Fighting chronic disease

Bulletin of the World Health Organization - Fighting chronic disease:
"Raising awareness is key to fighting chronic diseases, mental illness and injuries. Many health ministers of WHO's 192 Member States place this group of diseases and conditions high on their public health agendas. The challenge now is to persuade other ministers to come on board and put health first."

Programme budgeting and marginal analysis: bridging the divide between doctors and managers -- Ruta et al. 330 (7506): 1501 -- BMJ

Programme budgeting and marginal analysis: bridging the divide between doctors and managers -- Ruta et al. 330 (7506): 1501 -- BMJ
Tensions between doctors and managers and the differences between medical and managerial cultures have existed since the earliest provision of organised health care.1 In a resource allocation context, doctors are caricatured as taking the role of patient advocate while managers take the corporate, strategic view. Delivery of efficient (and in the case of the NHS, equitable) health care requires doctors to take responsibility for resources and to consider the needs of populations while managers need to become more outcome and patient centred. One economic approach, called programme budgeting and marginal analysis, has the potential to align the goals of doctors and managers and create common ground between them. We describe how the approach works and why it should be more widely used.

Who Can't Pay for Health Care?

De: Social Determinants of Health [mailto:SDOH@YORKU.CA] Em nome de Arlene Bierman
Enviada em: quarta-feira, 22 de junho de 2005 18:27
Para: SDOH@YORKU.CA
Assunto: Lessons from the US

Attached is an abstract from this months Journal of General Internal
Medicine that serves as a reminder of the inadequacy of private health
insurance fore the poor and chronically ill.

http://www.blackwell-synergy.com/doi/full/10.1111/j.1525-1497.2005.0087.x

ORIGINAL ARTICLE
Who Can't Pay for Health Care?
Robin M. Weinick, PhD1,2, Sepheen C. Byron, MHS1 and Arlene S. Bierman,
MD, MS3

Background: In an era of rising health care costs, many Americans
experience difficulty paying for needed health care services. With costs
expected to continue rising, changes to private insurance plans and
public programs aimed at containing costs may have a negative impact on
Americans' ability to afford care.

Objectives: To provide estimates of the number of adults who avoid
health care due to cost, and to assess the association of income,
functional status, and type of insurance with the extent to which people
with health insurance report financial barriers.

Research Design: Cross-sectional observational study using data from the
Commonwealth Fund 2001 Health Care Quality Survey, a nationally
representative telephone survey.

Participants: U.S. adults age 18 and older (N=6,722).

Measures: Six measures of avoiding health care due to cost, including
delaying or not seeking care; not filling prescription medicines; and
not following recommended treatment plan.

Results: The proportion of Americans with difficulty affording health
care varies by income and health insurance coverage. Overall, 16.9% of
Americans report at least 1 financial barrier. Among those with private
insurance, the poor (28.4%), near poor (24.3%), and those with
functional impairments (22.9%) were more likely to report avoiding care
due to cost. In multivariate models, the uninsured are more likely (OR,
2.3; 95% CI, 1.7 to 3.0) to have trouble paying for care. Independent of
insurance coverage and other demographic characteristics, the poor (OR,
3.6; 95% CI, 2.1 to 4.6), near poor (OR, 2.1; 95% CI, 1.9 to 3.7), and
middle-income (OR, 1.8; 95% CI, 1.3 to 2.5) respondents as well as those
with functional impairments (OR, 1.6; 95% CI, 1.3 to 2.0) are
significantly more likely to avoid care due to cost.

Conclusions: Privately and publicly insured individuals who have low
incomes or functional impairments encounter significant financial
barriers to care despite having health insurance. Proposals to expand
health insurance will need to address these barriers in order to be
effective.

