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Dissertação de Mestrado, Ciências Económicas e Empresariais, 20 de janeiro de 2020. A Educação e a Saúde são áreas que consomem recursos significativos na maioria dos países. Embora estas atividades possam ser levadas a efeito por entidades não governamentais, em muitos países a provisão direta por parte dos Estado é predominante, sendo isto justificado, por vezes, com base em questões de igualdade, externalidades, entre outras. Este trabalho analisa os determinantes da preferência dos indivíduos entre o Governo e outras entidades no que respeita à provisão de cuidados de Saúde e de Educação (básica). Os resultados indicam que tais preferências dependem de aspetos sociodemográficos, embora existam diferenças visíveis no seu contributo no que respeita às duas áreas analisadas. É de salientar ainda que, no que concerne quer à Educação, quer aos cuidados de Saúde, existem grandes diferenças nas preferências dos cidadãos associadas aos respetivos países de residência. ABSTRACT: Education and health care are areas that absorb a significant amount of resources in most countries. Although these activities may be carried out by non-governmental entities, in many countries the direct provision by the state is predominant, and this is sometimes justified on the basis of equality, externalities, among others. This study examines the determinants of individuals' preference between government and other entities for health care provision and education for children. The results indicate that such preferences depend on socio-demographic aspects, although there are noticeable differences in their contribution to the two areas analyzed. It should also be noted that, both in education and in health care, there are major differences in citizens' preferences associated with their countries of residence.

This paper explores the physicians’ perspective regarding the potential of computerised Cognitive Behavioural Therapies (cCBTs) to overcome inequalities in the context of mental health care provision. The main benefits were related to the ability of cCBTs to provide care in a convenient and efficient manner, enhancing its accessibility. These aspects were perceived more important than cost-effectivity of treatment, which is often claimed to be the key benefit of cCBTs. Age and general acceptance of CBT were the most significant individual-level separators of perceptions, while the sector in which the physician works was seen as the main structural-level separator. peerReviewed

The diploma thesis deals with the identification of risks which threaten students in the fields of Radiology Assistant, General Nurse and Paramedic. The aim of the thesis is to map the knowledge of risks during providing health care in students of selected fields at the Faculty of Health and Social Studies at the University of South Bohemia. Four hypotheses were set in the thesis. Hypothesis no. 1 saying that there are statistically significant differences in risk knowledge between students of the first and last year of individual fields of health care. Hypothesis no. 2 that there are statistically significant differences in stress perception as a risk-enhancing factor between paramedics and general nurses. Hypothesis no. 3 states that there is a statistically significant difference in the knowledge of the risk of ionizing radiation between radiological assistants and general nurses and hypothesis no. 4 that paramedics will call their future occupation more risky than general nurses. To achieve the objectives and verify the hypotheses, a questionnaire was prepared, a questionnaire survey was conducted and everything was evaluated using graphic and statistical methods. The questionnaire contained 23 questions and the research sample consisted of 105 respondents from the studied fields. The results show that hypothesis no. 1 was confirmed in the fields of Radiology Assistant and Paramedic and rejected by the General Nurse. Hypothesis no. 2 was also confirmed. Hypothesis no. 3 was rejected and hypothesis no. 4 was also rejected. The contribution of the thesis is a complex picture of the knowledge of risks during providing health care in the studied fields. The results can serve the faculty to further more effective teaching.

Background: Immigration into Europe has reached an all-time high. Provision of coordinated healthcare, especially to refugee women that are at increased risk for adverse pregnancy outcomes, is a challenge for receiving health care systems. Methods: We assessed pregnancy rates and associated primary healthcare needs in three refugee cohorts in Northern Germany during the current crisis. Results: Out of n = 2911 refugees, 18.0% were women of reproductive age, and 9.1% of these were pregnant. Pregnancy was associated with a significant, 3.7-fold increase in primary health care utilization. Language barrier and cultural customs impeded healthcare to some refugee pregnant women. The most common complaints were demand for pregnancy checkup without specific symptoms (48.6%), followed by abdominal pain or urinary tract infections (in 11.4% of cases each). In 4.2% of pregnancies, severe complications such as syphilis or suicide attempts occurred. Discussion: We present data on pregnancy rates and pregnancy associated medical need in three current refugee cohorts upon arrival in Germany. Healthcare providers should be particularly aware of the requirements of pregnant migrants and should adapt primary caretaking strategies accordingly.

