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Journal of the Academy of Hospital Administration

Notes, News and Journal Scan

Author(s): Rajiv Kumar Jain*, Sidhartha Satpathy**

Vol. 14, No. 2 (2002-07 - 2002-12)

Key Messages:

* A Total of 58 Million Americans Lack Health insurance
*Patients or profits? Professional ethics, co-operation and competition in health systems.
* Disease Control Priorities Project (DCPP)
* Therapeutic HIV vaccine nears registration
* Australian Medical Association calls for medical litigation rules overhaul
* New Law in Germany Compensates for drug side effects
* WHO Model Formulary Published

A Total of 58 Million Americans Lack Health insurance

Charles Marwick from Washington, DC reports to the Bitish Medical Journal that at some point in their lives, one in five members of American families lack health insurance for a year or more-a total of some 58 million people-and this threatens the health and financial stability of the entire household.

This is the principal finding from the third report of an investigation by the US Institute of Medicine on the effects of lack of health insurance on health.

Earlier reports had shown that people without insurance had poorer health than those who had insurance. The latest report, Health Insurance is a Family Matter, deals with the effects on the family when one or more member loses health insurance. Three further reports are expected over the next year. In effect they lay the groundwork for yet another debate on health insurance in the United States.

"The family is the basic unit in our society, both economically and socially," said Dr. Arthur Kellerman, professor in the department of emergency medicine at Emory University School of Medicine in Atlanta, Georgia. "This report brings a new and different perspective on the family. We share a common destiny within families, and if one member of the family is not covered for one reason or another, the entire family is vulnerable."

Announcing the release of the report, Dr Kellerman, who jointly chaired the committee that produced it, said it came to four major conclusions.

* The "hodgepodge" employment based and public insurance system in the United States leaves gaps in coverage

* Families that have even one member without insurance for a year often cannot afford major health expenses or buy insurance, so they avoid seeking care

* Pregnant women, newborn infants, and children without insurance have poorer access to care and receive fewer services, and as a result they often have poorer outcomes

* Children whose parents do not have health insurance are less likely to be insured, even if they are eligible, and so are less likely to receive care.

A particular concern is the effect that lack of health insurance has on children. "There are real downstream costs when illnesses are not treated promptly," Kellerman said

He cited several examples. Otitis media, if not treated, could result in hearing impairment, which could affect employment as an adult. Iron deficiency anaemia, if not detected early, could have serious consequences. If children with asthma were not given the right care they could end up in expensive hospital care and even die.

"Living without health insurance is like driving without a safety belt. It"s not a problem until you have a crash," he said. "Given tight budgets, families will scrimp on medical care-a short term saving, but it can have devastating financial and human consequences." [BMJ 2002; 325:678 (28 September].

Patients or Profits? Professional ethics, co-operation and competition in health systems.

The concept of "managed competition" to improve efficiency has been common in health sector reform in wealthy countries. It has also been exported to health systems in the South, involving privatization and marketisation. Research from the UK Institute of Development Studies questions whether this competitive approach is appropriate in a sector where ethical behavior, altruism and co-operation are essential for good quality services.

The prolonged recession of the 1980s brought neo-liberal economic policies to the developed world. Reforms in the public sector included:

* emphasis on private sector management styles rather than public service ethics
* assessing performance by quantifiable outputs rather than less easily measured quality of service and outcomes
* decentralization of services to corporatised units and introduction of market mechanisms such as tendering for fixed-term contracts.

These ideas were applied to health services as "health sector reform". The strategies have lost popularity in the North in recent years and there has been a shift back towards co-operation in several countries.

Economic crisis and structural adjustment in the 1980s had a disastrous effect on the quality and availability of healthcare in developing countries. Health workers have seen the real value of their salaries plummet, demotivation is common and self-serving behavior has increased. Staff reduction in the public sector has fed a growing uncontrolled private health sector. With regulation weak, a combination of economic need and the culture of the market place has impact. Especially in poorer countries, health strategies have tended to focus on public service delivery, rather than respond to market-based reform theory exported from the developed world.

Research revealed that:

* If contractual relationships involve financial or quantified output targets, these tend to take priority over improved quality of care and health outcomes.
* Providers may massage data to meet output obligations set out in contracts.
* Financial incentives for healthcare providers may mean that accountancy and profits displace people as the central focus of health systems.

