Health Equity: 12/12/08

Friday, December 12, 2008

[EQ] Tracking progress towards universal childhood immunisation and the impact of global initiatives

Tracking progress towards universal childhood immunisation and the impact of global initiatives:

a systematic analysis of three-dose diphtheria, tetanus, and pertussis immunisation coverage

Stephen S Lim PhD a, David B Stein BA a, Alexandra Charrow BA a, Prof Christopher JL Murray MD a

The Lancet, Volume 372, Issue 9655, Pages 2031 - 2046, 13 December 2008

doi:10.1016/S0140-6736(08)61869-3

Website: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61869-3/abstract [Subscription required]

Background: Substantial resources have been invested in increasing childhood immunisation coverage through global initiatives such as the Universal Childhood Immunisation (UCI) campaign and the Global Alliance on Vaccines and Immunisations (GAVI). There are longstanding concerns that target-oriented and performance-oriented initiatives such as UCI and GAVI's immunisation services support (ISS) might encourage over-reporting. We estimated the coverage of three doses of diphtheria, tetanus, and pertussis vaccine (DTP3) based on surveys using all available data.

Methods: We estimated DTP3 coverage by analysing unit record data from surveys and supplemented this with reported coverage from other surveys and administrative data. We used bidirectional distance-dependent regression to estimate trends in survey-based coverage in 193 countries during 1986—2006. We used standard time-series cross-sectional analysis to investigate any association in the difference between countries' official reports and survey-based coverage as the dependent variable and the presence of GAVI ISS as the independent variable, controlling for country and time effects.

Findings: Crude coverage of DTP3 based on surveys increased from 59% (95% uncertainty interval 51—65) in 1986 to 65% (60—68) in 1990, 70% (65—74) in 2000, and 74% (70—77) in 2006. There were substantial differences between officially reported and survey-based coverage during UCI. GAVI ISS significantly increased the difference between officially reported coverage and survey coverage. Up to 2006, in 51 countries receiving GAVI ISS payments, 7•4 million (5•7 million to 9•2 million) additional children were immunised with DTP3 based on surveys compared with officially reported estimates of 13•9 million. On the basis of the number of additional children immunised from surveys at a rate of US$20 each, GAVI ISS payments are estimated at $150 million (115 million to 184 million) compared with actual disbursements of $290 million.

Interpretation

Survey-based DTP3 immunisation coverage has improved more gradually and not to the level suggested by countries' official reports or WHO and UNICEF estimates. There is an urgent need for independent and contestable monitoring of health indicators in an era of global initiatives that are target-oriented and disburse funds based on performance….”

Prof Christopher J L Murray, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA

Funding Bill & Melinda Gates Foundation.

Comments by:

David M Bishai, Johns Hopkins Bloomberg School of Public Health, Baltimore
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61853-X/fulltext

“…With close to 600 surveys from 193 countries, this definitive study confirms that the correlation between mothers’ reports and official reports is not good. Sometimes survey data indicate higher, sometimes lower, coverage than official reports. This news is a cause for concern because there might be an upward trend in officially reported rates of vaccine coverage that has occurred in the years since the GAVI Alliance (previously the Global Alliance on Vaccines and Immunizations) began to pay countries proportionally to the number of DTP3-vaccinated children.2 An upward trend would be good news, except that sometimes the upward trend is only in the official reports and not in the survey data. To put it bluntly, the authors are worried that financial incentives to report DTP3 coverage are biasing some of the official reports…”

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[EQ] Integrating mental health into primary care

Integrating mental health into primary care

A global perspective

Michelle Funk, Department of Mental Health and Substance Abuse, World Health Organization

Gabriel Ivbijaro, Wonca Working Party on Mental Health, London UK

World Health Organization and World Organization of Family Doctors (Wonca) 2008

Available online PDF file [224p] at:
http://www.who.int/mental_health/policy/Mental%20health%20+%20primary%20care-%20final%20low-res%20140908.pdf

“….This report presents the justification and advantages of providing mental health services in primary care. At the same time, it provides advice on how to implement and scale-up primary care for mental health, and describes how a range of health systems have successfully undertaken this transformation.