The Henry Mintzberg’s myth #5 has been inspired by “conventional wisdom” according to which ownership of health care providers plays an important role in the efficiency in producing services. Moreover, Henry Mintzberg argues that health care is rightly controlled by the public sector, for the sake of equality (Mintzeberg 2012). Based on these two apparently contrasting arguments one can conclude that in the system where most of provision is public, there should be some trade-offs between equality and efficiency.

Faith-inspired institutions (FIIs) play an important role in improving health care in many African countries through the delivery of facility-based care, training of the health workforce, involvement in community-based activities, and participation in health promotion campaigns. FIIs represent a wide array of faiths and diverse motivations and goals. While a number of factors shape the approaches taken by FIIs in planning their activities, an often expressed priority is to serve the poor for whom care often remains unaffordable. Many faith-based providers also aim to provide preventive and/or curative care to those who are at a disadvantage or marginalized. In the case of Burkina Faso, significant progress has been achieved to facilitate access to care—examples include, among others, the construction of new facilities, vaccination campaigns, and the reduction or elimination of selected fees. As a result, many health statistics such as the rate of assisted childbirth, the use of health services, vaccination, and infant mortality have improved. Nevertheless, available household survey data suggest that apart from cases when an individual does not seek care because there is no need for it, or self-medicates when ill or sick, the main reason for not seeking care is cost.

Cost-effectiveness models for health care interventions generally make the assumption that all resources are available, as required, without capacity constraints. This assumption may be a reasonable approximation of the truth for a range of questions faced by decision makers in health care. However, in some health care settings, capacity constraints predominate leading to queue development. In these situations the use of a modelling technique that can accommodate these constraints would appear advisable to allow the efficiency of competing healthcare interventions to be determined. Nevertheless, there have been no empirical comparisons of economic modelling techniques that capture capacity constraints and those that do not. Further, there are only a few cost-effectiveness analyses (CEA) of health care that capture the effect of capacity constraints at all. This research seeks to explore these gaps in the literature in an applied manner.

SummaryThis study aimed to describe health care provision, resource consumption and related costs, as well as treatment patterns and quality of life in adult patients with pulmonary arterial hypertension (PAH) in Germany.Data for this retrospective and prospective cost-of-illness-study were derived from hospitals, general practitioners and patients. Costs were evaluated from the perspective of third party payer and patient. Quality of life data were collected by using three validated instruments.A total of 167 patients were enrolled at 10 hospitals. Time period from first occurrence of symptoms to confirmed diagnosis of PAH was 2.3 years on average. Mean number of GP visits was 1.5 per patient per month, and within 15 months, inpatient stays were reported for 50% of patients. The ratio of combination therapy to single-drug therapy for endothelin receptor antagonists, phosphodiesterase-5-inhibitor and prostacyclin analogues increased significantly during 15 months. Treatment costs were, on average, €47,400 per patient per year, arising mainly from drugs. Compared to the general population, quality of life of PAH patients was considerably impaired.This is the first study which evaluated aspects of the medical and economic consequences of PAH based on a large cohort of PAH patients in Germany.

The last few years have seen a growing commitment worldwide to universal health coverage (UHC). Yet there is a lack of clarity on how to measure progress towards UHC. This paper proposes a ‘mashup’ index that captures both aspects of UHC: that everyone—irrespective of their ability-to-pay—gets the health services they need; and that nobody suffers undue financial hardship as a result of receiving care. Service coverage is broken down into prevention and treatment, and financial protection into impoverishment and catastrophic spending; nationally representative household survey data are used to adjust population averages to capture inequalities between the poor and better off; nonlinear tradeoffs are allowed between and within the two dimensions of the UHC index; and all indicators are expressed such that scores run from 0 to 100, and higher scores are better. In a sample of 24 countries for which there are detailed information on UHC-inspired reforms, a cluster of high-performing countries emerges with UHC scores of between 79 and 84 (Brazil, Colombia, Costa Rica, Mexico and South Africa) and a cluster of low-performing countries emerges with UHC scores in the range 35–57 (Ethiopia, Guatemala, India, Indonesia and Vietnam). Countries have mostly improved their UHC scores between the earliest and latest years for which there are data—by about 5 points on average; however, the improvement has come from increases in receipt of key health interventions, not from reductions in the incidence of out-of-pocket payments on welfare.