Important issues raised for health sector policies in poor countries include:

* To recover form economic crisis, health systems require a tailored approach based on what works in different circumstances, not a predetermined recipe for reform.
* Decentralization of healthcare can increase local control and accountability, but can do more harm than good if not carefully prepared and phased in.
* Decision-making on health services should become more democratic and participatory to improve responsiveness, quality and efficiency.
* management capacity should be improved in public health services. Explicit programme goals and agreed financing frameworks facilitate better performance.
* Special attention should be paid to managing personnel, providing adequate salaries, motivating staff and ensuring the right mix and distribution of skills. A supportive environment and effective professional incentives can contribute to the promotion of a service ethic among health workers.

For recovery the lead policy should be reconstruction of public health systems. Public contracting of (not for profit) private providers can make sensible use of existing resources, but little or no evidence exists to support the proactive privatization or marketisation dictated by health sector reform theory.

Contributor(s): Malcolm Segall Source(s): From cooperation to competition in national health systems - and back? Impact on professional ethics and quality of care" by M. Segall, International Journal of Health Planning and Management 15 (2000) Funded by: The European Commission. Web:

Disease Control Priorities Project (DCPP)
The Disease Control Priorities Project (DCCP) is a new three-year effort launched on 3rd September 2002 to assess disease control priorities and produce science-based analyses and resource materials to inform health policy making in developing countries. The DCPP is a joint project of the Fogarty International Center (FIC) of the National Institutes of health (NIH), the World health Organization (WHO), and the World Bank. It is funded by a $3.5 million grant by the Bill and Melinda Gates Foundation.

"This project pushes disease-control studies into the 21st century by bringing scientific, demographic, and epidemiological advancements to bear on disease-control research and strategies in developing countries," said Gerald T. Keusch, M.D., FIC Director. "The DCPP will collaborate with partners around the world to generate information for national and international policy makers as they determine their health strategies and investments."

"For prevention and treatment programs to work, policy makers must have access to the best possible research and analysis to ensure that their health investments save as many lives as possible," said Sally Stansfield, M.D., Acting Director of Infectious Disease and Vaccines Program for the Bill and Melinda Gates Foundation. "The DCPP"s work will lead to highly effective, affordable health solutions that can be emulated in countries around the world."

The DCPP will help developing countries establish health priorities and cost-effective health interventions based on careful analysis of the cost of disease burden and the cost of treatment and prevention. The demographic, epidemiologic and economic information produced by DCPP will be shared through its new products, events, and tools including:

  • technical workshops involving experts and policy makers from developed and developing countries on estimating burden of disease and cost- effectiveness analysis;
  • interactive online discussions of the work in progress;
  • online, universally accessible DCPP working papers and other publications, available at;
  • demographic, epidemiologic, and econometric information and materials to increase the capacity of developing countries to determine national priorities;
  • the second volume of Disease Control Priorities in Developing Countries, which will be available in print and online in 2005.

"This project will assist developing-country leaders as they systematically examine their own country"s health conditions, including endemic and epidemic diseases, and initiate well reasoned, cost-effective actions to decrease the toll of those diseases," said Dean jamison, Ph.D., DCPP senior editor.

Therapeutic HIV Vaccine Nears Registration
Adrian Burton reports in "The Lancet Infectious Diseases Journal" that a therapeutic HIV vaccine being tested in Spain is closer to becoming commercially available. Final results of a phase 2 trial of the "Remune" vaccine (see Lancet Infect Dis 2001; 1:291), presented at a Federation of American Societies for Experimental Biology Conference in Tucson, AZ, USA (July 27-Aug 1), support its ability to rebuild the body"s immune response to HIV. Patients treated with the vaccine and entiretroviral therapy (ART) or highly active ART (Haart) were 37% less likely to enter virological failure over a 30-month observation period than those given placebo. This difference could have become greater if ethical concerns had not prompted the vaccination of placebo patients.

"In effect, 70% of vaccine-treated subjects received protection from the virus compared with only 59% of those on antivirals alone. For the first time we have managed to create immunity against HIV-and that"s a break through", says team leader Eduardo Fernandez-Cruz (Department of Immunology, Gregorio Maranon Hospital, Madrid, Spain).

Lauren Wood, senior clinical investigator in HIV and AIDS malignancy at the National Cancer Institute, Bethesda, MD, USA, remarked, "Given that virologic failure is virtually inevitable despite the potent HAART therapy currently available, these results warrant further confirmation in additional clinical studies".

These results have already prompted the Spanish Medication Agency (Agencia de Medicamento) to evaluate the vaccine favourably. September saw its report presented to the European agency-a necessary step towards European Union registration-with a view to a European phase 3 trial. Parallel approval is also being sought from the American and Canadian regulating bodies to include patients from these countries.

