Egypt and Cuba are both lower-middle income countries with a history of socialist rule and which have embarked on economic liberalisation since the 1990s. Health status in both countries is extremely different. While life expectancy of the Cuban population in all age-groups is similar to that of many high-income industrialised countries, health status in Egypt is relatively poor compared to countries with a similar national income and compared to regional comparators. Health care systems in both countries are also markedly different, although both share a socialist origin with centralised administration of funding and delivery, funding mainly from general taxation, and state-employed providers. In this article, health care financing mechanisms in both countries are analysed on their effectiveness, efficiency, and equity, with the objective of identifying the determinants of success in the Cuban health care system from which valuable lessons for current health reforms in Egypt may be derived.
Introduction: The Government of Egypt has embarked on a process of reforming health care financing in the country. Under the influence of external advisers it has so far focused on social health insurance as the main funding mechanism. Other options, in particular tax-based financing, have hardly been considered. Methods: Review of current health care financing arrangements in Egypt, of potential areas for improvement, and of stated health policy goals. Analysis of social health insurance and taxation-based financing on their ability to meet the stated policy goals and their viability. Results: Although both funding mechanisms have distinct advantages and disadvantages when applied to the Egyptian health system, tax-based financing seems better able to meet the official policy goals of the Government of Egypt than social health insurance on grounds of efficiency, equity and technical feasibility. Conclusions: The Government of Egypt will have to raise public health expenditure substantially to finance care at an adequate level. Expanding and refining the present tax-based financing scheme, rather than switching to an insurance-based scheme seems the technically superior strategy. Other measures to improve the coordination of financing, such as the creation of a single fundholding agency, are needed as well as tighter regulation of private providers and the pharmaceutical market. ; Hintergrund: Die ägyptische Regierung hat begonnen die Finanzierungs-mechanismen im Gesundheitssystem zu reformieren. Der Fokus der Überlegungen der Regierung und der externen Berater war bisher ein Sozialversicherungssystem. Andere Optionen, besonders ein aus Steuern finanziertes Gesundheitssystem, wurden bisher nicht ausreichend berücksichtigt. Methoden: Übersicht über derzeitige Finanzierungsmechanismen im ägyptischen Gesundheitssystem und Aufzeigen von möglichen Ansatzpunkten für Reformen und der gesundheitspolitischen Ziele der Regierung. Vergleichende Analyse des Verbesserungspotentials durch eine allgemeine Sozialversicherungspflicht oder eine Finanzierung aus Steuermitteln. Die offiziellen gesundheitspolitischen Ziele der Regierung werden dabei neben der technischen und politischen Umsetzbarkeit als Kriterien verwendet. Ergebnisse: Obwohl beide Finanzierungsmechanismen im Kontext des ägyptischen Gesundheitssystems unterschiedliche Vor- und Nachteile bieten, scheint eine Finanzierung aus Steuermitteln die geeignetere Finanzierungsart um die gesundheitspolitischen Ziele der Regierung wie Effizienz und Gerechtigkeit nachhaltig zu erreichen. Empfehlungen: Zum einen müsste die ägyptische Regierung die öffentliche Finanzierung des Gesundheitssystems deutlich erhöhen um eine adäquate Gesundheitsversorgung der Bevölkerung zu gewährleisten. Zum anderen scheint eine Ausweitung und Präzision des bestehenden steuerfinanzierten Systemanteils einer Ausweitung des Sozialversicherungsanteils die technisch überlegene Strategie zu sein. Andere flankierende Massnahmen wie die Schaffung einer zentralen Koordinationsstelle für die Gesundheitssystemfinanzierung und eine verbesserte Regulierung der privaten Anbieter und des Marktes für pharmazeutische Produkte sind ebenfalls wünschenswert.
