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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2009.05.030 Byline: Samantha Smith (a), Charles Normand (b) Abstract: There are concerns that existing methods for analysing equity in Irish health care financing, based on progressivity index measures, are not adequately capturing patterns of inequity that occur in practice. This paper follows a new direction in the literature whereby equity in health care financing and delivery are analysed together. A flow of funds for Irish health care resources is developed and applied to data for 2004. The framework traces the flow of public and private health resources from individuals to financial intermediaries, from there to health care providers and functions, and from there to individuals. Individuals are categorised by health care entitlement status. Findings indicate that broad progressive patterns in aggregate resource flows hide less equitable patterns that require further attention and there are complex interactions between public and private resources. The flow of funds approach complements existing analytic methods and generates policy lessons for Irish and international policy makers. Author Affiliation: (a) Economic and Social Research Institute, Whitaker Square, Sir John Rogerson's Quay, Dublin 2, Ireland (b) Health Policy and Management, Trinity College, Dublin 2, Ireland

There is growing evidence that community financing mechanisms can raise additional revenue, increase equitable access to primary health care (PHC), and improve social protection. More recently there has been interest in scaling up community financing as a step towards universal coverage either via tax-based systems or social health insurance. Using key informant interviews and focus group discussions, this study sought to assess the desirability and feasibility of scaling up community health insurance in Armenia. The results suggest that there is broad-based political support for scaling up the schemes and that community financing is synergistic with major health sector reforms. High levels of social capital within the rural communities should facilitate scaling up. Existing schemes have increased access and quality of care, but expansion of coverage is constrained by affordability, poor infrastructure, and weak linkages with the broader health system. Long-term subsidies and system-building will be essential if the expanded schemes are to be financially viable and pro-poor. Overall, successfully scaling up community financing in Armenia would depend on addressing a range of obstacles related to legislation, institutional capacity, human resources and resistance to change among certain stakeholders. Keywords: Community-based health financing/insurance; Scaling up; Decision making; Armenia; Low income

This paper presents findings from a study of the context and processes of provider mergers in the NHS in England. Mergers are an example of organisational restructuring, a key lever for change in the UK health care sector and elsewhere, although it is only one strategy for organisational change. The framework for the study is key themes from the organisational change literature: the complexity of the effects of change; the importance of context; and the role of organisational culture. The drivers for health care mergers and the evidence for these are analysed. Using documentary analysis and in-depth qualitative interviews with internal and external stakeholders, the first part of the paper reports on stated and unstated drivers in nine mergers. This provides the context for four in-depth case studies of the process of merger in the second and third years post-merger. Our study shows that the contexts of mergers, including drivers of change, are important. Merger is a process without clear boundaries, and this study shows problems persisting into the third year post-merger. Loss of management control and focus led to delays in service developments. Difficulties in the merger process included perceived differences in organisational culture and perceptions of 'takeover' which limited sharing of 'good practice' across newly merged organisations. Merger policy was based on simplistic assumptions about processes of organisational change that do not take into account the dynamic relationship between the organisation and its context and between the organisation and individuals within it. Understanding the process of merger better should lead to a more cautious approach to the likely gains, provide understanding of the problems that are likely in the period of change, and anticipate and avoid harmful consequences. Keywords: Mergers; Organisational change; Organisational restructuring; Organisational context; Organisational processes; UK

This paper considers how the information provided by economic evaluation for decision-makers can fail to optimise use of health resources and how assessment of the relative cost-effectiveness of health care interventions can be misleading unless heterogeneity within populations is taken into account. The cost-effectiveness of an intervention is not a point estimate but an average chosen from within a distribution of different results. The normal interpretation of the distribution around that point is often mistakenly assumed to be the 'white noise' of measurement error. In reality this variance is a combination of measurement error and true heterogeneity of results. There remains an overemphasis on pursuing certainty which stems from the fact that the methods involved were originally devised to measure dichotomous outcomes not continuous ones such as cost-effectiveness ratios. It is argued in this paper that more consideration be given to the heterogeneous nature of costs and effects across populations in analysis and policy making. Keywords: Certainty; Optimisation; Cost-effectiveness; Heterogeneity; Health gain

