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Improving clinical performance using measurement and payment incentives, including pay for performance (or P4P), has, so far, shown modest to no benefit on patient outcomes. Our objective was to assess the impact of a P4P programme on paediatric health outcomes in the Philippines. We used data from the Quality Improvement Demonstration Study. In this study, the P4P intervention, introduced in 2004, was randomly assigned to 10 community district hospitals, which were matched to 10 control sites. At all sites, physician quality was measured using Clinical Performance Vignettes (CPVs) among randomly selected physicians every 6 months over a 36-month period. In the hospitals randomized to the P4P intervention, physicians received bonus payments if they met qualifying scores on the CPV. We measured health outcomes 4-10 weeks after hospital discharge among children 5 years of age and under who had been hospitalized for diarrhoea and pneumonia (the two most common illnesses affecting this age cohort) and had been under the care of physicians participating in the study. Health outcomes data collection was done at baseline/pre-intervention and 2 years post-intervention on the following post-discharge outcomes: (1) age-adjusted wasting, (2) C-reactive protein in blood, (3) haemoglobin level and (4) parental assessment of child's health using general self-reported health (GSRH) measure. To evaluate changes in health outcomes in the control vs intervention sites over time (baseline vs post-intervention), we used a difference-in-difference logistic regression analysis, controlling for potential confounders. We found an improvement of 7 and 9 percentage points in GSRH and wasting over time (post-intervention vs baseline) in the intervention sites relative to the control sites (P ≤ 0.001). The results from this randomized social experiment indicate that the introduction of a performance-based incentive programme, which included measurement and feedback, led to improvements in two important child health outcomes.

Legislation to control tobacco use in developing countries has lagged behind the dramatic rise in tobacco consumption. India, the third largest grower of tobacco in the world, amassed 1.7 million disability-adjusted life years (DALYs) in 1990 due to disease and injury attributable to tobacco use in a population where 65% of the men and 38% of the women consume tobacco. India's anti-tobacco legislation, first passed at the national level in 1975, was largely limited to health warnings and proved to be insufficient. In the last decade state legislation has increasingly been used but has lacked uniformity and the multipronged strategies necessary to control demand. A new piece of national legislation, proposed in 2001, represents an advance. It includes the following key demand reduction measures: outlawing smoking in public places; forbidding sale of tobacco to minors; requiring more prominent health warning labels; and banning advertising at sports and cultural events. Despite these measures, the new legislation will not be enough to control the demand for tobacco products in India. The Indian Government must also introduce policies to raise taxes, control smuggling, close advertising loopholes, and create adequate provisions for the enforcement of tobacco control laws.

It is unclear whether health provider accreditation ensures or promotes quality of care. Using baseline data from the Quality Improvement Demonstration Study (QIDS) in the Philippines we measured the quality of pediatric care provided by private and public doctors working at the district hospital level in the country's central region. We found that national level accreditation by a national insurance program influences quality of care. However, our data also show that insurance payments have a similar, strong impact on quality of care. These results suggest that accreditation alone may not be sufficient to promote high quality of care. Further improvements may be achieved with properly monitored and well-designed payment or incentive schemes. Keywords: Accreditation Quality of care Insurance payment Philippines Physicians Pediatrics

