Challenges in physician supply planning: the case of Belgium

<p>Abstract</p> <p>Introduction</p> <p>Planning human resources for health (HRH) is a complex process for policy-makers and, as a result, many countries worldwide swing from surplus to shortage. In-depth case studies can help appraising the challenges encountered and the solutions implemented. This paper has two objectives: to identify the key challenges in HRH planning in Belgium and to formulate recommendations for an effective HRH planning, on the basis of the Belgian case study and lessons drawn from an international benchmarking.</p> <p>Case description</p> <p>In Belgium, a numerus clausus set up in 1997 and effective in 2004, aims to limit the total number of physicians working in the curative sector. The assumption of a positive relationship between physician densities and health care utilization was a major argument in favor of medical supply restrictions. This new regulation did not improve recurrent challenges such as specialty imbalances, with uncovered needs particularly among general practitioners, and geographical maldistribution. New difficulties also emerged. In particular, limiting national training of HRH turned out to be ineffective within the open European workforce market. The lack of integration of policies affecting HRH was noteworthy. We described in the paper what strategies were developed to address those challenges in Belgium and in neighboring countries.</p> <p>Discussion and evaluation</p> <p>Planning the medical workforce involves determining the numbers, mix, and distribution of health providers that will be required at some identified future point in time. To succeed in their task, health policy planners have to take a broader perspective on the healthcare system. Focusing on numbers is too restrictive and adopting innovative policies learned from benchmarking without integration and coordination is unfruitful. Evolving towards a strategic planning is essential to control the effects of the complex factors impacting on human resources. This evolution requires an effective monitoring of all key factors affecting supply and demand, a dynamic approach, and a system-level perspective, considering all healthcare professionals, and integrating manpower planning with workforce development.</p> <p>Conclusion</p> <p>To engage in an evidence-based action, policy-makers need a global manpower picture, from their own country and abroad, as well as reliable and comparable manpower databases allowing proper analysis and planning of the workforce.</p

Transmission of Vibrio cholerae Is Antagonized by Lytic Phage and Entry into the Aquatic Environment

Cholera outbreaks are proposed to propagate in explosive cycles powered by hyperinfectious Vibrio cholerae and quenched by lytic vibriophage. However, studies to elucidate how these factors affect transmission are lacking because the field experiments are almost intractable. One reason for this is that V. cholerae loses the ability to culture upon transfer to pond water. This phenotype is called the active but non-culturable state (ABNC; an alternative term is viable but non-culturable) because these cells maintain the capacity for metabolic activity. ABNC bacteria may serve as the environmental reservoir for outbreaks but rigorous animal studies to test this hypothesis have not been conducted. In this project, we wanted to determine the relevance of ABNC cells to transmission as well as the impact lytic phage have on V. cholerae as the bacteria enter the ABNC state. Rice-water stool that naturally harbored lytic phage or in vitro derived V. cholerae were incubated in a pond microcosm, and the culturability, infectious dose, and transcriptome were assayed over 24 h. The data show that the major contributors to infection are culturable V. cholerae and not ABNC cells. Phage did not affect colonization immediately after shedding from the patients because the phage titer was too low. However, V. cholerae failed to colonize the small intestine after 24 h of incubation in pond water—the point when the phage and ABNC cell titers were highest. The transcriptional analysis traced the transformation into the non-infectious ABNC state and supports models for the adaptation to nutrient poor aquatic environments. Phage had an undetectable impact on this adaptation. Taken together, the rise of ABNC cells and lytic phage blocked transmission. Thus, there is a fitness advantage if V. cholerae can make a rapid transfer to the next host before these negative selective pressures compound in the aquatic environment

Detection thresholds to stimulation of ventrobasal complex in cats.

Cats were trained to indicate, by bar pressing for food rewards, their detection of stimulation of the ventrobasal (VB) complex delivered through implanted bipolar electrodes. By varying stimulus intensity it was possible to determine thresholds for detection. Scaling stimulus intensity relative to the appearance of a minimal evoked potential allowed comparisons between animals and also comparisons with results obtained by stimulation of peripheral nerve. Animals could detect VB stimulation, but only at stimulus intensities consistently stronger than those required for minimal appearance of an evoked response in ipsilateral primary somatosensory cortex. Results of VB activation differed from cutaneous nerve effects in that VB detection thresholds were markedly influenced by stimulus frequency. They were lowest at frequencies above 30 Hz and increased greatly at lower frequencies. Discomfort or pain did not seem to result even from relatively high stimulus intensities. The results compare well with observations obtained from stimulation of VB in humans. The appearance of an evoked cortical response is not necessarily correlated with behavior. Under appropriate conditions, behavior can be elicited predictably with minimal electrocortical activity; under other conditions detection may be absent even when large numbers of cortical neurons are activated. We suggest that regions of the cerebral cortex receiving thalamocortical projections from VB may not be essential in the detection process

Detection thresholds to stimulation of ventrobasal complex in cats.

Cats were trained to indicate, by bar pressing for food rewards, their detection of stimulation of the ventrobasal (VB) complex delivered through implanted bipolar electrodes. By varying stimulus intensity it was possible to determine thresholds for detection. Scaling stimulus intensity relative to the appearance of a minimal evoked potential allowed comparisons between animals and also comparisons with results obtained by stimulation of peripheral nerve. Animals could detect VB stimulation, but only at stimulus intensities consistently stronger than those required for minimal appearance of an evoked response in ipsilateral primary somatosensory cortex. Results of VB activation differed from cutaneous nerve effects in that VB detection thresholds were markedly influenced by stimulus frequency. They were lowest at frequencies above 30 Hz and increased greatly at lower frequencies. Discomfort or pain did not seem to result even from relatively high stimulus intensities. The results compare well with observations obtained from stimulation of VB in humans. The appearance of an evoked cortical response is not necessarily correlated with behavior. Under appropriate conditions, behavior can be elicited predictably with minimal electrocortical activity; under other conditions detection may be absent even when large numbers of cortical neurons are activated. We suggest that regions of the cerebral cortex receiving thalamocortical projections from VB may not be essential in the detection process

EFFECTS OF CUTANEOUS AND MUSCLE SENSORY NERVE VOLLEYS IN AWAKE CATS: A STUDY IN PERCEPTION.

The hypothesis that discharges from afferent nerves from muscle stretch receptors do not participate in kinesthesis has been substantiated by test of discrimination thresholds. In awake, unrestrained cats, nerve stimulation activating group I and most group II sensory fibers (from muscle spindles and Golgi tendon organs) in pure muscular nerves failed to evoke sensory discrimination. Cutaneous nerve stimulation in the same animals produced sensory discrimination even below intensities required to elicit detectable nerve thresholds

EFFECTS OF CUTANEOUS AND MUSCLE SENSORY NERVE VOLLEYS IN AWAKE CATS: A STUDY IN PERCEPTION.

The hypothesis that discharges from afferent nerves from muscle stretch receptors do not participate in kinesthesis has been substantiated by test of discrimination thresholds. In awake, unrestrained cats, nerve stimulation activating group I and most group II sensory fibers (from muscle spindles and Golgi tendon organs) in pure muscular nerves failed to evoke sensory discrimination. Cutaneous nerve stimulation in the same animals produced sensory discrimination even below intensities required to elicit detectable nerve thresholds