Other experiments are planned to start in October to demonstrate whether the immunity developed can keep the virus checked when ART/HAART treatment is interrupted. Patients recruited from the phase 2 trial will receive either boosters during this time or no treatment at all. "This is a new approach to reducing antiretroviral toxicity while maintaining viral load and CD4 counts in long-term treatment patients", says Fernandez-Cruz. (The Lancet Infectious Diseases: 2002; 2:584(01 October 2002). (

Australian Medical Association calls for medical litigation rules overhaul:
Babeloff and Stephen Cordner report in the Lancet that Kerren Phelps, President of Australian Medical Association (AMA) called for an end to medical negligence litigation, and creation of a National compensation scheme for medical misadventures, in an address to National Press Club. This call has come in response to the recent crisis in medical insurance due to significant unfunded liabilities of Australias major medical indemnity organisation, United Medical Protection (UMP).

In Dec-2000, UMP imposed a one year additional call on its members, focussing some concern on the rising cost of medical insurance, as after the 9/11 termist attack, another by medical insurance, St Paul withdrew from the market. However, on April 29th UMP was forced to call in lignidators. The commonwealth govt. gave a guarantee to the liguidator that has enabled UMP to continue trading till end of 2002. The seenario after this has been presented as a paper to Australian Health Minister Advisory Council on 2nd Aug.

The options highlighted include; trying to reduce the need for litigation improving the handling of adverse event, encrmaging early resolution of claims before litigation starts and stream timing the process of ligation to avoid delays. To reduce the harm arising from adverse events, early access to rehabilitation and related assistance incl long term care will be encouraged. Recommendation will be made about the laws applicable to medical negligence to ensure that is an appropriate balance between the interests of health care consumers, doctors and community.

Marcia Neave, Chair of the working group responsible for developing these proposals, has stated that there need to be an integrated reforms package that meets the concerns of consumers and medical community. The present debate is focussed on premiums rather than looking at the overall system and the needs of those who may be harmed. The aim is to provide a balance between ensuring that people receive reasonable compensation while ensuring that premiums are affordable and sustainable. (The Lancet Vol 360. Aug 10, 2002)

New Law in Germany Compensates for drug side effects:
Claudia Orellana reports to the Lancet, that the German Govt. passed a new legislation on Ist Aug which will make it easier for patients who have adverse during reactions (ADRs) to get compensation from pharmaceutical companies. The new shifts the responsibility for an ADR back to the drug firms, so that to receive compensating patients no longer have to prove that a drug caused an unexpected side effect. After this new law, the drug manufacturer must prove that the adverse effect was not caused due to the drug, so as to avoid paying compensation.

"The Governments objective is to strengthen the legal portion of the patients and improve the enforcement of their rights" said Justice Minister Herta Daubler-Gmelin along with health Minister Ulla Schmidt in the Bundestag while introducing the new law. It is a part of the attempt to reform Germany"s liability and compensation laws.

To prove liability, patient must identify medical evidence proving that the drug in question can cause ADR. to help potential claimants, the new law gives patients the right to make enquires about adverse effects before starting legal action; and also compensates patients for the cost extra health care as a result of their illness. Another clause establistes the right to additional damages for pain and suffering even where negligence is not established.

Not surprisingly, although it was welcomed by judges and lawyers associations, it received a cubewarm response from drug manufacturers, who felt that there should be a natural right of engury, so that they could also get information about the claimant for instance about previous illness and other medicines he/she may be taking. However, Babite Diver of the Federal Working Group of Patient Associations welcomed the new registration as "a welcome step in the right direction." (The Lancet, Vol 360, Aug. 10, 2202)

WHO Model Formulary Published:
The World Health Organisation (WHO) published the first edition of the WHO Model Formulancy in Sept. 2002, which aims to promote the safe and cost effective use of medicines. This is the first of its kind to provide comprehensive information on all 325 medicines contained in the WHO Model List of Essential Drugs, and contains information on recommended use, dosage, adverse effects, contraindication and warnings for these medicines. Correct use of guidelines will improve patient safety and limit superthous medical spending. (The Lancet Vol 360, Sept. 24, 2002)

(Also see Book Review in this Journal)

* Deputy Chief Medical Director, Indian Railways Medical Service, New Delhi, India (for correspondance, 480, Sector 37, Faridabad 121003, Haryana, India, E-mail: [email protected] and [email protected].

** Associate Professor, Deptt. of Hospital Administration, AIIMS, New Delhi. E-mail:[email protected]

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