Elias Mossialos

Equity of access to health care: outlining the foundations for action

The Ministers of Health from Chile, Germany, Greece, New Zealand, Slovenia, Sweden, and the United Kingdom recently established The International Forum on Common Access to Health Care Services, based on a common belief that their citizens should enjoy universal and equitable access to good quality health care. The ministers intend to form a network to share thinking and evidence on healthcare improvements, with the specific aim of sustaining and promoting equitable access to health care. Despite a vast literature on the notion of equity of access, little agreement has been reached in the literature on exactly what this notion ought to mean. This article provides a brief description of the relevance of the access principle of equity, and summarises the research programme that is necessary for turning the principle into a useful, operational policy objective.

Performance measurement for health system improvement : experiences, challenges and prospects

of health providers to be measured, there is a need for a more strategic vision of the role that performance measurement can play in securing health system improvement. This volume meets this need by presenting the opportunities and challenges associated with performance measurement in a framework that is clear and easy to understand. It examines the various levels at which health system performance is undertaken, the technical instruments and tools available, and the implications using these may have for those charged with the governance of the health system.This summary makes the case for performance measurement as key tool for policy-makers endeavouring to improve health systems in the European Region. It highlights the various elements required of a comprehensive health system performance measurement framework; pinpoints how performance measurement can be used in practice; and stresses the role of government stewardship in securing improved performance. It reviews existing evidence and provides examples of the empirical application of performance measures, demonstrating that if governments invest in health they can expect those resources to be used well.

Health technology assessment and its influence on health-care priority setting

In this article, we review the development of health technology assessment (HTA) in England and Wales, France, The Netherlands, and Sweden, and we summarize the reaction to these developments from a variety of different disciplinary and stakeholder perspectives (political science, sociology, economics, ethics, public health, general practice, clinical medicine, patients, and the pharmaceutical industry). We conclude that translating HTA into policy is a highly complex business and that, despite the growth of HTA over the past two decades, its influence on policy making, and its perceived relevance for people from a broad range of different perspectives, remains marginal.

Cost containment and health care reform: a study of the European Union

This article gives a short summary of the organisation and financing of health services of the 12 Member States of the European Union. It then describes the latest developments in cost containment in each of the countries. The third section describes the new initiatives for reform in Spain, Italy, the Netherlands, Portugal and the United Kingdom. Finally, it gives a summary of the cost containment measures in the 12 countries, listing them under a set of headings. They are classified as budget control, alternatives to hospital care, cost sharing, influencing authorizing behaviour and limits on supply. The article shows the considerable convergence of policies which is developing. Overall budget control in some form is to be found in 8 of the countries. Where providers are paid by a number of different insurers, budgets are nevertheless applied to hospitals in three countries and in another only to public hospitals. Both Germany and France have used budgets to control other items of expenditure. Profits or the prices of drug companies are controlled in 8 countries and in one indirectly. Three have adopted reference price systems for drugs and another has taken powers to do so. Two have adopted or are moving towards provider markets.

Stoking the antibiotic pipeline

New antibiotics to tackle multidrug resistant bacteria are much needed. Chantal Morel and Elias Mossialos show how financial incentives might be used to persuade drug companies to develop them

Citizens and rationing: analysis of a European survey

While many studies have reviewed the issues involved in rationing and priority setting within health care services, few studies have comprehensively analysed the views and attitudes of a significant stakeholder in the debate - the public. The aims of this paper are to discuss the issues involved in involving the public in rationing and priority setting decision-making; and to analyse data pertaining to citizens attitudes towards rationing and priority setting. The data analysed were taken from the 1998 Eurobarometer Survey, with specific questions pertaining to rationing and priority setting asked in six countries within the European Union: Germany; France; Italy; the Netherlands; Britain and Sweden. The review of previous studies and the analysis of the Eurobarometer data, focus on issues relating to funding for health care; the need to set limits in health coverage; the role of stakeholders in setting priorities; and the use of age, and other factors, as a criteria for setting priorities.

