Friday, January 30, 2009

[EQ] Bridging the divide: global governance of trade and health

Bridging the divide: global governance of trade and health

 

Kelley Lee, Devi Sridhar, Mayur Patel

This is the second in a Series of six papers on trade and health Centre on Global Change and Health, London School of Hygiene and Tropical Medicine,

London, UK (K Lee DPhil); and All Souls College, Department of Politics and International Relations (D Sridhar DPhil) and Department of International

Development (M Patel MPhil), University of Oxford, Oxford, UK

Volume 373, Issue 9661, Pages 353-432 - 31 January 2009-6 February 2009

 

Abstract:  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61776-6/abstract

 

The main institutions responsible for governing international trade and health—the World Trade Organization (WTO), which replaced the General Agreement on Tariff s and Trade (GATT) in 1995, and WHO—were established after World War 2. For many decades the two institutions operated in isolation, with little cooperation between them.

The growth and expansion of world trade over the past half century amid economic globalisation, and the increased importance of health issues to the functioning of a more interconnected world, brings the two domains closer together on a broad range of issues. Foremost is the capacity of each to govern their respective domains, and their ability to cooperate in tackling issues that lie at the intersection of trade and health. This paper discusses how the governance of these two areas relate to one another, and how well existing institutions work together…”

 

Trade and Health SERIES – The Lancet

Launched in London, UK, Jan 21, 2009

"The fact that trade directly and indirectly affects the health of the global population with an unrivalled reach and depth undoubtedly makes it a key health issue", states a Comment introducing the Series.

Executive summary

Many health professionals perceive trade as complex or unrelated to their practice. The Series on trade and health provides timely analysis of the key challenges to achieving an appropriate balance between trade and health across a diverse range of issues. This six-part Series examines differences in structures of the World Trade Organization and the World Health Organization that promote wealth before health. Issues of global trade governance, effects of trade practices on health of workers and the implications of intellectual property rights for access to live-saving medicines are all explored.

 

Series Comments

Trade and health: time for the health sector to get involved

Full Text | PDF


Trade agreements and health in developing countries

Full Text | PDF


Health before profits? Learning from Thailand's experience

Full Text | PDF


Trade and health: the need for a political economic analysis

Full Text | PDF


Series Papers

Managing the pursuit of health and wealth: the key challenges

Summary | Full Text | PDF


Bridging the divide: global governance of trade and health

Summary | Full Text | PDF


Trade and social determinants of health

Summary | Full Text | PDF


Trade in health-related services

Summary | Full Text | PDF


Trade, TRIPS, and pharmaceuticals

Summary | Full Text | PDF


Trade and health: an agenda for action

Summary | Full Text | PDF

 

 

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[EQ] Instruments of development: Randomization in the tropics, and the search for the elusive keys to economic development

Instruments of development: Randomization in the tropics, and the search for the elusive keys to economic development

 

Angus Deaton

Research Program in Development Studies - Center for Health and Wellbeing

Princeton University - January, 2009

 

Available online as PDF file [56p.] at: http://www.princeton.edu/~deaton/downloads/Instruments_of_Development.pdf

 

“……There is currently much debate about the effectiveness of foreign aid and about what kind of projects can engender economic development. There is skepticism about the ability of econometric analysis to resolve these issues, or of development agencies to learn from their own experience. In response, there is movement in development economics towards the use of randomized controlled trials (RCTs) to accumulate credible knowledge of what works, without over-reliance on questionable theory or statistical methods.

 

When randomized controlled trials RCTs are not possible, this movement advocates quasi-randomization through instrumental variable (IV) techniques or natural experiments. I argue that many of these applications are unlikely to recover quantities that are useful for policy or understanding: two key issues are the misunderstanding of exogeneity, and the handling of heterogeneity. I illustrate from the literature on aid and growth. Actual randomization faces similar problems as quasi-randomization, notwithstanding rhetoric to the contrary.