Objective Generally, lead poisoning is not considered a significant environmental hazard for children in rural areas of developing countries. With a prospectively designed policy experiment, the research community and the government are conducting a broad-based investigation to introduce and evaluate the impact of health policy reforms on children in a rural area of the Philippines--the Quality Improvement Demonstration Study (QIDS). As part of this study, we researched lead exposure in children under the age of five. Methods We sampled a population of children from the Visayas region in the central Philippines, covering approximately one third of the country's geographical area. From December 2003 to September 2004, the survey collected blood lead levels (BLL) together with demographic, socioeconomic and child health data points. Supplemental field-testing among a sub-sample of the most exposed children assessed the sources of environmental lead exposure. Findings Among children in this study, 21% (601 of 2861 children) had BLL greater than 10 [micro] g/dl. BLL were associated independently with age, haemoglobin concentration, water source, roofing material, expenditures and history of breastfeeding. A follow-up assessment of possible environmental exposures among the sub-sample of children with elevated BLL revealed no single or predominant exposure source. Instead, there appear to be multiple potential sources, such as fossil-fuel combustion, lead paint (in or around 38% of homes) and household items. Conclusion Elevated BLL are common among children in the Visayas, and may signify an under-recognized threat to children living in rural areas of other developing nations. This setting has varied environmental sources of lead. Observed correlates of BLL may be of clinical, environmental and public health utility to identify and mitigate the consequences of lead toxicity. Objectif En general, l'intoxication par le plomb n'est pas consideree comme un danger environnemental important dans les zones rurales des pays en developpement. En appliquant une strategie experimentale de nature prospective, la communaute des chercheurs et les pouvoirs publics menent une enquete de grande ampleur [Quality Improvement Demonstration Study (QIDS)] pour connaitre et evaluer les effets des reformes de la politique sanitaire sur les enfants d'une zone rurale des Philippines. Dans le cadre de cette etude, nous avons etudie l'exposition au plomb des enfants de moins de cinq ans. Methodes Nous avons constitue un echantillon a partir d'une population vivant dans la region de Visayas au centre des Philippines, qui couvre approximativement un tiers de la surface du pays. De decembre 2003 a septembre 2004, l'enquete a recueilli les resultats de dosages sanguins du plomb (plombemies) chez des enfants en association avec des donnees demographiques, socioeconomiques et sanitaires concernant ces enfants. Des etudes sur le terrain supplementaires sur un sous-echantillon compose des enfants les plus exposes ont permis d'evaluer les sources de l'exposition environnementale au plomb. Resultats Parmi les enfants sujets de cette etude, 21% (601 sur 2861) presentaient une plombemie superieure a 10 [micro]g/dl. La plombemie etait associee de maniere independante a l'age, au taux d'hemoglobine, a la source d'approvisionnement en eau, au materiau de toiture, aux depenses et aux antecedents en matiere d'allaitement au sein. Une evaluation de type suivi des expositions environnementales potentielles parmi le sous-echantillon d'enfants dont la plombemie etait elevee n'a fait apparaitre aucune source d'exposition unique ou principale. Au contraire, il semble que les sources potentielles soient multiples : combustion de combustible fossile, peinture au plomb (a l'interieur ou autour de 38 % environ des habitations) et biens d'equipement menagers. Conclusion La presence d'une plombemie elevee est courante chez les enfants de la region de Visayas et peut representer une menace non reconnue pour les enfants vivant dans des zones rurales d'autres nations en developpement. Les Philippines abritent diverses sources environnementales de plomb. Les correlations observees concernant la plombemie peuvent etre utiles sur le plan clinique, environnemental et sanitaire pour identifier et attenuer les consequences de l'exposition toxique au plomb. Objetivo Generalmente se considera que la intoxicacion por plomo no constituye un peligro ambiental importante para ninos residentes en zonas rurales de los paises en desarrollo. Utilizando un experimento de politicas disefiado de forma prospectiva, investigadores y gobierno estan llevando a cabo una amplia investigacion (el Quality Improvement Demonstration Study. QIDS) para introducir reformas de la politica sanitaria y evaluar sus repercusiones en Ios ninos de una zona rural de Filipinas. Como parte de ese estudio, hemos investigado la exposicion al plomo en menores de cinco anos. Metodos Se muestreo una poblacion de ninos de la region de Visayas, en el centro de Filipinas, que representa aproximadamente un tercio de la superficie del pais. Desde diciembre de 2003 hasta septiembre de 2004 se midieron las concentraciones sanguineas de plomo (CSP) y se registraron las caracteristicas demograficas, socioeconomicas y sanitarias de Ios ninos. En un trabajo de campo complementario se examino una submuestra de Ios ninos mas expuestos para investigar las fuentes de la exposicion ambiental al plomo. Resultados EI 21% de los ninos estudiados (601 de 2861) presentaron CSP superiores a 10 [micron]g/dl. Las CSP se asociaron de forma independiente con la edad, la concentracion de hemoglobina, la fuente de agua, el material de los tejados, los gastos y los antecedentes de lactancia materna. Un estudio de seguimiento de las posibles exposiciones ambientales llevado a cabo en la submuestra de ninos con CSP elevadas no reveIo ninguna fuente de exposicion unica ni predominante. Por el contrario, parecia haber muItiples fuentes potenciales, tales como el consumo de combustibles fosiles, las pinturas con plomo (presentes dentro o en el entorno del 38% de los hogares) y los enseres domesticos. Conclusion Las CSP elevadas son frecuentes en los ninos de la region de Visayas y pueden suponer una amenaza subestimada para los ninos residentes en zonas rurales de paises en desarrollo. En este entorno fueron varias las fuentes ambientales de plomo. Los correlatos de las CSP elevadas pueden ser utiles desde el punto de vista clinico, medioambiental y de salud publica para identificar y mitigar las consecuencias de la toxicidad del plomo., Introduction Lead poisoning is one of the most significant environmental health threats children face. Even low levels of lead exposure are associated with impairment of childhood cognitive function (1) and [...]