This Public Expenditure Review (PER) for health in Zimbabwe is an analytical report developed by the World Bank Health, Nutrition and Population Task Team working with the World Bank’s Macroeconomics and Fiscal Management Global Practice team, Zimbabwe’s Ministry of Finance and Economic Development (MOFED) and Ministry of Health and Child Care (MOHCC), with input from development partners. The aims of the PER are to provide objective evidence to inform the allocation of resources to enable equitable, efficient, and sustainable health care provision and to highlight questions about health sector performance for policy makers and key stakeholders. The findings also aim to present Zimbabwe’s health sector spending in an international and regional perspective, highlighting key issues for improving health outcomes. The PER is based on analysis of primary and secondary data as well as an extensive review of existing literature. The research was complemented by interviews with key stakeholders, and data collection from major development partners and domestic health funders, including private companies. Micro-level data from household and health facility surveys in May–August 2014 (primarily for the impact evaluation of the Results-Based Financing (RBF) program supported by the World Bank) complemented these scarce data.

Despite their strong contribution to the overall world economic growth, gender gaps are wide in many countries in sub Saharan Africa and low representation of women in the private health sector is wider than in other sectors. While women and youth use the majority of health services both private and public, women are underrepresented as private health care providers and have limited access to financing to open their own private practices. This landscape has prompted the HNP Global Practice to take a critical look at the factors which hamper the growth of female and young private health practitioners vis a vis their male counterparts (usually older and more experienced in their profession). This assessment provides information on ways to close the gap which exists between male private service providers and female providers as well as recommends ways in which the existing gaps can be addressed. The assessment also provides the basis for further developing a strong public- private dialogue in health while providing avenues for building capacities for women to fully contribute to the development of the private health sector through the development of training module to be administered in private training schools as a pilot in Burkina Faso and Mali.

International and national campaigns to prevent HIV/AIDS and efforts to promote reproductive health remain separate in terms of conceptualisation and implementation. Local negotiations around reproductive health issues similarly seem to lack explicit attention to HIV/AIDS. This paper argues that even in reproductive health clinics a gap exists between the extent of knowledge of HIV/AIDS and AIDS talk. There also appears to be a mismatch between collective knowledge of the behavioural and biomedical context of HIV/AIDS and the socio-economic context of AIDS as a lived experience. Using an ethnographic account, I explore how one woman\'s lived experience and her knowledge of AIDS can teach us to take HIV/AIDS into account when theorising, promoting or providing services for improving African women\'s reproductive health. The background for this ethnography comes from data collected during 25 months of fieldwork at 10 maternal and child health/family planning (MCH/FP) clinic sites in the Morogoro, Ruvuma and Kilimanjaro regions of Tanzania. Rehema\'s story shows that AIDS, like other diseases, is significantly linked to host-susceptibility and economic vulnerability. Separate and competing vertical programmes on AIDS and MCH/FP, as commonly encountered throughout Africa, cannot meet the needs of women in countries like Tanzania. Yet, we still hear most often of abstinence, anti-retrovirals and condom use as the primary focus of HIV/AIDS prevention and intervention in Africa.Keywords: Africa, communication, ethnography, health care provision, family planning, national health care programmesAfrican Journal of AIDS Research 2005, 4(2): 83–90

This paper broadly examines the development process of Korea’s health care system toward the achievement of Universal Health Coverage. Korea implemented a series of health care reforms after a rapid expansion of population coverage to improve efficiency and equity in financing and delivery of health care. The authors also investigate changes in the governance structure of Korea’s national health Insurance, which is now represented by two agencies: National Health Insurance Service (NHIS) and Health Insurance Review and Assessment Service (HIRA). Health insurance agencies have improved the accountability and transparency of the health insurance system, thanks to the ICT-based centralized claim review and assessment. Lessons and challenges from Korea’s experiences and achievements on the road to UHC could provide valuable policy implications to low- and middle-income countries.