-------------------
Problems/Questions? Send it to Listserv owner: draphael@yorku.ca

Can the millennium development goals be attained? -- Haines and Cassels 329 (7462): 394 -- BMJ

Can the millennium development goals be attained? -- Haines and Cassels 329 (7462): 394 -- BMJ: "Can the millennium development goals be attained?
Andy Haines, dean1, Andrew Cassels, director, health and development policy2

1 London School of Hygiene and Tropical Medicine, London WC1E 7HT, 2 World Health Organization, 1211 Geneva 27, Switzerland

Correspondence to: A Haines andy.haines@lshtm.ac.uk

To achieve the UN's goals worldwide, less developed countries need to address weaknesses in health systems and policy makers need to look beyond aggregate national figures to inequalities in outcomes"

The Sachs report: Investing in health for economic development - Or increasing the size of the crumbs from the rich man's table? Part I

Full Record -- Content Enhancement Links 4.1
Katz A
The Commission on Macroeconomics and Health report (Sachs report) of 2001 has been heralded as inspiring and groundbreaking and is being adopted as the blueprint for global health policymaking. This article argues that the report is deeply conservative and unoriginal. It encourages medico-technical solutions to public health problems; it ignores macroeconomic determinants and other root causes of both poor health and poverty; it reverses public health logic and history; it is based on a set of flawed assumptions; it reflects one particular economic perspective to the exclusion of all others; and it recommends greater amounts of charity while preserving the status quo of a deeply unjust and irrational international economic order. A set of assumptions deriving from a neoliberal approach to health underlies the report. The author proposes an alternative set of assumptions deriving from a social justice and human rights-based approach to health.

Macroeconomics and health -- Morrow 325 (7355): 53 -- BMJ

Macroeconomics and health -- Morrow 325 (7355): 53 -- BMJ: "Macroeconomics and health

Despite shortcomings the plans in this report deserve strong support

Macroeconomics and Health, a provocative report from the World Health Organization, is a dramatic call for action from both rich countries and poor countries.1 The report emphasises the linkage of avoidable disease to poverty and argues that investments in health are fundamental to and perhaps a prerequisite for economic development. The report proposes a massive increase in funding for health in the poor countries, with a fivefold increase in support from wealthy countries and at least a doubling from the poor countries themselves."

FEE - Porto Alegre

FEE - Fundação de Economia e Estatística | Porto Alegre
População Total (2004): 1.402.886 habitantes
� Área (2004): 496,8 km2
� Densidade Demográfica (2004): 2.823,7 hab/km2
� Taxa de analfabetismo (2000): 3,45 %
� Expectativa de Vida ao Nascer (2000): 71,59 anos
� Coeficiente de Mortalidade Infantil (2004): 12,24 por mil nascidos vivos
� PIBpm(2002): R$ 13.079.160.258
� PIB per capita (2002): R$ 9.397
� Exportações Totais (2004): U$ FOB 635.642.965
� ICMS (2004): R$ 3.289.551.352
� Data de criação: 23/08/1808 (Alvará de)
� Município de origem: Um dos 4 municípios iniciais do RS

Rich-poor gap gaining attention | csmonitor.com

Rich-poor gap gaining attention | csmonitor.com: "Rich-poor gap gaining attention
A remark by Greenspan symbolizes concern that wealth disparities may destabilize the economy.

By Peter Grier | Staff writer of The Christian Science Monitor

WASHINGTON - The income gap between the rich and the rest of the US population has become so wide, and is growing so fast, that it might eventually threaten the stability of democratic capitalism itself."
Is that a liberal's talking point? Sure. But it's also a line from the recent public testimony of a champion of the free market: Federal Reserve Chairman Alan Greenspan.

America's powerful central banker hasn't suddenly lurched to the left of Democratic National Committee chief Howard Dean. His solution is better education today to create a flexible workforce for tomorrow - not confiscation of plutocrats' yachts.

But the fact that Mr. Greenspan speaks about this topic at all may show how much the growing concentration of national wealth at the top, combined with the uncertainties of increased globalization, worries economic policymakers as they peer into the future.

"He is the conventional wisdom," says Jared Bernstein, senior economist at the Economic Policy Institute, a liberal think tank. "When I'm arguing with people, I say, 'Even Alan Greenspan....' "

Greenspan's comments at a Joint Economic Committee hearing last week were typical, for him. Asked a leading question by Sen. Jack Reed (D) of Rhode Island, he agreed that over the past two quarters hourly wages have shown few signs of accelerating. Overall employee compensation has gone up - but mostly due to a surge in bonuses and stock-option exercises.

The Fed chief than added that the 80 percent of the workforce represented by nonsupervisory workers has recently seen little, if any, income growth at all. The top 20 percent of supervisory, salaried, and other workers has.

