A Step Towards Realization of the Twenty-Seventh Right?: A Preliminary Analysis of the Proposed National Health Insurance for South Africa

As part of a three-week social analysis study, the African National Congress’ (ANC) proposal for a National Health Insurance (NHI) scheme was examined. Legal commitments in Section 27 of the Constitution and Section 3 of the National Health Act oblige the South African government to work progressively towards realization of the right to healthcare. The latest push for NHI can be interpreted as an attempt to broaden realization of this right. Information on the NHI proposal was obtained primarily from documents released by the ANC and was supplemented by written analysis found through Internet research. A partial understanding of public opinion was achieved through interviews with South African citizens, including experts in various fields pertinent to the NHI. Time and other logistical constraints limited the amount of data incorporated into this paper. Biases resulting from personal views and/or desires of researchers or interviewees, as well as of the author, must be acknowledged in consideration of the findings. Using the ANC discussion document released in September 2010, potential flaws in the policy were identified. These included questions of affordability; likely discontent amongst the public with services provided under NHI; a lack of concrete policy and program outlines; the potential for government mismanagement; a reliance on a failing public system; and a lack of information technology systems for collecting data to be used in system evaluation, cost estimation, and policy formulation. Based on these potential problems and other findings, the author concluded that implementation of the NHI as proposed by the ANC within the suggested time frame is unlikely and would result in a probable system failure. Pursuit of an NHI based on the principles of universal coverage, the right to health, and social solidarity is a laudable and necessary action in the government’s quest to broaden realization of the twenty-seventh right. Implementation of such a system is possible, but must not rushed and should result from fully informed policies and programs that work gradually towards the complete implementation of a National Health Insurance scheme

Mapping and exploring health systems' response to intimate partner violence in Spain

Background: For a comprehensive health sector response to intimate partner violence (IPV), interventions should target individual and health facility levels, along with the broader health systems level which includes issues of governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. This study aims to map and explore the integration of IPV response in the Spanish national health system. Methods: Information was collected on five key areas based on WHO recommendations: policy environment, protocols, training, monitoring and prevention. A systematic review of public documents was conducted to assess 39 indicators in each of Spain’s 17 regional health systems. In addition, we performed qualitative content analysis of 26 individual interviews with key informants responsible for coordinating the health sector response to IPV in Spain. Results: In 88% of the 17 autonomous regions, the laws concerning IPV included the health sector response, but the integration of IPV in regional health plans was just 41%. Despite the existence of a supportive national structure, responding to IPV still relies strongly on the will of health professionals. All seventeen regions had published comprehensive protocols to guide the health sector response to IPV, but participants recognized that responding to IPV was more complex than merely following the steps of a protocol. Published training plans existed in 43% of the regional health systems, but none had institutionalized IPV training in medical and nursing schools. Only 12% of regional health systems collected information on the quality of the IPV response, and there are many limitations to collecting information on IPV within health services, for example underreporting, fears about confidentiality, and underuse of data for monitoring purposes. Finally, preventive activities that were considered essential were not institutionalized anywhere. Conclusions: Within the Spanish health system, differences exist in terms of achievements both between regions and between the areas assessed. Progress towards integration of IPV has been notable at the level of policy, less outstanding regarding health service delivery, and very limited in terms of preventive actions.This study has been funded by a COFAS grant (supported by COFUND action within the Marie Curie Action People, in the Seventh Framework programme and the Swedish Council for Working Life and Social Research/FAS-Forskningsradet för arbetsliv och socialvetenskap)

Electronic communication across organizational borders in healthcare: an empirical study

This empirical study of the national message exchange system is aimed to serve as a partial evaluation within a local context, based on user experiences. A qualitative method based on semi-structured, open-ended interviews with clinical system users at the University Hospital of Northern-Norway and in the healthcare service of the Municipality of Tromsø, combined with informal meetings with project members and a literature review, serves as basis for the data collection. Hospital users described message use as additional work tasks, and as a rule had to rely on several methods of communication to ensure a safe and robust transfer of clinical information across health levels. The reasons for this appeared to be the need for more synchronous communication and a divide between administrative and clinical information handling in the municipalities. Message structure was in many cases conceived as confusing, and there seemed to be a lack of a proper training strategy for system use. In communication between municipal healthcare and GPs, the system was experienced as time saving and convenient due to the way it supported the asynchronous work practices. We argue that an on-going, thorough evaluation during the implementation process could have supported the work of mapping unintended consequences and dealing with them. We have identified specific aspects that we believe could have contributed to this, such as closer follow-up and monitoring of smaller municipalities, a more thorough strategy for user education and message notification in the hospital’s EPR. However, the gap between intended use and existing work practices seems too wide to be bridged by these measures. We argue that the EME system matches poorly with existing local practices in the hospital especially, and that local practices should have been taken into consideration before implementing a system on such a large scale. It is obvious that there has been a lack of user perspectives in the evaluation of the EME system up to this point, and our thesis must be seen as a contribution towards a more comprehensive system evaluation

A global framework for action to improve the primary care response to chronic non-communicable diseases: a solution to a neglected problem.

BACKGROUND: Although in developing countries the burden of morbidity and mortality due to infectious diseases has often overshadowed that due to chronic non-communicable diseases (NCDs), there is evidence now of a shift of attention to NCDs. DISCUSSION: Decreasing the chronic NCD burden requires a two-pronged approach: implementation of the multisectoral policies aimed at decreasing population-level risks for NCDs, and effective and affordable delivery of primary care interventions for patients with chronic NCDs. The primary care response to common NCDs is often unstructured and inadequate. We therefore propose a programmatic, standardized approach to the delivery of primary care interventions for patients with NCDs, with a focus on hypertension, diabetes mellitus, chronic airflow obstruction, and obesity. The benefits of this approach will extend to patients with related conditions, e.g. those with chronic kidney disease caused by hypertension or diabetes. This framework for a "public health approach" is informed by experience of scaling up interventions for chronic infectious diseases (tuberculosis and HIV). The lessons learned from progress in rolling out these interventions include the importance of gaining political commitment, developing a robust strategy, delivering standardised interventions, and ensuring rigorous monitoring and evaluation of progress towards defined targets. The goal of the framework is to reduce the burden of morbidity, disability and premature mortality related to NCDs through a primary care strategy which has three elements: 1) identify and address modifiable risk factors, 2) screen for common NCDs and 3) and diagnose, treat and follow-up patients with common NCDs using standard protocols. The proposed framework for NCDs borrows the same elements as those developed for tuberculosis control, comprising a goal, strategy and targets for NCD control, a package of interventions for quality care, key operations for national implementation of these interventions (political commitment, case-finding among people attending primary care services, standardised diagnostic and treatment protocols, regular drug supply, and systematic monitoring and evaluation), and indicators to measure progress towards increasing the impact of primary care interventions on chronic NCDs. The framework needs evaluation, then adaptation in different settings. SUMMARY: A framework for a programmatic "public health approach" has the potential to improve on the current unstructured approach to primary care of people with chronic NCDs. Research to establish the cost, value and feasibility of implementing the framework will pave the way for international support to extend the benefit of this approach to the millions of people worldwide with chronic NCDs