Research has revealed significant variation in both the quality of clinical care and the health status of populations. We conducted a study to determine if variations in the quality of clinical care can be quantitatively linked to variations in health status, at the patient and the population level. This study, conducted at health facilities in four municipalities in Macedonia, collected cross-sectional data on (1) structural measures (such as infrastructure, facilities, equipment and costs) and the quality of clinical care provided by physicians (as measured by clinical vignettes): (2) detailed health and socioeconomic status information on patients using the facilities: and (3) nearly the same information on a random sample of adults in each municipality. Data were collected from a total of 57 facilities, 273 physicians, 1451 patients, and 1627 adults from the general population. The main outcome measure was health status, based on self-reported health surveys. Objective health measures were obtained to control for preexisting conditions. The main explanatory variable was quality of clinical care, based on physicians' clinical vignette scores. Structural measures were included in our model but had a more distal relationship to health status. We found that quality of care strongly predicted sell-reported health status of patients using the facilities even after controlling for other factors (p < .05). Quality of care was also associated with higher health status for the population living in the surrounding community, regardless of utilization (p < .05). This linkage between quality of clinical care and health suggests that policies that improve clinical practice have the potential to improve population health more rapidly than other interventions. Keywords: Quality of care; Health outcomes; International health services; Population health status; Cross-national comparative research

The Republic of Macedonia is undertaking sweeping reforms of its health sector. Funded by a World Bank credit, the reforms seek to improve the efficiency and quality of primary health care (PHC) by significantly strengthening the role of the market in health care provision. On the supply-side, one of the key reform proposals is to implement a capitation payment system for PHC physicians. By placing individual physicians on productivity-based contracts, these reforms will effectively marketize all PHC provision. In addition, the Ministry of Health is considering the sale or concessions of public PHC clinics to private groups, indicating the government's commitment to marketization of health care provision. Macedonia is in a unique position to develop a new role for the private sector in PHC provision. The private provision of outpatient care was legalized soon after independence in 1991; private physicians now account for nearly 10% of all physicians and 22% of PHC physicians. If the reforms are fully realized, all PHC physicians--over 40% of all physicians--will be financially responsible for their clinical practices. This study draws on Macedonia's experience with limited development of private outpatient care starting in 1991 and the reform proposals for PHC, finding a network of policies and procedures throughout the health sector that negatively impact private and public sector provision. An assessment of the effects that this greater policy environment has on private sector provision identifies opportunities to strategically enhance the reforms. With respect to established market economies, the study finds justification for a greater role for government intervention in private health markets in transition economies. In addition to micro-level payment incentives and administrative controls, marketization in Central and Eastern Europe requires an examination of insurance contracting procedures, quality assurance practices, public clinic ownership, referral practices, hospital privileges, and capital investment policies. Keywords: Private care; Reform; Primary care; Eastern Europe

Australia has demonstrated that a health care system that controls costs can still offer universal coverage and ensure adequate health outcomes for most of its people. Australia spent only 8.5% of its gross domestic product on health care in 1993, compared to 13.9% in the US that year. Health services are provided by both the private and public sector. Over 40% of all Australian physicians are general practitioners, compared to 10.7% in the US. Australia has kept costs low by limiting expensive technology, and controlling physician's fees and hospital budgets.

From a purely economic perspective, structural adjustment programs (SAPs) and economic reform policies are viewed as short-term austerities that lead to long-term growth and development. These intertemporal trade-offs, however, are not always acceptable in health. Unique biologic events such as intrauterine development and neural development cannot be postponed even for a short period. Health policymakers need to understand the expected and unexpected impacts of economic reform on health outcomes in individuals and on the population. The interactions are complex, involve multiple sectors, and can be better understood by looking at the experience of developing countries over almost fifteen years of SAP experience. Health care budgets may be vulnerable to reduced government spending, quality of care deteriorates, nutrition will suffer more likely in urban areas, and cost-effective preventive programs may stop if labor and capital are not properly matched. Health outcomes overall do not appear to suffer but a more detailed look, with better data, shows that the incidence of preventable diseases rises and irreversible deterioration in health status does occur within countries. To prevent this from happening in the future, health policymakers need to take a multidisciplinary focus to first understand the effects of economic reform and then to plan a coordinated response. Better data, alternative financing, and strong political leadership are also important lessons. Key words - health policy, developing countries, health economics, structural adjustment, health outcomes, quality of care