The result of this, said Greenspan, is that the US now has a significant divergence in the fortunes of different groups in its labor market. "As I've often said, this is not the type of thing which a democratic society - a capitalist democratic society - can really accept without addressing," Greenspan told the congressional hearing.

The cause of this problem? Education, according to Greenspan. Specifically, high school education. US children test above world average levels at the 4th grade level, he noted. By the 12th grade, they do not. "We have to do something to prevent that from happening," said Greenspan.

So are liberals overjoyed by these words from a man who is the high priest of capitalism? Not really, or at least not entirely.

For one thing, some liberal analysts prefer to focus on the very tip of the income scale, not the top 20 percent. Recent Congressional Budget Office data show that the top 1 percent of the population received 11.4 percent of national after-tax income in 2002, points out Isaac Shapiro of the Center on Budget and Policy Priorities in a new study. That's up from a 7.5 percent share in 1979.

By contrast, the middle fifth of the population saw its share of national after-tax income fall over that same period of time, from 16.5 to 15.8. "Income is now more concentrated at the very top of the income spectrum than in all but six years since the mid-1930s," asserts Mr. Shapiro in his report.

For another, some Democratic analysts believe that Greenspan's emphasis on education as a cure ignores other causal factors of inequity. Data show an income gap widening among college graduates, says Mr. Bernstein. The quality of US high schools has nothing to do with that, he says. Instead it's partly a function of overall monetary and fiscal policies. "Greenspan takes a very long term view of the situation," says Bernstein.

On the other hand, some conservatives label the whole inequality debate a myth. The media's recent focus on the subject stems from its liberal bias and clever press management by Democrats, they say.

Inequality studies often ignore the wealth created by rising house prices, for instance - and homes represent the most substantial investment by many, if not most, Americans.

Nor do US workers necessarily perceive themselves on the losing end of a rigged capitalist game. A recent New York Times survey found that while 44 percent of respondents said they had a working-class childhood, only 35 percent said they were working class today, points out Bruce Bartlett, a senior fellow at the National Center for Policy Analysis. Eighteen percent said they grew up lower class, while only 7 percent said they remained in that societal segment.

When Democrats today raise the inequality flag, they are simply trying to attack President Bush's tax cuts, albeit indirectly, says Mr. Bartlett. "A lot of this is driven by the estate-tax debate," he says.

And as Greenspan himself points out, by many measures the economy is doing well. Unemployment is down, GDP is up. Inflation still slumbers. Current standards of living are unmatched.

"So you can look at the system and say it's got a lot of problems to it, and sure it does. It always has," Greenspan told the JEC last week. "But you can't get around the fact that this is the most extraordinarily successful economy in history."

Full HTML version of this story which may include photos, graphics, and related links

The U.N. Millennium Project: Practical Action Plan to Combat Poverty

The Earth Institute at Columbia University: "On Monday, January 17, in the most comprehensive strategy ever put forward for combating global poverty, hunger and disease, the U.N. Millennium Project released a blueprint for achieving the Millennium Development Goals by 2015. The report “Investing in Development: A Practical Plan to Achieve the Millennium Development Goals” was prepared by a team of 265 of the world’s leading development experts, including many scientists from The Earth Institute at Columbia University. It includes specific cost-effective measures that together could cut extreme poverty in half and radically improve the lives of at least one billion people in poor developing countries by 2015.

“Until now, we did not have a concrete plan for achieving the Millennium Development Goals,” said Jeffrey Sachs, director of the Earth Institute and director of the three-year U.N. Millennium Project. “The experts who contributed to this huge undertaking have shown without a doubt that we can still meet the Goals — if we start putting this plan into action right now.”"