Gérard Reach,1,2 Silla M Consoli,3,4 Serge Halimi,5 Claude Colas,6 Martine Duclos,7–9 Pierre Fontaine,10 Caroline Martineau,11 Carole Avril,12 Catherine Tourette-Turgis,13 Sylvie Pucheu,4 Olivier Brunet14 1Department of Endocrinology, Diabetes and Metabolic Diseases, Avicenne Hospital, Bobigny, 2EA 3412, CRNH-IDF, Paris 13 University, Sorbonne Paris Cité, Bobigny, 3Paris Descartes University, Paris Sorbonne Cité, Faculty of Medicine, Paris, 4University Service of Adult and Elderly Psychiatry, European Georges-Pompidou Hospital, Paris, 5Department of Diabetology, Endocrinology and Nutrition, Joseph Fourier University and CHU Grenoble, Grenoble, 6Department of Diabetology, Hôtel-Dieu Hospital, Paris, 7Department of Sport Medicine and Functional Explorations, Montpied Hospital, Clermont-Ferrand, 8Department of Human Nutrition, Centre de Recherche en Nutrition Humaine, Institut National de la Recherche Agronomique, Clermont-Ferrand, 9Department of Human Nutrition, University of Auvergne, Clermont-Ferrand, 10Department of Endocrinology, Diabetes and Metabolic Diseases, Huriez Hospital, Lille 2 University, Lille, 11Department of Dietetics, Larrey Hospital, CHU Toulouse,12French Diabetics Federation, Paris,13UPMC-Sorbonne Universités, Paris, 14Generalpractitioner, Seraincourt, France Aim: The second Diabetes, Attitudes, Wishes and Needs (DAWN2™) multinational cross-sectional study was aimed at generating insights to facilitate innovative efforts by people with diabetes (PWD), family members (FMs), and health care professionals (HCPs) to improve self-management and psychosocial support in diabetes. Here, the French data from the DAWN2™ study are described.Methods: In France, 500 PWD (80 with type 1 diabetes [T1] and 420 with type 2 diabetes [T2]), 120 FMs, and 288 HCPs were recruited. The questionnaires assessed the impact of diabetes on quality of life and mood, self-management, attitudes/beliefs, and care/support.Results: Diabetes negatively impacted the emotional well-being of 59% of people with T1 versus 45% of people with T2 (P

The World Bank supported the community nutrition project (CNP) in the Lao People’s Democratic Republic (PDR) from 2009 to 2013, ostensibly to respond to the global food crisis of 2007-08. The evaluation finds an attributable effect on only one of the six formal project indicators: children in intervention areas were more likely to receive full diphtheria, pertussis, and tetanus (DPT) vaccines. This impact evaluation seeks to address whether the CNP can make causal claims to improving indicators related to its six stated project development objective measurements for mothers and children under two years old: antenatal care visits, institutional delivery, well-child checkups, breastfeeding, immunization, and diarrhea oral rehydration solutions. The results of quasi-experimental impact evaluation methods indicate that although general effects for these outcomes are mixed, the project shows improvements for the poorest 40 percent of the population.

Objetivo: determinar qué condiciones pueden explicar la inasistencia a citas programadas de control prenatal (CPN) y evaluar si la eliminación de las barreras de acceso mejora las condiciones de salud de las gestantes. Metodología: se realizó un estudio de diseño mixto, multietápico, de cohorte prospectivo. Resultados: la dificultad para el pago de transporte fue la principal barrera de acceso causante de inasistencia. Mediante la entrega de subsidios de transporte, las inasistencias disminuyeron 87%. Los determinantes de la salud asociados con mayor probabilidad de presentar complicaciones perinatales fueron: estrato socioeconómico bajo, distancia de la vivienda respecto al sitio de atención y alta puntuación en escala de riesgo biopsicosocial. Adicionalmente, factores como educación superior y sustento económico a cargo del hombre cabeza de familia se asociaron a reducción del riesgo de complicaciones materno-fetales. Conclusiones: las barreras económicas, socioculturales y geográficas, obviadas por el sistema de salud colombiano, afectan la accesibilidad al CPN. Objective: To determine conditions that may explain the failure to attend the programmed prenatal control appointments (CPN), and assessing whether eliminating the access barriers improves the health conditions of pregnant women. Methodology: We performed a mixed design prospective cohort study in several stages. Results: The main access barrier that caused failures to attend was difficulties to pay for transportation. By giving transportation subsidies, the failures to attend to the appointments were reduced by 87%. The health determinants associated with a higher probability of having perinatal complications were: low socio-economic status, distance from their residence to the attention site, and a high score in the biopsychosocial risk scale. Additionally, factors like tertiary education and economic support in charge of the man head of the household were associated with a decrease in the risk of maternal-fetal complications. Conclusions: the economic, socio-cultural and geographical barriers ignored by the Colombian health system affect access to the CPN. Objetivo: determinar quais condções podem explicar o não comparecimento as consultas médicas programadas de controle prénatal (CPN) e avaliar se a remocao das barreiras de acesso melhora as condições de saúde das gestantes. Metodologia: realizou-se estudo de desenho misto, multiestágio, de coorte prospectivo. Resultados: a dificuldade para o pagamento de transporte foi a principal barreira de acesso causante do nao comparecimento. Ao fornecer subsidios de transporte, os nao comparecimentos diminuíram 87%. Os determinantes da saúde associados com maior probabilidade de apresentar complicacoes perinatais foram: baixo estrato socioeconómico, distancia da moradia respeito do local de atendimento e alta pontuacao em escala de risco biopsicosocial. Aliás, fatores como ensino superior e sustento económico a cargo do homem cabeca de familia foram associados a reducao de risco de complicares materno-fetais. Conclusões: as barreiras económicas, socioculturais e geográficas, obviadas pelo sistema de saúde colombiano, afetam a acessibilidade ao CPN.

