourth National Health Service Survey. An analysis of catastrophic health expenditure and impoverishment from medical expenses was undertaken with a sample of 55 556 households of different characteristics and located in rural and urban settings in different parts of the country. Logistic regression was used to identify the determinants of catastrophic health expenditure. FINDINGS The rate of catastrophic health expenditure was 13.0%; that of impoverishment was 7.5%. Rates of catastrophic health expenditure were higher among households having members who were hospitalized, elderly, or chronically ill, as well as in households in rural or poorer regions. A combination of adverse factors increased the risk of catastrophic health expenditure. Families enrolled in the urban employee or resident insurance schemes had lower rates of catastrophic health expenditure than those enrolled in the new rural corporative scheme. The need for and use of health care, demographics, type of benefit package and type of provider payment method were the determinants of catastrophic health expenditure. CONCLUSION Although China has greatly expanded health insurance coverage, financial protection remains insufficient. Policy-makers should focus on designing improved insurance plans by expanding the benefit package, redesigning cost sharing arrangements and provider payment methods and developing more effective expenditure control strategies.

Pushing the international health research agenda towards equity and effectiveness

Despite substantial sums of money being devoted to health research most of it does not benefit the health of poor people living in developing countries—a matter of concern to civil society networks such as the People’s Health Movement. Health research should play a more influential part in improving the health of poor people not only through the distribution of knowledge but also by answering questions such as why health and healthcare inequities continue to grow despite greatly increased global wealth enhanced knowledge and more effective technologies. Previous Editorials in this journal and other reports have already highlighted three important issues. First that the 10:90 gap—whereby only 10% of worldwide health research funds are allocated to the problems responsible for 90% of the world’s burden of disease mainly in poor countries—needs to be reversed. Second that greater emphasis should be placed on research in the social economic and political determinants of ill health relative to clinical and biological research. Third that the barriers to the transfer of knowledge from research into policy and practice need to be overcome. (excerpt)

The potential for multi-disciplinary primary health care services to take action on the social determinants of health: actions and constraints

BackgroundThe Commission on the Social Determinants of Health and the World Health Organization have called for action to address the social determinants of health. This paper considers the extent to which primary health care services in Australia are able to respond to this call. We report on interview data from an empirical study of primary health care centres in Adelaide and Alice Springs, Australia.MethodsSixty-eight interviews were held with staff and managers at six case study primary health care services, regional health executives, and departmental funders to explore how their work responded to the social determinants of health and the dilemmas in doing so. The six case study sites included an Aboriginal Community Controlled Organisation, a sexual health non-government organisation, and four services funded and managed by the South Australian government.ResultsWhile respondents varied in the extent to which they exhibited an understanding of social determinants most were reflexive about the constraints on their ability to take action. Services’ responses to social determinants included delivering services in a way that takes account of the limitations individuals face from their life circumstances, and physical spaces in the primary health care services being designed to do more than simply deliver services to individuals. The services also undertake advocacy for policies that create healthier communities but note barriers to them doing this work. Our findings suggest that primary health care workers are required to transverse “dilemmatic space” in their work.ConclusionsThe absence of systematic supportive policy, frameworks and structure means that it is hard for PHC services to act on the Commission on the Social Determinants of Health’s recommendations. Our study does, however, provide evidence of the potential for PHC services to be more responsive to social determinants given more support and by building alliances with communities and social movements. Further research on the value of community control of PHC services and the types of policy, resource and managerial environments that support action on social determinants is warranted by this study’s findings.

Negotiating Tensions in Developing Organizational Policy Capacity: Comparative Lessons to be Drawn

Abstract This article explores how organizational policy capacity can be developed, drawing on a study conducted in a large human services agency in Australia. Building policy capacity within government agencies is widely acknowledged as important for successfully responding to complex policy problems. The existing literature suggests a range of strategies for building organizational capacity. Findings from interviews with policy workers support the principles for building policy capacity identified in the literature but uncovered a surprising degree of scepticism pointing to significant barriers to their realization. These barriers are identified as emerging out of the tensions between policy capacity and two other domains of governing capacity: administrative capacity and state capacity. These tensions however are highly contingent and dynamic; managing them requires a degree of discretion and judgement, in brief, policy leadership. A focus on developing policy leadership at the level of policy units and teams may present a strategic approach to building organizational capacity for policy work.