The Earth Institute at Columbia University

The Earth Institute at Columbia University
The End of Poverty: Economic Possibilities for Our Time
Jeffrey D. Sachs writes a realistic blueprint for worldwide economic success
"Extreme poverty can be ended, not in the time of our grandchildren, but our time." Thus forecasts Jeffrey D. Sachs, whose twenty-five years of experience observing the world from many vantage points has helped him shed light on the most vital issues facing our planet: the causes of poverty, the role of rich-country policies, and the very real possibilities for a poverty-free future. Deemed "the most important economist in the world" by The New York Times Magazine and "the world's best-known economist" by Time magazine, Sachs brings his considerable expertise to bear in the landmark The End of Poverty: Economic Possibilities for Our Time, his highly anticipated blueprint for world-wide economic success — a goal, he argues, we can reach in a mere twenty years. visit End of Poverty website

Marrying vivid eyewitness storytelling with concrete analysis, Sachs provides a conceptual map of the world economy and the different categories into which countries fall, explaining why wealth and poverty have diverged and evolved as they have and why the poorest nations have been so markedly unable to escape the cruel vortex of poverty. The End of Poverty does not deliver its worldviews from on high: Sachs plunges into the messy realities of economies, leading his readers through his work in Bolivia, Poland, Russia, India, China, and Africa, and concludes with an integrated set of solutions to the tangled economic, political, environmental, and social issues that most frequently hold societies back.

Writes singer Bono in the forward, "[Sachs] is an economist who can bring to life statistics that were, after all, lives in the first place. He can look up from the numbers and see faces through the spreadsheets." Rather than a sense of how daunting the world's problems are, Sachs provides an understanding of how solvable they are — and why making the effort is both our ethical duty and a self-interested strategic necessity.

Center for Global Health and Economic Development

Center for Global Health and Economic Development
The world faces extraordinary new health and economic challenges during the next ten years. Against the backdrop of expanding HIV/AIDS, tuberculosis and malaria epidemics, it has become increasingly clear that economic progress in developing countries depends on healthy citizens and environments. The Center for Global Health and Economic Development is a joint venture between Columbia University's Mailman School of Public Health and Earth Institute and seeks to address these critical issues. The Center mobilizes global health programs that help resource-poor countries address the burden of disease, and more specifically, helps achieve the ambitious Millennium Development Goals.

In an effort to prevent the morbidity and mortality caused by preventable and treatable diseases, the Center spearheads several programs which are actively engaged in delivering on-the-ground technical assistance.

Cardiovascular Disease And Global Health: Threat And Opportunity -- Greenberg et al., 10.1377/hlthaff.w5.31 -- Health Affairs

Cardiovascular Disease And Global Health: Threat And Opportunity -- Greenberg et al., 10.1377/hlthaff.w5.31 -- Health Affairs
Cardiovascular Disease And Global Health: Threat And Opportunity
Cardiovascular disease is a new problem for the less developed world to contemplate.
by Henry Greenberg, Susan U. Raymond, and Stephen R. Leeder
ABSTRACT: The transition in global health from infectious to chronic disease, especially cardiovascular disease, poses a threat to the economies of the less developed world. As a more sophisticated workforce becomes a highly valued and harder-to-replace economic investment, the increasing prevalence of cardiovascular risk factors becomes a threat to economic development. The next two decades offer a critical period for intervention to blunt the impact of these diseases. The response of the global assistance community has been inadequate and without impact. A new global health assistance paradigm is needed to support long-term prevention strategies to combat this epidemic.

Commission on Macroeconomics and Health :: Description

Commission on Macroeconomics and Health :: Description

The Commission on Macroeconomics and Health (CMH) was launched by WHO Director-General Dr. Gro Harlem Brundtland in January 2000. Over a two-year period, the Commission will analyze the impact of health on development and examine the appropriate modalities through which health related investments could have a positive impact on economic growth and equity in developing countries. It will recommend a set of measures designed to maximize the poverty reduction and economic development benefits of health sector investment.

The Purpose of the Commission:

The purpose of the Commission is to analyze the impact of health on development and to produce reports and scholarly studies on health-related interventions and their impact on economic growth and equity in developing countries. The Commission will recommend a set of health measures to minimize poverty and maximize economic development in these countries. The CMH will consolidate its findings into a final report for dissemination to the international development community and to Ministers of Health at the 2002 World Health Assembly. (more)