 

I argue that experiments have no special ability to produce more credible knowledge than other methods, and that actual experiments are frequently subject to practical problems that undermine any claims to statistical or epistemic superiority. I illustrate using prominent experiments in development. As with instrumental variable IV methods, randomized controlled trials RCT-based evaluation of projects is unlikely to lead to scientific progress in the understanding of economic development. I welcome recent trends in development experimentation away from the evaluation of projects and towards the evaluation of theoretical mechanisms….”  Author

 

 

 

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[EQ] Principles for allocation of scarce medical interventions

Principles for allocation of scarce medical interventions

 

Govind Persad, Alan Wertheimer, Ezekiel J Emanuel

Department of Bioethics, The Clinical Center, National Institutes of Health, Bethesda, Maryland, USA

Volume 373, Issue 9661, Pages 353-432 - 31 January 2009-6 February 2009

 

Website: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60137-9/fulltext

 

“…..Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge.
We evaluate eight simple allocation principles that can be classified into four categories:
- treating people equally,
- favouring the worst-off ,
- maximising total benefits, and
- promoting and rewarding social usefulness.

 

No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles….”

 

 

 

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Thursday, January 29, 2009

[EQ] Value In Health Care

Value In Health Care

Health Affairs, doi: 10.1377/hlthaff.28.2.w205  by Project HOPE 
27 January 2009 

From The Editor Susan Dentzer

“……..A paramount topic at the moment is value in health care: What should we pay for and how much? Resources aren’t unlimited, and desires or demands for health care should be balanced against various realities--including the effectiveness of care or the desire for other goods and services. Especially in a depressed economy, questions about value in health care may well be at the center of coming health reform debates.

Value discussions raise other issues, including efficiency, measurement, the influence of the payment system, and the locus of accountability for quality. The papers in this volume take up these and other aspects of the value equation. …………”

Building Organizational Capacity: A Cornerstone Of Health System Reform
Janet Corrigan and Dwight McNeill

Payment Reform Alone Will Not Transform Health Care Delivery - Charles N. Kahn III

Fostering Accountable Health Care: Moving Forward In Medicare
Elliott S. Fisher, Mark B. McClellan, John Bertko, Steven M. Lieberman,
Julie J. Lee, Julie L. Lewis, and Jonathan S. Skinner

Medicare: The Place To Start Delivery System Reform - Francis J. Crosson

A Consumer Perspective On Physician Payment Reform - John Rother

Using Medicare Payment Policy To Transform The Health System: A Framework For Improving Performance
Stuart Guterman, Karen Davis, Stephen Schoenbaum, and Anthony Shih

Measuring Outcomes And Efficiency In Medicare Value-Based Purchasing
Christopher P. Tompkins, Aparna R. HIggins, and Grant A. Ritter

Payment Reform Options: Episode Payment Is A Good Place To Start
Robert E. Mechanic and Stuart H. Altman

Consumer-Driven Health Care: Promise And Performance
James C. Robinson and Paul B. Ginsburg

Costs And Benefits Of Health Information Technology: New Trends From The Literature
Caroline Lubick Goldzweig, Ali Towfigh, Margaret Maglione, and Paul G. Shekelle

Measuring, Monitoring, And Managing Quality In Germany's Hospitals
Reinhard Busse, Ulrike Nimptsch, and Thomas Mansky

 

 

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[EQ] Health and Medical Research in Spain

Health and Medical Research in Spain

Health Research Observatory

 

Fragiskos Archontakis
RAND Europe’s Health Research Observatory 2008
Documented Briefing series, funded by the UK Department of Health

Available online PDF [66p.] at: http://www.rand.org/pubs/documented_briefings/2009/RAND_DB566.pdf

This report provides an overview of health and medical research in Spain. The report is part of a series of country-specific reports available from RAND Europe's Health Research Observatory. The report describes the structure of Spain's health research system, the processes and performance of the Spain health research system, and an outlook which considers current and emerging health research issues in Spain.

