The World Bank and Healthcare Reforms: A Cross‐National Analysis of Policy Prescriptions in South America

Recent literature on comparative welfare states has recognised the central role international financial institutions (IFIs) play in shaping social policy. Particularly in low‐ and middle‐income countries (LMICs), where constraints often lead to reliance on foreign resources, IFIs can act as agenda‐setters, transferring their ideas to vulnerable governments. The neoliberal model promoted by IFIs at the end of the 20th century reveals their influence on domestic policy in South America. This study analyses the impact of World Bank (WB) prescriptions on healthcare reform legislation in five South American countries: Argentina, Bolivia, Colombia, Paraguay, and Peru. In doing so, it attempts to answer the following questions: Are LMICs receptive to IFIs’ healthcare system prescriptions? More precisely, have WB policy prescriptions been adopted in healthcare reform legislation in South American countries? If so, in what way? Through content analysis, this study examines domestic healthcare legislation vis‐à‐vis the WB’s prescriptions. The main findings show that countries are receptive to IFIs prescriptions, making them a legitimate source of policy recommendations. Further, the results suggest a correlation between economic development and reliance on foreign resources and the degree to which countries adhere to IFIs prescriptions.

Person-centred care in psychiatry: a clinical and philosophically informed approach

SUMMARY After many years of mental healthcare reform there is still a lot of unease among patients about healthcare workers’ lack of attention to their daily needs and to the tensions and ambiguities that accompany their attempts to integrate their condition into their lives. Person-centred care is often presented as a solution, but the term refers to many differing approaches and needs further specification depending on the problem it aims to resolve. This article presents and discusses a clinical and philosophically informed approach that flexibly focuses on the person- and context-bound aspects of the patient's condition and on the co-regulatory role of the clinician in the patient's attempt to regulate their condition. This approach is a way of thinking, rather than yet another model. It will be shown how this approach can be integrated in the core curriculum of specialty (residency) training in psychiatry.

Ten years of China’s new healthcare reform: a longitudinal study on changes in health resources

Background China launched a new round of healthcare-system reform in 2009 and proposed the goal of equal and guaranteed essential medical and health services for all by 2020. We aimed to investigate the changes in China’s health resources over the past ten years after the healthcare reform. Methods Data were collected from the China Statistical Yearbook and China Health Statistics Yearbook from 2009 to 2018. Four categories and ten indicators of health resources were analyzed. A descriptive analysis was used to present the overall condition. The Health Resource Density Index was applied to showcase health-resource distribution in demographic and geographic dimensions. The global and local Moran’s I were used to assess the spatial autocorrelation of health resources. Concentration Index (CI) was used to quantify the equity of health-resource distribution. A Geo-Detector model and Geographic Weighted Regression (GWR) were applied to assess the association between gross domestic product (GDP) per capita and health resources. Results Health resources have increased over the past ten years. The global and local Moran’s I suggested spatial aggregation in the distribution of health resources. Hospital beds were concentrated in wealthier areas, but this inequity decreased yearly (from CI=0.0587 in 2009 to CI=0.0021 in 2018). Primary medical and health institutions (PMHI) and their beds were concentrated in poorer areas (CI remained negative). Healthcare employees were concentrated in wealthier areas (CI remained positive). In 2017, the q-statistics indicated that the explanatory power of GDP per capita to beds, health personnel, and health expenditure was 40.7%, 50.3%, and 42.5%, respectively. The coefficients of GWR remained positive with statistical significance, indicating the positive association between GDP per capita and health resources. Conclusions From 2009 to 2018, the total amount of health resources in China has increased substantially. Spatial aggregation existed in the health-resources distribution. Health resources tended to be concentrated in wealthier areas. When allocating health resources, the governments should take economic factors into account.

Primary healthcare reform for chronic conditions in countries with high or very high human development index: A systematic review

Objective To address the growing burden of chronic disease globally, many countries have developed a national policy for primary healthcare reform. In some countries with high and very high human development index, evaluations of the implementation of these reforms have been published. To date, there has been no systematic review of these evaluations. The objectives of this review are to identify: (a) the vision for primary healthcare; (b) the features of primary healthcare reforms; and (c) evaluation findings of primary healthcare reforms. Methods A systematic literature review was conducted guided by the PRISMA statement. We searched for academic articles and grey literature from 1 March 2008 to 1 September 2020. Screening and data extraction were conducted by two authors. Descriptive analysis and narrative synthesis were applied. Results A vision for integrated primary healthcare shifting chronic disease management from specialist hospital services to primary care was found to require new organization and funding models such as collaborative primary healthcare networks and commissioning along with shared governance across health sectors. The need for general practitioner leadership and engagement to support primary healthcare reform was identified. Although there was evidence of barriers in progressing primary healthcare reform, evaluation results showed some positive outcomes, most notably shifts in services towards increased primary care access and utilization. Discussion A challenge in undertaking the review was the heterogeneity of articles with little consistency in how primary healthcare reform was evaluated and reported on across countries. Evaluation of national health reforms involves complex system-wide projects and is an area that needs further exploration and discussion to determine the most appropriate methodologies for collecting and analysing large-scale data with consideration for service and health outcomes.