This paper analyses the system of financial and non-financial incentives underlying job preferences of doctors in Bangladesh who work both in government health services and in private practice. The study is based on a survey of 100 government-employed doctors with private practice, across different levels of care and geographical areas. In-depth interviews were carried out in a sub-sample of 28 respondents. The study explores the beliefs and attitudes towards the arrangements of joint private/public practice, establishes profiles of fee levels and earnings and examines the options to change the incentive system in a way that ensures an increased involvement of dual job holding practitioners in the priority areas of care. Consultation fees were Tk120 on average (range Tk20-300) and found to be correlated with the qualification of the practice owner and the type of service offered. A majority of the respondents reported at least to double their government income by engaging in private practice. Significant predictors of total income included the number of patients seen in private practice (p = 0.000), employment in a secondary or tertiary care facility (p = 0.001) and ownership of premises for private practice (p = 0.033). Age was found to be marginally significant (p = 0.084). No association was found between total income and specialisation, private practice costs, level of government salary or a degree from abroad. The data suggest that doctors have adopted individual strategies to accommodate the advantages of both government employment and private practice in their career development, thus maximising benefit from the incentives provided to them e.g. status of a government job, and minimising opportunity costs of economic losses e.g. lower salaries. Commitment to government services was found to be greater among doctors in primary health care who reported they would give up private practice if paid a higher salary. Among doctors in secondary and tertiary care, the propensity to give up private practice was found to be low. Financial incentives that aim to increase numbers of doctors in rural areas, such as a non-private-practice allowance, are more likely to be appreciated by doctors who are at the beginning of their career. Improved training and career opportunities also appear to be of high importance for job satisfaction. Policy changes to ensure a better resource allocation to the priority areas of the health sector have to reflect an understanding of the incentives generated by the organisational and financial context within which dual job holding practitioners operate. Keywords: Bangladesh; Health economics; Human resource development; Incentives

A study was conducted to examine major issues in health care finance and the manner with which health insurance can help in dealing with some of the issues. The objective was to prove the hypothesis that the choice of health care financing mechanisms should begin with a clear focus on policy goals. Results indicate that the lack of cost control mechanisms poses a serious risk in the development of social health insurance. Thus, it is essential to develop clear mechanisms for setting priorities if policy goals are to be met.

New models of care are needed following the closure of long-stay mental handicap hospitals. Based on an evaluation of a recently established assessment and treatment service in south-east England, this paper is concerned with the costs and likely benefits of different patterns of services for people with mild learning disabilities and severely challenging behaviour. Different models of provision are compared in terms of their costs and quality of life opportunities for clients. The assessment and treatment services provided a better understanding of the care needs, and achieved a reduction in challenging behaviours. It was therefore possible to give access to care settings closer to a normal life. For approximately 25% additional expenditure, 20 out of 34 clients who received the service moved to community placements, including three who had been referred following a breakdown in the community. If community care is to be implemented as a policy for clients with learning disabilities and serious challenging behaviours, it is necessary to recognise the financial implications. Better quality of life opportunities for this client group are associated with higher costs. When seen in the dynamic context of the costs and quality of life opportunities of the subsequent care, a high cost assessment and treatment service may be a good investment. On current evidence, the additional benefits of community homes, with a closer association with the local community, and greater freedom for clients is bought only at quite a high cost. Key words - learning disabilities, challenging behaviour, community care

Background: patient empowerment, through which patients become self-determining agents with some control over their health and healthcare, is a common theme across health policies globally. Most care for older people is in the acute setting, but there is little evidence to inform the delivery of empowering hospital care. Objective: we aimed to explore challenges to and facilitators of empowerment among older people with advanced disease in hospital, and the impact of palliative care. Methods: we conducted an ethnography in six hospitals in England, Ireland and the USA. The ethnography involved: interviews with patients aged ≥65, informal caregivers, specialist palliative care (SPC) staff and other clinicians who cared for older adults with advanced disease, and fieldwork. Data were analysed using directed thematic analysis. Results: analysis of 91 interviews and 340 h of observational data revealed substantial challenges to empowerment: poor communication and information provision, combined with routinised and fragmented inpatient care, restricted patients' self-efficacy, self-management, choice and decision-making. Information and knowledge were often necessary for empowerment, but not sufficient: empowerment depended on patient-centredness being enacted at an organisational and staff level. SPC facilitated empowerment by prioritising patient-centred care, tailored communication and information provision, and the support of other clinicians. Conclusions: empowering older people in the acute setting requires changes throughout the health system. Facilitators of empowerment include excellent staff-patient communication, patient-centred, relational care, an organisational focus on patient experience rather than throughput, and appropriate access to SPC. Findings have relevance for many high- and middle-income countries with a growing population of older patients with advanced disease. [ABSTRACT FROM AUTHOR]