From "retailers" to health care providers : Transforming the role of community pharmacists in chronic disease management

Community pharmacists are the third largest healthcare professional group in the world after physicians and nurses. Despite their considerable training, community pharmacists are the only health professionals who are not primarily rewarded for delivering health care and hence are under-utilized as public health professionals. An emerging consensus among academics, professional organizations, and policymakers is that community pharmacists, who work outside of hospital settings, should adopt an expanded role in order to contribute to the safe, effective, and efficient use of drugs-particularly when caring for people with multiple chronic conditions. Community pharmacists could help to improve health by reducing drug-related adverse events and promoting better medication adherence, which in turn may help in reducing unnecessary provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the health system. This paper reviews recent strategies to expand the role of community pharmacists in Australia, Canada, England, the Netherlands, Scotland, and the United States. The developments achieved or under way in these countries carry lessons for policymakers world-wide, where progress thus far in expanding the role of community pharmacists has been more limited. Future policies should focus on effectively integrating community pharmacists into primary care; developing a shared vision for different levels of pharmacist services; and devising new incentive mechanisms for improving quality and outcomes.

Diabetes and urbanization in the Omani population: an analysis of national survey data

BackgroundThe prevalence of type 2 diabetes in Oman is high and appears to be rising. Rising rates of diabetes and associated risk factors have been observed in populations undergoing epidemiological transition and urbanization. A previous study in Oman indicated that urban-dwellers were not significantly more likely to have diabetes. This study was undertaken to determine if a more accurate urban and rural categorization would reveal different findings.MethodsThis study included 7179 individuals aged 20 years or above who participated in a cross-sectional interviewer-administered survey in Oman including blood and anthropomorphic tests. Multiple logistic regression analyses were conducted to analyze the factors associated with diabetes, first in the whole population and then stratified according to region.ResultsThe prevalence of diabetes (fasting blood glucose ≥ 7 mmol/l) in the capital region of Muscat was 17.7% compared to 10.5% in rural areas. The prevalence of self-reported diabetes was 4.3%. Urban residence was significantly associated with diabetes (adjusted odds ratio (OR) = 1.7, 95% confidence interval (CI): 1.4–2.1), as was age (OR = 1.2, 95% CI: 1.1- 1.2), obesity (abnormal waist circumference) (OR = 1.8, 95% CI: 1.5–2.1), and systolic blood pressure (SBP) 120–139 (OR = 1.4, 95% CI:1.04–1.8), SBP 140–159 (OR = 1.9, 95% CI: 1.4–2.6), SBP ≥ 160 (OR = 1.7, 95% CI: 1.2–2.5). Stratified analyses revealed higher education was associated with reduced likelihood of diabetes in rural areas (OR = 0.6, 95% CI: 0.4–0.9).ConclusionA high prevalence of diabetes, obesity, hypertension and high cholesterol exist in the Omani population, particularly among urban-dwellers and older individuals. It is vital to continue monitoring chronic disease in Oman and to direct public health policy towards preventing an epidemic.

Measuring Socioeconomic Differences in Use of Health Care Services by Wealth Versus by Income

OBJECTIVES We compared the extent of socioeconomic differences in use of health care services based on wealth (i.e., accumulated assets) as the socioeconomic ranking variable with the extent of differences based on income to explore the sensitivity of the estimates of equity to the choice of the socioeconomic indicator. METHODS We used data from the Health and Retirement Study in the United States and the Survey of Health, Ageing, and Retirement in Europe to estimate levels of income- and wealth-related disparity in use of physician and dental services among adults 50 or older in 12 countries. RESULTS We found socioeconomic differences in use of physician services after standardizing for need in about half of the countries studied. No consistent pattern in levels of disparity measured by wealth versus those measured by income was found. However, the rich were significantly more likely to use dental services in all countries. Wealth-related differences in dental service use were consistently higher than were income-related differences. CONCLUSIONS We found some support for wealth as a more sensitive indicator of socioeconomic status among older adults than was income. Wealth may thus allow more accurate measurements of socioeconomic differences in use of health care services for this population.

What impact do prescription drug charges have on efficiency and equity? Evidence from high-income countries.

As pharmaceutical expenditure continues to rise, third-party payers in most high-income countries have increasingly shifted the burden of payment for prescription drugs to patients. A large body of literature has examined the relationship between prescription charges and outcomes such as expenditure, use, and health, but few reviews explicitly link cost sharing for prescription drugs to efficiency and equity. This article reviews 173 studies from 15 high-income countries and discusses their implications for important issues sometimes ignored in the literature; in particular, the extent to which prescription charges contain health care costs and enhance efficiency without lowering equity of access to care.