Global Health and Economic Development

The Pfizer Journal': Global Health and Economic Development
Global Health and Economic Develoment
The road between health and income runs both ways: the health of a group of people can forecast future growth in income.
The problem with poverty is it takes up all your time. Willem de Kooning (1904-1997). [1]
Toward the end of a long life, the painter Willem de Kooning recalled the ingenuity he had needed to subsist hand-to-mouth on wages as an immigrant day laborer in Depression-era New York. In time, de Kooning found his escape out of the deadening routine of mundane survival tasks thanks to ambition, unrelenting hard work, and the inborn talent that kept him in the front rank of 20th-century artists even after Alzheimer’s disease pillaged his memory.
Throughout his struggle de Kooning was buoyed by unusual advantages. After all, he had left one industrialized country for another. He was literate. He had a sturdy constitution that allowed him vigorous physical health well into his tenth decade. And he was reasonably certain that if he could only win his initial struggle with poverty, the artistic and monetary rewards could exceed his dreams.
Considered against the background of today’s developing world, de Kooning’s poverty was a matter of degree. Work as a housepainter earned him enough to buy food, clothing, and a few luxuries, and keep a roof over his head. Nevertheless, it was his perception as an artist that let him convey in so few words the grinding frustration of being in want: “It takes up all your time.”

Social Determinants of Health: Present Status, Unanswered Questions, and Future Directions

Social Determinants of Health: Present Status, Unanswered Questions, and Future Directions

Dennis Raphael, PhD - School of Health Policy and Management - York University, Toronto, Canada

Keywords: social determinants of health, health promotion, political economy perspective

Paper was presented at the conference Dahlgren and Whitehead and Beyond: The Social Determinants of Health in Research, Policy and Service Delivery, April 21, 2005, Cardiff, Wales, UK.
Correspondence to:Dr. Dennis Raphael 62 First Avenue, Toronto, Ontario M4M 1W8
email: draphael@yorku.ca

Abstract:
This article reviews the current status of theory and research concerning the social determinants of health. It provides an overview of current conceptualizations and the evidence concerning the impact of various social determinants of health. The contributions of various disciplines – epidemiology, sociology, political economy, and the human rights perspectives -- to the field are acknowledged but profound gaps persist in our understanding of the forces that drive the quality of various social determinants of health and why research is too infrequently translated into action. Many of these gaps in knowledge concern the political, economic, and social forces that make implementation of public policy agendas focused on strengthening the social determinants of health problematic. The areas of inquiry needed to help translate research into action are identified. (full text available)

Doctor's prognosis: Health care ills rooted in market-based system

Doctor's prognosis: Health care ills rooted in market-based system: "Doctor's prognosis: Health care ills rooted in market-based system

By Maryann Ullman | Special to the Vermont Guardian

Posted June 17, 2005

The U.S. health care system is in a state of emergency due its focus on commercial, rather than health, values according to a former family doctor turned activist.

Dr. John Abramson, author of the book Overdosed America: The Broken Promise of American Medicine, spoke in Brattleboro Thursday evening at an event sponsored by Vermont Citizens Campaign for Health.

“He’s questioning long-held assumptions held by the medical community,” said Richard Davis, executive director of VCCH, which is sponsoring an ongoing series of talks to help foster support for a single payer health care system in Vermont.

“He’s bucking the trend that health care should be based on profit. He’s providing some very defensible arguments and information for moving to universal health care, and moving to a system that actually keeps people healthy. That’s radical to some people,” Davis said.

One of Abramson’s arguments is that medical spending has little to do with actual quality of care, and may even have an inverse relationship. In a graph of 22 industrialized countries, Abramson showed that Japan spends among the least on health care per person, and has the highest rate of life expectancy. Twenty other countries cluster around the middle, and the United States, in the opposite corner by itself, has the most expensive health care, and the lowest life expectancy.

“We’re the only industrial country that doesn’t have universal health care,” Abramson pointed out. “We’re the only health care system that is run like a free-market entrepreneurial system.”

A lot of money gets wasted on endorsing products and services that don’t necessarily even help people, he said, and sometimes even harm them. For example, he compared the United States to Canada, saying far more people get bypass surgery here who don’t need it, despite the fact that it causes cognitive problems in 50 percent of the elderly. But they do it because hospitals stand to make $20,000 to $40,000 per surgery.

According to Abramson, $600 billion gets spent every year in the United States on unnecessary and often harmful medical care. “You could have universal health care three times over for that,” he said.

He concedes that Canada does need more money in its health care system, but says that’s because the country made a political decision to cap it, not because the system is flawed.

According to the Institute of Medicine, 70 percent of preventable health problems are due to lifestyle and environmental factors. But most of the money goes to direct medical care.