Mental disorders affect hundreds of millions of people and, if left untreated, create an enormous toll of suffering, disability and economic loss. Yet despite the potential to successfully treat mental disorders, only a small minority of those in need receive even the most basic treatment.

Integrating mental health services into primary care is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need. Primary care for mental health is affordable, and investments can bring important benefits.

Key Messages:
1. Mental disorders affect hundreds of millions of people and, if left untreated, create an enormous toll of suffering, disability and economic loss.

2. Despite the potential to successfully treat mental disorders, only a small minority of those in need receive even the most basic treatment.

3. Integrating mental health services into primary care is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need.

4. Primary care for mental health is affordable, and investments can bring important benefits.

5. Certain skills and competencies are required to effectively assess, diagnose, treat, support and refer people with mental disorders; it is essential that primary care workers are adequately prepared and supported in their mental health work.

6. There is no single best practice model that can be followed by all countries. Rather, successes have been achieved through sensible local application of broad principles.

7. Integration is most successful when mental health is incorporated into health policy and legislative frameworks and supported by senior leadership, adequate resources, and ongoing governance.

8. To be fully effective and efficient, primary care for mental health must be coordinated with a network of services at different levels of care and complemented by broader health system development.

9. Numerous low- and middle-income countries have successfully made the transition to integrated primary care for mental health.

10. Mental health is central to the values and principles of the Alma Ata Declaration; holistic care will never be achieved until mental health is integrated into primary care….”

Content:

Executive summary

Introduction

PART 1: Primary care for mental health in context

Chapter 1: Primary care for mental health withina pyramid of health care

Chapter 2: Seven good reasons for integrating mental health into primary care

PART 2: Primary care for mental health in practice

10 principles for integrating mental health into primary care

Argentina: Physician-led primary care for mental health in Neuquén province, Patagonia region

Australia: Integrated mental health care for older people in general practices of inner-city Sydney

Belize: Nationwide district-based mental health care.

Brazil: Integrated primary care for mental health in the city of Sobral

Chile: Integrated primary care for mental health in the Macul district of Santiago.

India: Integrated primary care for mental health in the Thiruvananthapuram District, Kerala State.

Islamic Republic of Iran: Nationwide integration of mental health into primary care

Saudi Arabia: Integrated primary care for mental health in the Eastern Province

South Africa: Integrated primary care services and a partnership for mental health primary care – Ehlanzeni District, Mpumalanga Province, and Moorreesburg District, Western Cape Province.

Uganda: Integrated primary care for mental health in the Sembabule District

United Kingdom of Great Britain and Northern Ireland: Primary care for mental health for disadvantaged communities in London

Report conclusions

Annex 1: Improving the practice of primary care for mental health

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[EQ] Doctors, Dollars & Quality

Doctors, Dollars & Quality

Health Affairs, doi: 10.1377/hlthaff.28.1.w91 - Published online December 4, 2008

Table of Contents

From The Editor Susan Dentzer

“……..examining the connections among the supply of doctors,the composition of the physician workforce, the quality of healthcare, and health spending. It is critically important to establishjust what these connections are. The United States faces a numberof major and potentially competing challenges: improving thehealth status of the population; expanding health coverage andaccess to care; coping with a future of aging and chronicallyill individuals; and constraining the growth of health spending.Policymakers clearly need to understand how to get the biggestbang for the buck in improving health and in delivering high-qualityhealth care. Among the top priorities is determining whetheror not the nation needs more physicians, and of what sort, toaccomplish these goals….”

Preface

Philip Musgrove, Deputy Editor, Health Affairs

“…..Does the United States have enough doctors, given the enormousdemand for health care and forecasts about a future filled withaging and chronically ill baby boomers? And do we have the rightmix of doctors--since specialists "cost" more to produce thangeneral practitioners, are paid more under current reimbursementsystems, and prescribe more health care to boot? …”

States With More Physicians Have Better-Quality Health Care

Richard A. Cooper, is a professor of medicine in the Leonard Davis Institute at the Wharton School, University of Pennsylvania, in Philadelphia.