Moving beyond formulae: a review of international population-based resource allocation policy and implications for Ireland in an era of healthcare reform

Background: Population-based resource allocation is a specific approach to population health planning that is used to address differences in population need to promote equity and efficiency in health and health system outcomes. However, while previous studies have described this type of funding model, they have not compared how such policies and practices have been implemented across jurisdictions. This research examined the impacts and outcomes of population-based resource allocation across six high-income countries, with a view to informing strategic decision-making as Ireland progresses its universal healthcare reform agenda. Methods: A concurrent multi-method approach was employed to examine the experiences of six jurisdictions selected for analysis: Australia (New South Wales), Canada (Alberta), England, New Zealand, Scotland and Sweden (Stockholm). A documentary analysis of key policy, strategy and planning publications was combined with a narrative rapid review of peer-reviewed and grey literature (n = 8) to determine how population-based resource allocation is specified and implemented. The findings were checked and verified by national experts. Results: Notable differences were observed across countries in terms of the stated objectives and descriptions of models as well as the criteria for choosing variables and the variables ultimately used in funding formulae. While population-based resource allocation can help improve equity related to healthcare outcomes and access, a number of tensions were revealed between the need to ensure alignment between policy goals and model design; transition between models; support regionalisation policies; and develop robust governance and monitoring mechanisms to maximise outcomes. Conclusions: The review progresses ‘thinking’ about population-based resource allocation beyond the technical aspects of model or formulae construction. Population-based resource allocation should be viewed as just one lever of large-scale health system reform that can be thoughtfully developed, monitored and adjusted in a way that supports the goals of Sláintecare and the delivery of universal healthcare.

DRG grouping by machine learning: from expert-oriented to data-based method

Background Diagnosis-related groups (DRGs) are a payment system that could effectively solve the problem of excessive increases in healthcare costs which are applied as a principal measure in the healthcare reform in China. However, expert-oriented DRG grouping is a black box with the drawbacks of upcoding and high cost. Methods This study proposes a method of data-based grouping, designed and updated by machine learning algorithms, which could be trained by real cases, or even simulated cases. It inherits the decision-making rules from the expert-oriented grouping and improves performance by incorporating continuous updates at low cost. Five typical classification algorithms were assessed and some suggestions were made for algorithm choice. The kappa coefficients were reported to evaluate the performance of grouping. Results Based on tenfold cross-validation, experiments showed that data-based grouping had a similar classification performance to the expert-oriented grouping when choosing suitable algorithms. The groupings trained by simulated cases had less accuracy when they were tested by the real cases rather than simulated cases, but the kappa coefficients of the best model were still higher than 0.6. When the grouping was tested in a new DRGs system, the average kappa coefficients were significantly improved from 0.1534 to 0.6435 by the update; and with enough computation resources, the update process could be completed in a very short time. Conclusions As a new potential option, the data-based grouping meets the requirements of the DRGs system and has the advantages of high transparency and low cost in the design and update process.

Impact of Beijing healthcare reform on the curative care expenditure of outpatients with noncommunicable diseases based on SHA2011 and interrupted time series analysis

Background To analyse the changes in curative care expenditure (CCE) associated with noncommunicable diseases (NCDs) before and after the Beijing healthcare reform, thus providing a reference for the healthcare system. Methods A total of 60 medical institutions were selected using multistage stratified cluster random sampling in Beijing, China. The records of approximately 100 million outpatients with NCDs in 2016–2018 were extracted. System of Health Accounts 2011 (SHA2011) was used to estimate the CCE. The segmented regression model was established to observe both the instant change and the slope change of intervention in interrupted time series analysis (ITSA). The study was conducted from December 2019 to May 2020 in Beijing, China. Results From SHA2011, we found that the CCE for outpatients with NCDs in Beijing were 58.59, 61.46 and 71.96 billion RMB in 2016, 2017 and 2018, respectively. The CCE continued to rise at all hospital levels, namely, tertiary, secondary, and community-level hospitals. However, the proportion of CCE in tertiary hospitals decreased. From ITSA, we can also conclude that the CCE showed a significant increasing trend change at the three hospital levels after the intervention. The drug proportion showed a significant decreasing trend change in secondary and tertiary hospitals. Conclusions Beijing healthcare reform does have an impact on the CCE of NCDs.