Riti Shimkhada

Tobacco control in India

Legislation to control tobacco use in developing countries has lagged behind the dramatic rise in tobacco consumption. India, the third largest grower of tobacco in the world, amassed 1.7 million disability-adjusted life years (DALYs) in 1990 due to disease and injury attributable to tobacco use in a population where 65% of the men and 38% of the women consume tobacco. Indias anti-tobacco legislation, first passed at the national level in 1975, was largely limited to health warnings and proved to be insufficient. In the last decade state legislation has increasingly been used but has lacked uniformity and the multipronged strategies necessary to control demand. A new piece of national legislation, proposed in 2001, represents an advance. It includes the following key demand reduction measures: outlawing smoking in public places; forbidding sale of tobacco to minors; requiring more prominent health warning labels; and banning advertising at sports and cultural events. Despite these measures, the new legislation will not be enough to control the demand for tobacco products in India. The Indian Government must also introduce policies to raise taxes, control smuggling, close advertising loopholes, and create adequate provisions for the enforcement of tobacco control laws.

Financial Incentives And Measurement Improved Physicians’ Quality Of Care In The Philippines

The merits of using financial incentives to improve clinical quality have much appeal, yet few studies have rigorously assessed the potential benefits. The uncertainty surrounding assessments of quality can lead to poor policy decisions, possibly resulting in increased cost with little or no quality improvement, or missed opportunities to improve care. We conducted an experiment involving physicians in thirty Philippine hospitals that overcomes many of the limitations of previous studies. We measured clinical performance and then examined whether modest bonuses equal to about 5 percent of a physicians salary, as well as system-level incentives that increased compensation to hospitals and across groups of physicians, led to improvements in the quality of care. We found that both the bonus and system-level incentives improved scores in a quality measurement system used in our study by ten percentage points. Our findings suggest that when careful measurement is combined with the types of incentives we studied, there may be a larger impact on quality than previously recognized.

Public Health Impact of Extremely Low-Frequency Electromagnetic Fields

Introduction The association between exposure to extremely low-frequency electric and magnetic fields (ELF) and childhood leukemia has led to the classification of magnetic fields by the International Agency for Research on Cancer as a “possible human carcinogen.” This association is regarded as the critical effect in risk assessment. Creating effective policy in light of widespread exposure and the undisputed value of safe, reliable, and economic electricity to society is difficult and requires estimates of the potential public health impact and associated uncertainties. Objectives Although a causal relationship between magnetic fields and childhood leukemia has not been established, we present estimates of the possible pubic health impact using attributable fractions to provide a potentially useful input into policy analysis under different scenarios. Methods Using ELF exposure distributions from various countries and dose–response functions from two pooled analyses, we calculate country-specific and worldwide estimates of attributable fractions (AFs) and attributable cases. Results Even given a wide range of assumptions, we find that the AF remains < 10%, with point estimates ranging from < 1% to about 4%. For small countries with low exposure, the number of attributable cases is less than one extra case per year. Worldwide the range is from 100 to 2,400 cases possibly attributable to ELF exposure. Conclusion The fraction of childhood leukemia cases possibly attributable to ELF exposure across the globe appears to be small. There remain, however, a number of uncertainties in these AF estimates, particularly in the exposure distributions.

Projected health impact of the Los Angeles City living wage ordinance

Study objective: To estimate the relative health effects of the income and health insurance provisions of the Los Angeles City living wage ordinance. Setting and participants: About 10 000 employees of city contractors are subject to the Los Angeles City living wage ordinance, which establishes an annually adjusted minimum wage (

The impact of performance incentives on child health outcomes: results from a cluster randomized controlled trial in the Philippines

7.99 per hour in July 2002) and requires employers to contribute

Evidence of a causal link between health outcomes, insurance coverage, and a policy to expand access: experimental data from children in the Philippines.

1.25 per hour worked towards employees’ health insurance, or, if health insurance is not provided, to add this amount to wages. Design: As part of a comprehensive health impact assessment (HIA), we used estimates of the effects of health insurance and income on mortality from the published literature to construct a model to estimate and compare potential reductions in mortality attributable to the increases in wage and changes in health insurance status among workers covered by the Los Angeles City living wage ordinance. Results: The model predicts that the ordinance currently reduces mortality by 1.4 deaths per year per 10 000 workers at a cost of

The health and cost impact of care delay and the experimental impact of insurance on reducing delays.

27.5 million per death prevented. If the ordinance were modified so that all uninsured workers received health insurance, mortality would be reduced by eight deaths per year per 10 000 workers at a cost of

The Quality Improvement Demonstration Study: An example of evidence-based policy-making in practice

3.4 million per death prevented. Conclusions: The health insurance provisions of the ordinance have the potential to benefit the health of covered workers far more cost effectively than the wage provisions of the ordinance. This analytical model can be adapted and used in other health impact assessments of related policy actions that might affect either income or access to health insurance in the affected population.

Should we have confidence if a physician is accredited? A study of the relative impacts of accreditation and insurance payments on quality of care in the Philippines

Improving clinical performance using measurement and payment incentives, including pay for performance (or P4P), has, so far, shown modest to no benefit on patient outcomes. Our objective was to assess the impact of a P4P programme on paediatric health outcomes in the Philippines. We used data from the Quality Improvement Demonstration Study. In this study, the P4P intervention, introduced in 2004, was randomly assigned to 10 community district hospitals, which were matched to 10 control sites. At all sites, physician quality was measured using Clinical Performance Vignettes (CPVs) among randomly selected physicians every 6 months over a 36-month period. In the hospitals randomized to the P4P intervention, physicians received bonus payments if they met qualifying scores on the CPV. We measured health outcomes 4-10 weeks after hospital discharge among children 5 years of age and under who had been hospitalized for diarrhoea and pneumonia (the two most common illnesses affecting this age cohort) and had been under the care of physicians participating in the study. Health outcomes data collection was done at baseline/pre-intervention and 2 years post-intervention on the following post-discharge outcomes: (1) age-adjusted wasting, (2) C-reactive protein in blood, (3) haemoglobin level and (4) parental assessment of childs health using general self-reported health (GSRH) measure. To evaluate changes in health outcomes in the control vs intervention sites over time (baseline vs post-intervention), we used a difference-in-difference logistic regression analysis, controlling for potential confounders. We found an improvement of 7 and 9 percentage points in GSRH and wasting over time (post-intervention vs baseline) in the intervention sites relative to the control sites (P ≤ 0.001). The results from this randomized social experiment indicate that the introduction of a performance-based incentive programme, which included measurement and feedback, led to improvements in two important child health outcomes.

Quality variation and its impact on costs and satisfaction: evidence from the QIDS study.

In this paper, we present evidence on the health effects of a health insurance intervention targeted to poor children using data from a randomized policy experiment known as the Quality Improvement Demonstration Study. Among study participants, using a difference-in-difference regression model, we estimated a 9-12 and 4-9 percentage point reduction in the likelihood of wasting and having an infection, respectively, as measured by a common biomarker C-reactive Protein. Interestingly, these benefits were not apparent at the time of discharge; the beneficial health effects were manifest several weeks after release from the hospital.