Introduction The study ‘Mental healthcare provision for adults with intellectual disability and a mental disorder’ (MEMENTA) is a cross-sectional epidemiological study carried out in three different regions of Germany. Its main aim is to assess the prevalence of mental disorders in adults with intellectual disability (ID) as well as quality of mental healthcare for this population. Methods and analysis The target population are persons aged between 18 and 65 years with a mild or moderate ID. The study population will be recruited through service providers. A representative sample is realised by two-stage sampling. First, institutions providing services for people with ID (sheltered workshops) are selected in a stratified cluster sampling, with strata being (1) types of service-providing non-governmental organisations and (2) sizes of their sheltered workshops. Then persons working in selected sheltered workshops are selected by simple random sampling. An estimated number of 600 adults with ID will be included. Information will be obtained from the group leaders in the sheltered workshops, informal carers or staff members in sheltered housing institutions and the person with ID. Besides the main outcome parameter of psychiatric symptomatology and problem behaviour, other outcome parameters such as needs for care, quality of life, caregiver burden, health services utilisation and costs for care are assessed using well-established standardised instruments. If a comorbid mental disorder is diagnosed, quality of mental healthcare will be assessed with open questions to all interview partners and, in addition, problem-focused interviews with a small subgroup. Analyses will be carried out using quantitative and qualitative methods. Ethics and dissemination Approval of all three local ethics committees was obtained. Research findings will add much needed empirical information in order to improve services provided to this vulnerable group of patients. Trial Registration number NCT01695395.

Welfare systems are designed on geographical and membership boundaries. In terms of access to health care this implies that, as a general rule, only individuals residing in their national territory can obtain health care from providers located there. However, in the past few years medical tourism has grown at an explosive pace throughout the world and in Europe. Each year in fact a small, but significant number of European citizens seek medical treatment that is financed by their public insurer in another EU country. From an economic point of view, it is important to distinguish between the two following sources of patients’ mobility: a regulated mobility, where the third payer decides to send patients abroad and patients’ choice, where the patient himself decides to seek care abroad. In this article we show how the combined effect of restrictions to the use of health care, transfer prices, and mobility rules determine social welfare and its allocation between Regions. The results are quite interesting: if the price set for these patients is equal to the marginal cost of the more efficient Region, patients’ mobility should be preferred to patients’ choice. On the other hand, if the price is equal to the marginal cost of the less efficient Region, patient choice should be preferred. The other interesting result is a possible trade off between a static model where each Region chooses its level of cost/effectiveness and a more long term situation, where patient mobility determines a common level for this parameter.