Die Verkehrssicherheit von Kindern ist ein Kernpunkt des Sicherheitsberichts der Organisation für ökonomische Kooperation und Entwicklung (OECD). In ihrem Bericht "Keeping Children Safe in Traffic" wird auf erfolgreiche Programme für mehr Sicherheit für Kinder im Straßenverkehr verwiesen. In-wieweit die Empfehlungen in den Mitgliedsstaaten erfolgreich umgesetzt werden, bleibt im Bericht jedoch offen. Ziel der Arbeit ist, eine Basis für die Überprüfung der Evidenz der Verkehrspolitik in Deutschland zu legen. Die vorliegende Situationsanalyse zur Datenlage von Verkehrssicherheitsmaßnahmen für Kinder überprüfte die Daten zwischen 1990 und 2005 zu Verkehrsunfällen von Kindern in Deutschland. Zusätzlich wurden Studien zu ausgewählten Bereichen Verkehrserziehung, Schutzausrüstung, Bau und Raum, Überwachung und Regulation sowie psychologische und soziale Aspekte recherchiert und dem aktuellen Unfallverhütungsbericht der Bundesregierung gegenübergestellt. Alle bearbeiteten Studien wurden tabellarisch zusammengefasst. Darüber hinaus werden Beispiele für eine evidenzbasierte und erfolgreiche Umsetzung von Maßnahmen der Verkehrssicherheit für Kinder auf lokaler Ebene aufgezeigt. Die Analysen der Daten ergaben, dass das Risiko für Kinder zu verunglücken in Deutschland in den vergangenen Jahren eher gestiegen ist. Jedoch wer-den diese Daten in den Bericht der Bundesregierung gegenteilig dargestellt. Dies hängt vor allem von den gewählten Bezugszahlen der Berechnungen ab. Eine erfolgreiche Reduzierung von Unfällen mit Kinderbeteiligung wurde am Beispiel der Stadt Hamm aufgezeigt. In Deutschland bleiben nach dem derzeitigen Kenntnisstand der Arbeit, evi-denzbasierte Verkehrsicherheitsmaßnahmen Einzelmaßnahmen. Um eine evidenzbasierte Verkehrspolitik zu erreichen, bedarf es als Voraussetzung mehr Transparenz der Daten und Studien. Ebenso sollten Forschungsergeb-nisse besser strukturiert und den politischen Entscheidungsträgern in einer leicht zugänglichen und verständlichen Form zur Verfügung stehen. Darüber hinaus sollten die Erfahrungen anderer Länder in der nationalen Verkehrspolitik Berücksichtigung finden. Das in Schweden, Großbritannien und den Niederlanden bereits erklärte Ziel einer Verkehrspolitik mit null Verkehrstoten ("Vision Zero") sollte auch in Deutschland selbstverständlich sein. ; Road traffic safety for children is a priority for the Organisation for Economic Co-Operation and Development (OECD). Successful interventions to increase the safety of children were highlighted in their report "Keeping children safe in traffic". However, to what extent the successful interventions have been implemented in member states is not reported. The aim of this study is to lay the basis for the analysis of the evidence base of road traffic policy in Germany. This encompasses both an analysis of the current epidemiological situation of road traffic safety for children between 1990 and 2005. In addition, research studies which address topics of traffic education, individual protective measures, urban and traffic design, monitoring and regulation as well as psychological and social factors were reviewed and compared with the most recent Federal Report on Injury Prevention. Best practice examples for the successful implementation of road safety measures for children on the local level are highlighted. The analysis of the available epidemiological data demonstrated that the risk of a child getting injured in traffic has increased during recent years. This is in stark contrast with the most recent report by the Federal Government which stated the contrary. The main reason for this discrepancy is the choice of denominators. A successful example on how to reduce road traffic accidents with injuries of children is given using the city of Hamm. Evidence-based policies to increase road safety for children in Germany are largely missing and are limited to single interventions at the local level. As prerequisites to a comprehensive road safety policy, there is a need for more data transparency and research. Also existing research should be analysed and made available to policy decision-makers in an easy-to-use format. Experiences from other countries should also be used to improve national road safety policies. The objective of reducing road traffic deaths to zero - "vision zero" adopted by Sweden, the United Kingdom and the Netherlands should also guide German road safety policies.