“…..As efforts begin to expand the physician workforce in responseto deepening shortages of physicians, attention has focusedon the value of what physicians do. There is a widely held beliefthat states with more specialists have poorer-quality healthcare, while quality is better in states with more family physicians.This is myth. Quality is better in states with more physicians,both specialists and family physicians. Access depends on totalphysician supply, irrespective of specialty. Population density,per capita income, and regional factors all influence this relationship,but the data are unequivocal….”

States With More Health Care Spending Have Better-Quality Health Care: Lessons About Medicare

Richard A. Cooper, is a professor of medicine in the Leonard Davis Institute at the Wharton School, University of Pennsylvania, in Philadelphia.

“….Based on broad measures of health system quality and performance, states with more total health spending per capita have better-quality care. This fact contrasts with a previous finding that states with higher Medicare spending per enrollee have poorer-quality care. However, quality results from the total funds available and not from Medicare or any single payer. Moreover, Medicare payments are disproportionately high in states that have a disproportionately large social burden and low health care spending overall. These and other vagaries of Medicare spending pose critical challenges to research that depends on Medicare spending to define regional variation in health care….”

Cooper's Analysis Is Incorrect

Katherine Baicker is professor of health economics at the Harvard School of Public Health and a research associate at the National Bureau of Economic Research (NBER) in Cambridge, Massachusetts.
Amitabh Chandra is an assistant professor of public policy at Harvard's Kennedy School of Government and a faculty research fellow at the NBER.

“….In his papers, Richard Cooper finds positive associations between health care quality and both specialist and generalist physicians, but he misinterprets his results. Instead of undermining the findings of our study, which found higher quality in areas with more generalists relative to specialists, his results bolster ours: they suggest that the effect of generalists on quality is ten times larger than that of specialists. Furthermore, his rejection of multiple regression in favor of exclusive reliance on isolated correlations precludes him from gauging the relative contributions of specialists, generalists, and other factors. Unfortunately, these deficiencies mean that we can learn little from Cooper's analyses…”

The Elusive Connection Between Health Care Spending And Quality

Jon Skinner is the John Sloan Dickey Third Century Professor in Economics in the Department of Economics, Dartmouth College, in Hanover, New Hampshire.
Amitabh Chandra is a professor in the Kennedy School of Government, Harvard University, in Cambridge, Massachusetts.
David Goodman is a professor of pediatrics and of community and family medicine at Dartmouth Medical School and associate director of the Center for Health Policy Research at Dartmouth.
Elliott Fisher is director of the Center for Health Policy Research and a professor of medicine and of community and family medicine, Dartmouth Institute for Health Policy and Clinical Practice

“…..Richard Cooper has shown a positive association between health care quality and "total spending" at the state level, but he does not appear to understand the limitations of this total spending measure; simply adjusting for median age causes the significant positive correlation to disappear. Cooper also finds that some third factor--we think that it is "social capital"--is the key to explaining health care quality. Cooper may believe that this result challenges three decades of research by the Dartmouth group. Instead, it supports the group's view that improved efficiency--and not more doctors and hospital beds--is central to improving quality…”

More Is More And Less Is Less: The Case Of Mississippi

Richard A. Cooper, is a professor of medicine in the Leonard Davis Institute at the Wharton School, University of Pennsylvania, in Philadelphia

“….One can't help but admire the vigor with which some members of the Dartmouth group defend their core belief that "more is less." But polemics aside, some questions still linger. Does Mississippi actually have more specialists (as represented in Katherine Baicker and Amitabh Chandra's Exhibit 6), and does it spend more on health care (as in their Exhibit 1) than almost every other state? And can Mississippi, which ranks near the bottom in health care quality, lift its status by simply improving its health care productivity, as Jon Skinner and colleagues suggest? If these questions gnaw at you, as they did at me, there's a need to probe further…”

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