Asclepius and Hippocrates focused medical practice on the natural approach and treatment of diseases, highlighting the importance of understanding the patient’s health, independence of mind, and the need for harmony between the individual, social and natural environment, as reflected in the Hippocratic Oath. The aim of this study was to present the philosophy of care provision in ancient Greece and to highlight the influence of the Hippocratic ideal in modern health care practices. A literature review was carried out using browser methods in international databases. According to the literature, “healthy mind in a healthy body” was the main component of the Hippocratic philosophy. Three main categories were observed in the Hippocratic provision of care: health promotion, interventions on trauma care, and mental care and art therapy interventions. Health promotion included physical activity as an essential part of physical and mental health, and emphasized the importance of nutrition to improve performance in the Olympic Games. Interventions on trauma care included surgical practices developed by Hippocrates, mainly due to the frequent wars in ancient Greece. Mental care and art therapy interventions were in accordance with the first classification of mental disorders, which was proposed by Hippocrates. In this category music and drama were used as management tools in the treatment of illness and in the improvement of human behavior. The role of Asclepieion of Kos was highlighted which clearly indicates a holistic health care model in care provision. Finally, all practices regarded detailed recordings and evaluation of information within the guidelines. The Hippocratic philosophy on health care provision focused on the holistic health care model, applying standards and ethical rules that are still valid today.

Pay-for-performance schemes targeting quality improvements and cost reductions in markets for medical care have become increasingly popular among health policy- makers during the last decade. Typically, such schemes attach financial incentives to a set of indicators which consist of some processed information that is believed to constitute an adequate description of the provider. Due to the asymmetric information inherent in medical markets, changes in the information structure are likely to cause substantial change to the environment in which health care providers operate. Since monitoring of physician treatment decisions is a necessary prerequisite in a pay-for performance scheme, and also an important factor influencing the information struc- ture in the market, disentangling the effect of a change in the information regime from a change in financial incentives is difficult. By means of a laboratory experiment we are able to identify the ceteris-paribus effect of a change in information regime. We find that introducing transparency, and making medical students’ treatment decisions known to their peers, have a positive impact on patients’ health benefit. The results also suggest that disclosure of physician performance increase social welfare.

During 2010-2012, a Leonardo da Vinci-funded EU project focused on enhancing the language skills of Deaf people, interpreters and Health Care Professionals. Project partners from Cyprus, Ireland, Poland, Scotland and Sweden reviewed current knowledge of policy and practice, and embedded the resulting analysis into a programme of materials to support reflection, knowledge and skills development internationally. This report presents the project's initial 'state-of-the-art' review, with particular reference to the partner countries. MEDISIGNS

In 2008, India launched Rashtriya Swasthya Bima Yojana (RSBY), a government subsidized health insurance scheme for the poor that covers secondary hospital care for Below Poverty Line (BPL) households. Designed to improve access to healthcare and reduce the financial burden of healthcare expenses, RSBY currently covers 32 million households. The authors exploit the phased rollout of RSBY to estimate the impact of the scheme in its early days on hospitalization rates and out-of-pocket health expenditure using a difference-in-differences approach with matching. We use secondary data from the National Sample Survey Organization conducted in 2009-10. We find that the scheme has led to a small decrease in out-of-pocket household outpatient expenditure and consequently total medical expenditure. The authors also find limited evidence of increase in the number of households that have had a hospitalization case though there are regional variations in the nature of impact. It is unclear whether the improved access to inpatient care is reducing outpatient expenses through decreased need for outpatient care or because some people or hospitals are colluding to convert outpatient treatment to inpatient to avail of the scheme. The authors suggest that additional evidence with a more recent data set allowing for more time for RSBY to display effects is needed to strengthen these early findings.

The reforms that have reshaped the public health care systems have often been coupled with devolution. However, this process has frequently been accompanied by widespread soft budget constraint policies. In this paper we argue that the soft budget constraint arises from a cooperative game between local authorities that force Central Government to bail them out. Our theoretical model is tested using data for Italian regions for the period 2002–2006 and our hypothesis is verified. Although the model uses Italy as a benchmark, we believe that the framework we propose could be extended to other federal contexts where resources are distributed unevenly and preferences are asymmetric.

What motivates religious not-for-profit health care providers? This paper uses a change in financing of not-for-profit health care providers in Uganda to test two theories of organizational behavior. We show that financial aid leads to more laboratory testing, lower user charges, and increased utilization. These findings are consistent with the view that religious not-for-profit providers are intrinsically motivated to serve (poor) people and that these preferences matter quantitatively.