Summary: Key Points

- Key funders of health R&D in Spain are industry, central government, and the local governments of the autonomous communities

- Important role of Carlos III Health Institute as a funds manager and of the Spanish National Research Council as a research driver

- R&D funding in Spain has increased year on year, and health R&D funding is also increasing as a percentage of total funding

- The INGENIO 2010 initiative includes a series of policies and strategic actions

- Research productivity (as measured by publications) has been increasing in biomedical sciences

Content:

Summary
Introduction
Structure of the Spanish Health Research System
Processes and Performance of the Spanish Health Research System
Outlook
Reference List.

See Also: Free, downloadable PDF file(s) full text, available online.

Australia

Canada

Japan

New Zealand

Sweden

United Kingdom

United States

Guiding Good Research

 

 

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[EQ] Exchange in Int J Epidemiology on individualistic fallacy,ecological fallacy, and the importance of history & societal context

fyi: an exchange just published in the International Journal of Epidemiology (advanced access)

 

-- the 1st article critiques the individualistic fallacy of the classic paper on ecologic fallacy by Robinson (1950), provides new evidence regarding a contributing source of the documented ecologic fallacy, and does so by bringing in historical and societal context, including the impact of Jim Crow (legalized segregation) on population outcomes

 

-- the additional 4 articles include the original Robinson paper, two commentaries, and a response to the commentaries

 

Below is a list of the article titles, followed by the article titles + abstracts (or excerpts)

 

 

ARTICLE TITLES

 

1)      Revisiting Robinson: The perils of individualistic and ecologic fallacy


S V Subramanian, Kelvyn Jones, Afamia Kaddour, and Nancy Krieger

1 Department of Society, Human Development and Health, Harvard School of Public Health, Boston, USA.

2 School of Geographical Sciences, University of Bristol, Bristol, UK.

3 Department of Global Health and Population, Harvard School of Public Health, Boston MA

IJE Advance Access published on January 28, 2009.

doi:10.1093/ije/dyn359  http://ije.oxfordjournals.org/cgi/content/abstract/dyn359

 

 

Background W S Robinson made a seminal contribution by demonstrating that correlations for the same two variables can be different at the individual and ecologic level. This study reanalyzes and historically situates Robinson's influential study that laid the foundation for the primacy of analyzing data at only the individual level.

 

Methods

We applied a binomial multilevel logistic model to analyse variation in illiteracy as enumerated by the 1930 US. Census (the same data as used by Robinson). The outcome was log odds of being illiterate, while predictors were race/nativity (‘native whites’, ‘foreign-born whites’ and ‘negroes’) at the individual-level, and presence of Jim Crow segregation laws for education at the state-level. We conducted historical research to identify the social and scientific context within which Robinson's study was produced and favourably received.

 

Results Empirically, the substantial state variations in illiteracy could not be accounted by the states' race/nativity composition. Different approaches to modelling state-effects yielded considerably attenuated associations at the individual-level between illiteracy and race/nativity. Furthermore, state variation in illiteracy was different across the race/nativity groups, with state variation being largest for whites and least for foreign-born whites. Strong effects of Jim Crow education laws on illiteracy were observed with the effect being strongest for blacks. Historically, Robinson's study was consonant with the post-World War II ascendancy of methodological individualism.

 

Conclusion Applying a historically informed multilevel perspective to Robinson's profoundly influential study, we demonstrate that meaningful analysis of individual-level relationships requires attention to substantial heterogeneity in state characteristics. The implication is that perils are posed by not only ecological fallacy but also individualistic fallacy. Multilevel thinking, grounded in historical and spatiotemporal context, is thus a necessity, not an option.

