The health care systems are fairly similar in the Scandinavian countries. The exact details vary, but in all three countries the system is almost exclusively publicly funded through taxation, and most (or all) hospitals are also publicly owned and managed. The countries also have a fairly strong primary care sector (even though it varies between the countries), with family physicians to various degrees acting as gatekeepers to specialist services. In Denmark most of the GP services are free. For the patient in Norway and Sweden there are out-of-pocket co-payments for GP consultations, with upper limits, but consultations for children are free. Hospital treatment is free in Denmark while the other countries use a system with out-of-pocket co-payment. There is a very strong public commitment to access to high quality health care for all. Solidarity and equality form the ideological basis for the Scandinavian welfare state. Means testing, for instance, has been widely rejected in the Scandinavian countries on the grounds that public services should not stigmatise any particular group. Solidarity also means devoting special consideration to the needs of those who have less chance than others of making their voices heard or exercising their rights. Issues of limited access are now, however, challenging the thinking about a health care system based on solidarity.
To explore the current and pending strategic agenda of Ontario hospitals (the largest consumers of the provincial healthcare budget), a survey of Ontario acute care hospital CEOs was conducted in January 2004. The survey, with an 82% response rate, identifies 29 strategic priorities under seven key strategic themes consistent across different hospital types. These themes include (1) human resources cultivation, (2) service integration and partnerships, (3) consumer engagement, (4) corporate governance and management, (5) organizational efficiency and redesign, (6) improved information use for decision-making, (7) patient care management. The extent to which an individual hospital's control over strategic resolutions is perceived may affect multilevel strategic priority-setting and action-planning. In addition to supporting ongoing development of meaningful performance measures and information critical to strategic decision-making, this study's findings may facilitate a better understanding of hospitals' key resource commitments, the extent of competition and collaboration for key resources, the perceived degree of individual control over strategic issue resolution and where systemic resolutions may be required.
This paper reviews Russia's health crisis, financing, and organization and public health reform needs.
The structure, policy, supply of services, and health status indicators of Russia's health system are examined.
Longevity is declining; mortality rates from cardiovascular diseases and trauma are high and rising; maternal and infant mortality are high. Vaccine-preventable diseases have reappeared in epidemic form. Nutrition status is problematic.
The crisis relates to Russia's economic transition, but it also goes deep into the former Soviet health system. The epidemiologic transition from a predominance of infectious to noninfectious diseases was addressed by increasing the quantity of services. The health system lacked mechanisms for epidemiologic or economic analysis and accountability to the public. Policy and funding favored hospitals over ambulatory care and individual routine checkups over community-oriented preventive approaches. Reform since 1991 has centered on national health insurance and decentralized management of services. A national health strategy to address fundamental public health problems is recommended.
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The Canadian health system is undergoing reform. Over the past decade a prominent trend has been creation of health regions. This structural shift is concurrent with a greater emphasis on population health and the broad determinants of health. In parallel, there is a movement toward more intersectoral collaboration (i.e., collaboration between diverse segments of the health system, and between the health system and other sectors of society). The purpose of this exploratory study is to determine the self-reported level of internal action (within regional health authorities) and intersectoral collaboration around 10 determinants of health by regional health authorities across Canada.
From September 2003 to February 2004, we undertook a survey of regional health authorities in Canadian provinces (N = 69). Using SPSS 12.0, we generated frequencies for the self-reported level of internal and intersectoral action for each determinant. Other analyses were done to compare rural/suburban and urban regions, and to compare Western, Central and Eastern Canada.
Of the 10 determinants of health surveyed, child development and personal health practices were self-reported by the majority of health regions to receive greatest attention, both internally and through intersectoral activities. Culture, gender and employment/working conditions received least attention in most regions.
The exploratory survey results give us the first Canadian snapshot of health regions' activities in relation to the broad range of non-medical determinants of health. They provide a starting data set for baselining future progress, and for beginning deeper analyses of specific areas of action and intersectoral collaboration.
Norway introduced 32 priority guidelines for elective health treatment in the specialist health service in the period 2008-9. The guidelines were intended to reduce large differences in waiting times among hospitals, streamline referrals and ensure that patients accessed the necessary healthcare to which they were entitled for certain conditions. Referral information guided the priorities. As the referral information was key to future evaluation of the guidelines, this study validates the referral information in hospital patient records against discharge diagnoses, because only the discharge diagnosis is recorded in the Norwegian Patient Register (NPR) database, which is used in the main evaluation.
Of the specific conditions from 10 priority guidelines, 20 were selected for review for the period 2008-9 at 4 hospitals in Norway. The ICD-10 diagnoses per disease or condition were given in retrospect by clinicians who participated in the expert groups developing the priority guidelines. Reasons for deviations between referral information and discharge diagnoses were coded into four categories, according to the degree of precision of the former compared with the latter.
In all, 1854 medical records were available for review. The diagnostic precision of the referrals differed significantly between hospitals, and across the 2 years 2008 and 2009. The overall sensitivity was 0.93 (95% confidence interval 0.92-0.94). For the separate conditions, sensitivity was in the range 0.60-1.00. Experience showed that it was necessary to pay careful attention to the selection of ICD-10 diagnoses for identifying patients. The medical records of psychiatry patients were unavailable in some cases and for certain conditions some were unavailable after use of our record extraction algorithm.
The sensitivity of the referral information on diagnosis or condition was high compared with the discharge diagnosis for the 20 selected conditions from the 10 priority guidelines. Although the review assessed a limited number of the total, we consider the results sufficiently representative and, hence, they will allow use of the NPR data for analyses of the introduction and follow-up of the 32 priority guidelines.