Aim: To investigate the importance of issues related to health care provision in the 2005 Presidential elections in Croatia. Methods: A computer randomized, two-stage stratified telephone survey of a 1000 respondents sample of the Croatian voting population was surveyed in December 2004, 5 days prior to Presidential elections. Respondents were asked to rank priority areas in politics and specific priority areas in health care. Only responses from those voters who identified the two most likely candidates were used in analysis: candidates Stipe Mesić and Jadranka Kosor (center left and center right political options). Results were analyzed with chi-square test and binary logistic regression. Results: Citizens ranked health care issues as their second most important priority in politics, preceded only by economic issues. Top three priority areas recognized in health care were organization (24.7%), financing (23.2%) and corruption (24.3%). Ranking of priority areas in health care varied insignificantly between left and right wing candidate voters. However, right wing oriented voters were more likely to identify lack of finances as the top health priority in the multivariable model (Odds ratios 2.21, 95% CI 1.25 - 3.89). There were no other differences between the two candidate groups. Conclusion: Health and health care ranked as the second most important issue in the list of general priorities in Croatia. The study recorded a strikingly high level of homogeneity between specific health care priority areas in the two groups of voters. The phenomenon might be attributed to the magnitude and importance of issues that burden the basic functioning of the health care system: poor organization, inadequate financing and corruption. Public opinion on health care priorities might be a useful tool in determining priorities for policymaking, especially in transitional health care systems undergoing reforms.

In the debate on 'Third options' for health care delivery in low- and middle-income countries it is proposed that self-help should play a larger role. Self-help is expected to contribute towards improving population health outcomes and reducing government health care expenditure. We review scope and limitations of self-help groups in Europe and South Asia and assess their potential role in health care within the context of health sector reform. Self-help groups are voluntary unions of peers, formed for mutual assistance in accomplishing a health-related purpose. In Europe, self-help groups developed out of dissatisfaction with a de-personalised health care system. They successfully complement existing social and health services but cannot be instrumentalized to improve health outcomes while reducing health expenditure. In South Asia, with its hierarchical society, instrumental approaches towards self-help prevail in Non-governmental Organizations and government. The utility of this approach is limited as self-help groups are unlikely to be sustainable and effective when steered from outside. Self-help groups are typical for individualistic societies with developed health care systems – they are less suitable for hierarchical societies with unmet demand for regulated health care. We conclude that self-help groups can help to achieve some degree of synergy between health care providers and users but cannot be prescribed to partially replace government health services in low-income countries, thereby reducing health care expenditure and ensuring equity in health care.

Background In 2002, the World Health Organization published a health system performance ranking for 191 member countries. The ranking was based on five indicators, with fixed weights common to all countries. Methods We investigate the feasibility and desirability of using mathematical programming techniques that allow weights to vary across countries to reflect their varying circumstances and objectives. Results By global distributional measures, scores and ranks are found to be not very sensitive to changes in weights, although differences can be large for individual countries. Conclusions Building the flexibility of variable weights into calculation of the performance index is a useful way to respond to the debates and criticisms appearing since publication of the ranking.

Usage of health facilities in Ethiopia is among the lowest in the world; raising usage rates is probably critical for improving health outcomes. The government has diagnosed the principal problem as the lack of primary health facilities and is devoting a large share of the health budget to building more facilities. But household data suggest that usage of health facilities is sensitive not just to the distance to the nearest facility but also to the quality of health care provided. If the quality of weak facilities were raised to that currently provided by the majority of facilities in Ethiopia, usage would rise significantly. National data suggest that given the current density and quality of service provision, additional expenditure on improving the quality of service delivery will be more cost-effective than increasing the density of service provision. The budget allocation rule presented in the article can help local policymakers make decisions about how to allocate funds between improving the quality of care and decreasing the distance to the nearest health care facility.

We address the question of how a third-party payer (e.g. an insurer) decides what providers to contract with. Three different mechanisms are studied and their properties compared. A first mechanism consists in the third-party payer setting up a bargaining procedure with both providers jointly and simultaneously. A second mechanism envisages the outcome of the same simultaneous bargaining but independently with every provider. Finally, the last mechanism is of different nature. It is the so-called "any willing provider" where the third-party payer announces a contract and every provider freely decides to sign it or not. The main finding is that the decision of the third-party payer depends on the surplus to be shared. When it is relatively high the third-party payer prefers the any willing provider system. When, on the contrary, the surplus is relatively low, the third-party payer will select one of the other two systems according to how bargaining power is distributed., Financial support of SGR98-0062, DGES97-0181 and HP98-0057 (Xavier Martinez-Giralt) and AILE E52/99 and Praxis XXI 13132/1998 (Pedro Pita Barros) is gratefully acknowledged.