Revitalising primary healthcare requires an equitable global economic system - now more than ever

The promised revitalisation of primary healthcare (PHC) is happening at a time when the contradictions and unfairness of the global economic system have become clear, suggesting that the current system is unsustainable. In the past two decades, one of the most significant impediments to the implementation of comprehensive PHC has been neoliberal economic policies and their imposition globally. This article questions what will be required for PHC to flourish. PHC incorporates five key principles: equitable provision of services, comprehensive care, intersectoral action, community involvement and appropriate technology. This article considers intersectoral action and comprehensiveness and their potential to be implemented in the current global environment. It highlights the constraints to intersectoral action through a case study of nutrition in the context of globalisation of the food chain. It also explores the challenges to implementing a comprehensive approach to health that are posed by neoliberal health sector reforms and donor practices. The paper concludes that even well-designed health systems based on PHC have little influence over the broader economic forces that shape their operation and their ability to improve health. Reforming these economic forces will require greater regulation of the national and global economic environment to emphasise peoples health rather than private profit, and action to address climate change. Revitalisation of PHC and progress towards health equity are unlikely without strong regulation of the market. The further development and strengthening of social movements for health will be key to successful advocacy action.

Policy Contradictions Limiting Hospital Performance in China

In this paper we explore some of the ways in which the current health policy environment in China enables and constrains performance improvement in the teaching hospital sector. We commenced this research with concerns about the quality and efficiency of hospital services. We aimed to estimate the degree to which these problems are due to weaknesses in management training and/or to wider system factors. We collected data from managers in three teaching hospitals in south-western China. Our results demonstrate some shortfalls in organisational performance in the three hospitals, some of which are partly due to lack of management expertise. However, there are also contradictions and perverse incentives in the wider policy environment that would prevent even the best-trained managers from achieving high levels of quality and efficiency. In this paper we explore some of the key policy constraints limiting the development of hospital performance in China and the implications of these for policy-makers.

Future of WHO hangs in the balance.

WHO is in crisis. Unless member states can be persuaded to “untie” their donations and give the organisation leeway to control its budget and set priorities WHO will slide further into irrelevance with disastrous consequences for global health, warns David Legge

The evaluation of health development: the next methodological frontier?