In Germany, cost-sharing for health care has been used as a financing mechanism since 1923. In this article, the historical development of user charges in Germany since the 1980s is presented in more detail by type of private expenditure, including direct payments, cost-sharing measures, and voluntary health insurance. This is followed by a mapping of current cost-sharing measures including a discussion of protection mechanisms and responsibility for decision-making on cost-sharing measures and a summary of national policy debates. In the final section, the results of a systematic review of the literature on the impact of cost-sharing on equity, efficiency and health outcomes in Germany are presented. ; Die Selbstbeteiligung des Patienten an den Gesundheitsversorgungskosten hat in Deutschland eine lange Tradition und geht auf das Jahr 1923 zurück. In dieser Arbeit wird die historische Entwicklung und Bedeutung von Kostenselbstbeteiligung im Gesundheitswesen seit 1980 detailliert nach Art der Gesundheitsausgaben dargestellt. Dies beinhaltet direkte Zahlungen, Kostenbeteiligung, und private Krankenversicherung. Darauf folgt eine Darstellung der derzeitigen Regelungen zur Selbstbeteiligung mit Berücksichtigung der verschiedenen Mechanismen zum Schutz vor katastrophalen Gesundheitsausgaben und der Zuständigkeit für politische und administrative Entscheidungsfindungen zur Selbstbeteiligung. Im letzten Abschnitt werden die Ergebnisse einer systematischen Literatursuche zu den Auswirkungen von Kostenbeteiligungen auf Effizienz, Gerechtigkeit und Gesundheitsstatus in Deutschland dargestellt.
AbstractDrawing on wider sociologies of risk, this article examines the complexity of clinical risks and their management, focusing on risk management systems, expert decision‐making and safety standards in health care. At the time of this study preventing venous thromboembolism (VTE) among in‐patients was one of the top priorities for hospital safety in the English National Health Service (NHS). An analysis of 50 interviews examining hospital professionals' perceptions aboutVTErisks and prophylaxis illuminates how National Institute for Health and Clinical Excellence (NICE) guidelines influenced clinical decision‐making in four hospitals in oneNHSregion. We examine four themes: the identification of new risks, the institutionalisation and management of risk, the relationship between risk and danger and the tensions between risk management systems and expert decision‐making. The implementation ofNICEguidelines forVTEprevention extended managerial control over risk management but some irreducible clinical dangers remained that were beyond the scope of the newVTErisk management systems. Linking sociologies of risk with the realities of hospital risk management reveals the capacity of these theories to illuminate both the possibilities and the limits of managerialism in health care.
Health interventions vary substantially in the degree of effort required to implement them. To some extent this is apparent in their financial cost, but the nature and availability of non-financial resources is often of similar importance. In particular, human resource requirements are frequently a major constraint. We propose a conceptual framework for the analysis of interventions according to their degree of technical complexity; this complements the notion of institutional capacity in considering the feasibility of implementing an intervention. Interventions are categorized into four dimensions: characteristics of the basic intervention; characteristics of delivery; requirements on government capacity; and usage characteristics. The analysis of intervention complexity should lead to a better understanding of supply- and demand-side constraints to scaling up, indicate priorities for further research and development, and can point to potential areas for improvement of specific aspects of each intervention to close the gap between the complexity of an intervention and the capacity to implement it. The framework is illustrated using the examples of scaling up condom social marketing programmes, and the DOTS strategy for tuberculosis control in highly resource-constrained countries. The framework could be used as a tool for policy-makers, planners and programme managers when considering the expansion of existing projects or the introduction of new interventions. Intervention complexity thus complements the considerations of burden of disease, cost-effectiveness, affordability and political feasibility in health policy decision-making. Reducing the technical complexity of interventions will be crucial to meeting the health-related Millennium Development Goals.
Health interventions vary substantially in the degree of effort required to implement them. To some extent this is apparent in their financial cost, but the nature and availability of non-financial resources is often of similar importance. In particular, human resource requirements are frequently a major constraint. We propose a conceptual framework for the analysis of interventions according to their degree of technical complexity; this complements the notion of institutional capacity in considering the feasibility of implementing an intervention. Interventions are categorized into four dimensions: characteristics of the basic intervention; characteristics of delivery; requirements on government capacity; and usage characteristics. The analysis of intervention complexity should lead to a better understanding of supply- and demand-side constraints to scaling up, indicate priorities for further research and development, and can point to potential areas for improvement of specific aspects of each intervention to close the gap between the complexity of an intervention and the capacity to implement it. The framework is illustrated using the examples of scaling up condom social marketing programmes, and the DOTS strategy for tuberculosis control in highly resource-constrained countries. The framework could be used as a tool for policy-makers, planners and programme managers when considering the expansion of existing projects or the introduction of new interventions. Intervention complexity thus complements the considerations of burden of disease, cost-effectiveness, affordability and political feasibility in health policy decision-making. Reducing the technical complexity of interventions will be crucial to meeting the health-related Millennium Development Goals.