 

 

2) Reprints and Reiterations

    WS Robinson

    Ecological Correlations and the Behavior of Individuals

    IJE Advance Access published on January 28, 2009.

    doi:10.1093/ije/dyn357 http://ije.oxfordjournals.org/cgi/content/extract/dyn357

 

 

AN INDIVIDUAL CORRELATION is a correlation in which the statistical object or thing described is indivisible. The correlation between color and illiteracy for persons in the United States, shown later in Table I, is an individual correlation, because the kind of thing described is an indivisible unit, a person. In an individual correlation the variables are descriptive properties of individuals, such as height, income, eye color, or race, and not descriptive statistical constants such as rates or means.

 

In an ecological correlation the statistical object is a group of persons. The correlation between the percentage of the population which is Negro and the percentage of the population which is illiterate for the 48 states, shown later as Figure 2, is an ecological correlation. The thing described is the population of a state, and not a single individual. The variables are percentages, descriptive properties of groups, and not descriptive properties . . .

 

 

 

3) Glenn Firebaugh

    Commentary: ‘Is the Social World Flat? W.S. Robinson and the Ecologic Fallacy’

    IJE Advance Access published on January 28, 2009.

    doi:10.1093/ije/dyn355  http://ije.oxfordjournals.org/cgi/content/extract/dyn355

 

If the social world were ‘flat’ in the sense that it did not matter where you lived or with whom you associated-no place effects, no context effects, no contagion effects-then single-level analysis would do. The message of Subramanian, Jones, Kaddour and Krieger1 is that the social world usually is not flat, so multilevel analysis usually is called for. The idea that single-level analysis is problematic when there are multilevel effects is quite consistent with Robinson's classic warning about the ecologic fallacy.2 In fact, I suspect that Robinson himself would have embraced multilevel analysis had it existed in his day.

 

 

4) J Michael Oakes

    Commentary: Individual, ecological and multilevel fallacies

    IJE Advance Access originally published on January 27, 2009. This version published January 28, 2009.

    doi:10.1093/ije/dyn356 URL:
http://ije.oxfordjournals.org/cgi/content/full/dyn356v2?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=J+Michael+Oakes&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

 

The new paper by Drs Subramanian, Jones, Kaddour and Krieger (hereinafter Authors) contains many important and subtle insights about the fallacies of single-level research, be it at the individual or ecological level.1 The Authors urge epidemiologists to consider contexts and multilevel phenomena when investigating and explaining population health. They also criticize the late William S. Robinson and his classic 1950 paper, and methodological individualism (MI) as a research paradigm.2 Support comes from historical anecdotes, theory and a re-analysis of Robinson's data.

 

Assuming I understood it properly, I am in full agreement with the primary aim of the new paper. Epidemiologists, especially those interested in the effect of social forces on health, should consider contexts and multilevel phenomena. And as a general proposition, I also agree that critical examination of a scientist's culture, history and personal motivation can be enlightening. The Authors’ scholarship on these matters merits careful study.

 

 

5) SV Subramanian, Kelvyn Jones, Afamia Kaddour, and Nancy Krieger

     Response: The value of a historically informed multilevel analysis of Robinson's data

     IJE Advance Access published on January 28, 2009.

     doi:10.1093/ije/dyn354 http://ije.oxfordjournals.org/cgi/content/extract/dyn354

 

“….Our story begins where Robinson's classic study ended.1 Could a study of relationship between two variables measured only at the individual-level-emblematic of most epidemiologic and social science research when individual data are available-lead to an impoverished description of the relationship?


Using the same data on illiteracy and race that Robinson employed and supplementing it with relevant ecologic data that would have been available at that time, we showed that, in this particular case, studying solely the ‘behavior of individuals’, while ignoring their historical and ecological state context, was both limiting and misleading.2 The comments of the two discussants,3,4 whom we thank for their efforts, underscore the importance of a multilevel approach to scientific research. Neither of their commentaries, importantly, alters the central tenets and conclusions of our study and instead serves only to bolster them….”

 

 

 

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