“We’re spending 75 percent of our money on 30 percent of the problem,” said Abramson. “One of the reasons why we don’t do it, why it’s a threat to have universal health care, is that it would threaten the profit structure. We would have to find real determinants of health problems.”

He pointed to 1980, the onset of the Reagan era, when university medical researchers began accepting funding from drug companies for their work, as funding from the National Institutes of Health dropped. “As there’s been this privatization of knowledge, there’s been a weakening of oversight,” he said. “Universities aren’t going to so it anymore. They’re addicted to the drug money. We can’t count on them anymore. Why not just consolidate everything and have the advertising agencies oversee it all?”

According to a 2003 poll by the Kaiser Foundation, 79 percent of Americans favor health coverage for all, even if it means giving up tax cuts.

Two recent polls in Vermont find wide support for universal coverage. One poll, for WCAX-TV, found that 67 percent of Vermonters favored a publicly-funded health care system, and a recent Vermont Public Radio poll found that 42 percent of Vermonters favored such a system.

The Democratically-controlled Vermont Legislature passed a bill that would have moved Vermont toward a universal health care system, but Gov. Jim Douglas, a Republican, has pledged to veto the bill. Despite the veto, the state's 2006 spending plan does include funding for a commission to evaluate various approaches to providing publicly-funded universal health coverage.

“There’s a real failure of our system to implement the will of the people,” said Abramson."

The Millennium Development Goals: a Latin American and Caribbean perspective

The Millennium Development Goals: a Latin American and Caribbean perspective: "In September 2000, 147 heads of State and Government, together with 42 ministers and heads of delegation, gathered at the General Assembly of the United Nations to explore ways of pooling their combined will and efforts to revitalize international cooperation on behalf of the less developed countries and, in particular, to mount a frontal assault on extreme poverty.

On that occasion they identified goals for their efforts to combat poverty and hunger, reverse environmental degradation, achieve improvements in the fields of education and health, and promote gender equality. It also became clear that, because the lack of development is a problem that concerns the entire world, the formation of a partnership to enrich and reinvigorate international cooperation while at the same time honing it and increasing its effectiveness should be one of the eight Goals. These deliberations thus gave rise to what came to be known as the Millennium Development Goals."

Social Determinants of Health Conceptual framework

CSDH Doc 2 - Conceptual framework.pdf (application/pdf Object)
The Commission on Social Determinants of Health (CSDH) has affirmed its desire to be judged not only on the scientific rigor of its analyses, but on the policy and institutional changes catalysed in countries through Commission advocacy and partnership. To set feasible objectives for its political work and send consistent messages to partners and the public, the CSDH requires clarity on basic conceptual issues. These include:
• The concept of social determinants of health (SDH)
• The values that ground the Commission's analysis and policy recommendations
• The pathways by which SDH affect health status and outcomes
• How SDH relate to health inequities
• The most important SDH for the Commission to address, and why
• Appropriate intervention levels and entry points for policy action on SDH
• The ultimate goal of SDH policies (improving average health status or reducing health inequities)
This paper outlines a conceptual framework we hope can serve as a basis for discussion and clarification of these issues within the CSDH. The paper in its current form is an early draft, which aims to open debate rather than furnish definitive answers. It summarizes the results of an initial phase of research and analysis by the CSDH secretariat. The paper will pass through subsequent iterations to incorporate input from Commissioners and yield a final document succinctly laying out the conceptual foundations of the Commission's work.
The paper begins by recalling the CSDH definition of social determinants and some methodological implications. It then takes up the question of values. We propose the concept of health equity as a cornerstone for the Commission's normative framework. Applying equity criteria, we consider the implications of policy approaches focused respectively on: (1) tackling health disadvantages in targeted population groups; (2) reducing health gaps; and (3) addressing the health gradient across the full spectrum of socioeconomic positions. The next section of the paper reviews several models that have sought to explain relationships among SDH and their causal role in generating health inequities. Drawing lessons from these approaches, we propose a comprehensive SDH framework that situates the major determinants and clarifies levels for policy action. Using this model, we then show how and why a set of key thematic foci for the Commission's work have been proposed. Finally, we review several evaluative frameworks the CSDH could use in developing policy recommendations and suggest some principles to ground those policy choices.