Social conditions, or ‘factors in the social environment’, comprise a major set of influences on the health of populations.These include material factors (access to resources and exposure to material hazard), social and cultural factors (social cohesion, level of education) and emotional/psychological factors (being in control of one’s life, belonging, being loved and valued).’ Some of these are individual factors (being in control of one’s life); some are group factors (social cohesion); and others could be constructed as either (exposure to material hazard). These different factors are all subject to debate: their relative importance, how they are best theorised and the mechanisms through which they affect health. Many different constructs and explanatory models have been developed which overlap each other in varying degrees. There is presently a great deal of interest in the concept of ‘social capital’ as a way of theorising and measuring the influence of social factors on population health. There is also a lively debate about the relationships between material deprivation and inequality per se. The measurement of indicators which correspond to these various theoretical constructs is difficult and controversial.’ Various principles, strategies and styles of practice designed to address the social determinants of health have been developed in different sectors of public health practice, under somewhat different labelc. These include: intersectoral policy collaboration; community development and empowering styles of health education. All are widely deployed, usually with a view to changing the social conditions which frame people’s health chances. In this editorial, the term ‘health development’ is used as a generic hold-all to encompass the range of principles, strategies and styles of practice which have been developed in various sectors of public health practice to address the social (including economic, political and cultural) influences on population health.The logic and directions of health development are most famously expressed in theAlma-Ata Declaration of 1978 and the Ottawa Charter of I986 although they have been implemented in strategies and styles of practice which extend beyond the boundaries of primary health care and health promotion. Well before Alma-Ata, primary health care practitioners were working in partnership with communities to address the wider social conditions which shape their health and health educators were developing an empowering approach in their work (under the influence of Paulo Friere in particular).3 Well before the Ottawa Charter, public health officials were working with the food industry, housing authorities, the education system and land use planners to deveIop and implement ‘healthy public policy’. Health development has never been the dominant paradigm of public health practice but today i t is in particular jeopardy. It is in jeopardy for two reasons: an unsympathetic ideological climate and a vulnerability with respect to outcomes and evidence. This latter vulnerability may reflect the weaknesses of evaluation methodology more than the ineffectiveness of health development. Economic rationalism is not sympathetic to projects like ‘creating a healthier society’. Neo-liberalism, the political philosophy which informs economic rationalism, is sceptical of the assumption that people and governments might, through democratic discussion and decision, actively build better futures. Neoliberalism warns about the unintended adverse consequences of government action and calls for small government, arguing that the invisible hand of the market (working through consumer choice and entrepreneurial competition) is generally a more reliable motive principle.‘ Mainstream public health is fairly secure despite the ideologues. There is strong political support and in some cases strong economic arguments for important public health programs such as food safety, occupational health and various programs directed towards illness and injury prevention. In fact, the disciplines imposed through economic rationalism may have benefitted public health in some ways. The increased focus on outcomes and on evidence-based practice may have helped to refocus policy and expenditure priorities on interventions that work, rather than on programs that are well-established or well-marketed. The ascendancy of the doctrine of outcomes and evidencebased practice has boosted the standing and the funding of those disciplines within public health whose business i t is to measure outcomes and evaluate interventions. However, with this increased authority comes increased responsibility. The methodologists and evaluationists are increasingly placed in the position of endorsing or rejecting interventions and methods from widely varying settings of public health practice. In circumstances where the methodological tools for outcome measurement and evaluation are inadequate, important sectors of public health activity may be placed in jeopardy because they are not able to demonstrate outcomes or effectiveness in the terms defined by mkthodogical orthodoxy. Health development is a case in point. Health development strategies are commonly directed at outcomes which are projected some considerable distance into the future. This is particularly so where the conditions for poor health are embedded in history and social relations, as in the case ofAboriginal health, or in the distribution of power and income, as in the case of socio-economic inequalities.The specification of program objectives and time lines in such circumstances is clouded by uncertainty. Society is a ‘complex adaptive system’, both complex and very sensitive to conting e n ~ y . ~ We can be confident of the outcomes of any set of actions only across a relatively short time frame. This is recognised in most sectors of health development through the setting of short and long-term objectives and focusing on capacity-building in relation to the medium and longer term. My colleagues and I identified three outcome horizons in published accounts of primary health care practice?’ outcomes for today (measurable health gains); outcomes for tomorrow (improved health care or health

Strengthening public health engagement in trade policy: PHAA's policy on Trade Agreements and Health

AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 7

Micro macro integration: Reframing primary healthcare practice and community development in health

The idea of micro macro integration (MMI) provides a useful framework for thinking about primary healthcare (PHC) and community development in health (CD). PHC and CD are important strategies for addressing the structural determinants of health. They are each based on a powerful logic and have a significant body of support. However, while exemplary, even inspiring, instances of practice are common, attempts to replicate models of good practice (or ‘scale up’) often flounder. As frameworks for analysing this paradox, both PHC and CD have limitations, partly because they are overburdened with different and conflicting meanings. This paper explores an alternative framework based on a common aspiration of both PHC and CD: to effect change at both the micro level (meeting the immediate health needs of individuals, families and communities) and also at the macro level (of political, economic and social structures). The MMI framework assumes that health issues can be analysed at different levels of scale and of term (from the micro to the macro); that objectives and strategies can be conceived at these different levels; and that a coherent programme of activities can be conceived and implemented which addresses both the immediate and local problems and the larger scale and longer term phenomena that reproduce those patterns of need. The idea of MMI is less ambitious than either PHC or CD but (partly because of this) has value as a framework for analysing barriers to good practice.