Strengthening health management: experience of district teams in The Gambia.
The lack of basic management skills of district-level health teams is often described as a major constraint to implementation of primary health care in developing countries. To improve district-level management in The Gambia, a 'management strengthening' project was implemented in two out of the three health regions. Against a background of health sector decentralization policy the project had two main objectives: to improve health team management skills and to improve resources management under specially-trained administrators. The project used a problem-solving and participatory strategy for planning and implementing activities. The project resulted in some improvements in the management of district-level health services, particularly in the quality of team planning and coordination, and the management of the limited available resources. However, the project demonstrated that though health teams had better management skills and systems, their effectiveness was often limited by the policy and practice of the national level government and donor agencies. In particular, they were limited by the degree to which decision making was centralized on issues of staffing, budgeting, and planning, and by the extent to which national level managers have lacked skills and motivation for management change. They were also limited by the extent to which donor-supported programmes were still based on standardized models which did not allow for varying and complex environments at district level. These are common problems despite growing advocacy for more devolution of decision making to the local level. (+info)
Health outcomes and managed care: discussing the hidden issues.
Too often the debate over health outcomes and managed care has glossed over a series of complex social, political, and ethical issues. Exciting advances in outcomes research have raised hopes for logical medical reform. However, science alone will not optimize our patients' health, since value judgements are necessary and integral parts of attempts to improve health outcomes within managed care organizations. Therefore, to form healthcare policy that is both fair and efficient, we must examine the fundamental values and ethical concerns that are imbedded in our efforts to shape care. We must openly discuss the hidden issues including: (1) trade-offs between standardization of care and provider-patient autonomy; (2) effects of financial incentives on physicians' professionalism; (3) opportunity costs inherent in the design of insurance plans; (4) responsibilities of managed care plans for the health of the public; (5) judicious and valid uses of data systems; and (6) the politics of uncertainty. (+info)
Role of technology assessment in health benefits coverage for medical devices.
With the profusion of new medical technology, managed care organizations are faced with the challenge of determining which medical devices and services warrant health benefits coverage. To aid in this decision-making process, managed care companies turn to technology assessment, a process that differs from the Food and Drug Administration's review of medical devices. Health plans typically use a structured approach to implementing coverage requirements in employer group benefits contracts and use technology assessment to evaluate the scientific evidence of effectiveness to support coverage decisions. Also important is the societal context for decisions regarding coverage for new technologies and the options being considered by policy makers for accountability in technology assessment by private insurers and health plans. (+info)
Evaluation designs for adequacy, plausibility and probability of public health programme performance and impact.
The question of why to evaluate a programme is seldom discussed in the literature. The present paper argues that the answer to this question is essential for choosing an appropriate evaluation design. The discussion is centered on summative evaluations of large-scale programme effectiveness, drawing upon examples from the fields of health and nutrition but the findings may be applicable to other subject areas. The main objective of an evaluation is to influence decisions. How complex and precise the evaluation must be depends on who the decision maker is and on what types of decisions will be taken as a consequence of the findings. Different decision makers demand not only different types of information but also vary in their requirements of how informative and precise the findings must be. Both complex and simple evaluations, however, should be equally rigorous in relating the design to the decisions. Based on the types of decisions that may be taken, a framework is proposed for deciding upon appropriate evaluation designs. Its first axis concerns the indicators of interest, whether these refer to provision or utilization of services, coverage or impact measures. The second axis refers to the type of inference to be made, whether this is a statement of adequacy, plausibility or probability. In addition to the above framework, other factors affect the choice of an evaluation design, including the efficacy of the intervention, the field of knowledge, timing and costs. Regarding the latter, decision makers should be made aware that evaluation costs increase rapidly with complexity so that often a compromise must be reached. Examples are given of how to use the two classification axes, as well as these additional factors, for helping decision makers and evaluators translate the need for evaluation--the why--into the appropriate design--the how. (+info)
Innovation and public accountability in clinical research.
For more than 20 years, clinical researchers have expressed alarm about the decline of their field, but they have failed to achieve a consensus on policies to revitalize and sustain it. Although they have traced the plight of clinical research to profound changes in science, medicine, and public expectations, their conservative vision and preference for short-term measures inhibit effective policy formulation. These trends are the outcome of historical developments, and they seem to mandate a new approach to public policy. A potential source for more viable and socially accountable policies lies in practitioners' notion that clinical research bridges basic and applied science (by translating scientific innovations into practical measures). Exploiting that idea, however, would require a major reorientation of the field toward health services research and the institutions that are struggling to support it. (+info)
Genetic privacy: orthodoxy or oxymoron?
In this paper we question whether the concept of "genetic privacy" is a contradiction in terms. And, if so, whether the implications of such a conclusion, inevitably impact on how society comes to perceive privacy and responsibility generally. Current law and ethical discourse place a high value on self-determination and the rights of individuals. In the medical sphere, the recognition of patient "rights" has resulted in health professionals being given clear duties of candour and frankness. Dilemmas arise, however, when patients decline to know relevant information or, knowing it, refuse to share it with others who may also need to know. This paper considers the notions of interconnectedness and responsibility to others which are brought to the fore in the genetic sphere and which challenge the primacy afforded to personal autonomy. It also explores the extent to which an individual's perceived moral obligations can or should be enforced. (+info)
Can we learn from eugenics?
Eugenics casts a long shadow over contemporary genetics. Any measure, whether in clinical genetics or biotechnology, which is suspected of eugenic intent is likely to be opposed on that ground. Yet there is little consensus on what this word signifies, and often only a remote connection to the very complex set of social movements which took that name. After a brief historical summary of eugenics, this essay attempts to locate any wrongs inherent in eugenic doctrines. Four candidates are examined and rejected. The moral challenge posed by eugenics for genetics in our own time, I argue, is to achieve social justice. (+info)
History of medicine and concepts of health.
It was not until the exemplary social reform of the 19th century and the introduction of modern health insurance schemes that people started to consider health as some kind of basic right which could be ensured by insurance and doctors, rather than by individual responsibility. The recent explosion of health system costs in countries like Germany has given rise to an unprecedented situation whereby the limited capacities of insurance systems and state organizations are becoming more and more evident. Health economists are now questioning the feasibility of optimal medical treatment for everybody. One consequence of this situation is that people are being forced to recall the old virtue of individual responsibility for one's own physical and mental well-being. This article examines the nature of health from a historical point of view. The point is made that health is not the same thing as a life free from complaints, although this erroneous belief is wide-spread today. Galen himself identified a neutral physical state between health and illness (neutralitas), that could be observed in many people who could not be described as being either healthy or ill. It is necessary to accept this state as part of the natural fate of humankind and to understand that individual responsibility and the demands on society and insurance companies for well-being or absolute freedom from ailments are not one and the same thing. (+info)