Many countries are reconfiguring their emergency care systems to improve quality and efficiency of care, and this often includes the concentration of emergency departments (EDs). This trend is evident in the Netherlands, but the best approach is the subject of debate among stakeholders. We (i) examined the views of stakeholders on the concentration of EDs in the Netherlands and (ii) identified the main conflicting interests and trade-offs that are relevant for health policy. To do this, we organised focus groups and semi-structured interviews with emergency care professionals, hospital executives and selected external stakeholders. First, the participants saw both advantages and disadvantages to concentration, but these were also contested and debated. Second, we found that – sometimes conflicting – public health care goals (i.e. quality, accessibility and affordability) and narrower interests (e.g. the interests of specific hospitals, insurers, medical specialists and local administrators) were both pointed out. Third, there was no clear preferred approach to the future organisation of EDs, although most stakeholders mentioned some form of centralised decision-making at the national level, combined with regional customisation. Our findings will facilitate health policy decision-making around the reconfiguration of emergency care with the long-term goal of achieving efficient and high-quality emergency care.

Psychiatric deinstitutionalization (PDI) processes aim to transform long-term psychiatric care by closing or reducing psychiatric hospitals, reallocating beds, and establishing comprehensive community-based services for individuals with severe and persistent mental health difficulties. This scoping review explores the extensive literature on PDI, spanning decades, regions, socio-political contexts, and disciplines, to identify barriers and facilitators of PDI implementation, providing researchers and policymakers with a categorization of these factors. To identify barriers and facilitators, three electronic databases (Medline, CINAHL, and Sociological Abstracts) were searched, yielding 2,250 references. After screening and reviewing, 52 studies were included in the final analysis. Thematic synthesis was utilized to categorize the identified factors, responding to the review question. The analysis revealed that barriers to PDI include inadequate planning, funding, and leadership, limited knowledge, competing interests, insufficient community-based alternatives, and resistance from the workforce, community, and family/caregivers. In contrast, facilitators encompass careful planning, financing and coordination, available research and evidence, strong and sustained advocacy, comprehensive community services, and a well-trained workforce engaged in the process. Exogenous factors, such as conflict and humanitarian disasters, can also play a role in PDI processes. Implementing PDI requires a multifaceted strategy, strong leadership, diverse stakeholder participation, and long-term political and financial support. Understanding local needs and forces is crucial, and studying PDI necessitates methodological flexibility and sensitivity to contextual variation. At the same time, based on the development of the review itself, we identify four limitations in the literature, concerning “time,” “location,” “focus,” and “voice.” We call for a renewed research and advocacy agenda around this neglected aspect of contemporary global mental health policy is needed.

Gene therapies to treat sickle cell disease are in development and are expected to have high costs. The large eligible population size — by far, the largest for a gene therapy — poses daunting budget challenges and threatens to exacerbate health disparities for Black patients, who make up the vast majority of American sickle cell patients.

The Affordable Care Act requires all insurance plans sold on health insurance marketplaces and individual and small-group plans to cover 10 Essential Health Benefits (EHB), including behavioral health services. Instead of applying a uniform EHB plan design, the Department of Health and Human Services let states define their own EHB plan. This approach was seen as the best balance between flexibility and comprehensiveness, and assumed there would be little state-to-state variation. Limited federal oversight runs the risk of variation in EHB coverage definitions and requirements, as well as potential divergence from standardized medical guidelines. We analyzed 112 EHB documents from all states for behavioral health coverage in effect from 2012 to 2017. We find wide variation among states in their EHB plan required-coverage, and divergence between medical-practice guidelines and EHB plans. These results emphasize consideration of federated regulation over health insurance coverage standards. Federal flexibility in states benefit design nods to state-specific policymaking-processes and population needs. However, flexibility becomes problematic if it leads to inadequate coverage that reduces access to critical health care services. The EHBs demonstrate an incomplete effort to establish appropriate minimum standards of coverage for behavioral health services.

Equitable access to and utilization of health services is a primary goal for many health care systems, particularly in countries with universal publicly funded systems. Despite concerns regarding potentially adverse implications of the 1990s’ health care policy and other reforms, whether and how income inequalities in service utilization changed remains unclear. This study addressed the impact of income on physician and hospital utilization from 1992–2002 among adults aged 50 and older in British Columbia. Those with lower incomes were found less likely to access general practitioner and specialist services but more likely to access hospital services. Income-related disparities in physician care increased over time; hospital care declined. Volume of GP and hospital care was inversely associated with income; these differences increased regarding GP services only. Findings of declines in hospital-care access, accompanied by increasing income-related disparities in physician-services access, show that inequities are increasing within Canada’s health care system.

States’ policy decisions regarding the Affordable Care Act (ACA) of 2010 have often been explained as predominantly, if not solely, partisan. Might rival explanations also apply? Using a cross-sectional 50-state regression model, we studied standard political variables coupled with public-health indicators. This work differs from existing research by employing a dependent variable of five additive measures of ACA support, examining the impact of both political and socioeconomic indicators on state policy decisions. Expanding on recent empirical studies with our more nuanced additive index of support measures, we found that same-party control of a state’s executive and legislative branches was indeed by far the single best predictor of policy decisions. Public-health indicators, overwhelmed by partisan effect, did not sufficiently explain state policy choice. This result does not allay the concerns that health policy has become synonymous with health politics and that health politics now has little to do with health itself.

Health care reforms have always been critical political arenas within which the parameters of citizens' access to health care services and thus the new terms of social bargain that backs social policies are negotiated. Despite the relative success of Turkey in establishing public health insurance schemes and developing a public capacity for health care service delivery since the late 1940s, Turkey's health care system has largely failed to institute equality of access to health care services. With the promise of abolishing the inequalities, the ruling Justice and Development Party (AKP) launched Turkey's Health Transformation Program in 2003. Since then, Turkey's health care system has been undergoing a significant transformation. On the one hand, with the unification of all public health insurance schemes under a compulsory universal health insurance scheme and the equalization of benefit packages for all publicly insured, the program has succeeded in abolishing the occupational status-based inequalities in access to health care services. On the other, this article suggests that the program has changed the main origin of inequalities in service access from occupational status to income. As the country suffers from an uneven distribution of income, it is argued that these incomebased inequalities in access pose a significant threat to the realization of the social citizenship ideal in Turkey.

American Emergency Medical Services (EMS) agencies largely have been untouched by the dramatic health care reform efforts underway, although change seems imminent. Clarifying the role of the modern EMS system, and the yardsticks used to evaluate its performance, will be a challenge.

This paper introduces the concept of value (or outcomes to cost ratio) in EMS, and offers value assessment as a means by which reform decisions can be framed. The best reform decisions are those that optimize both costs and outcomes. This includes: (1) attention to the patient experience; (2) disallowing the provision of unhelpful, harmful or disproven prehospital care; and (3) expanding patient dispositions beyond Emergency Departments. Costs of care will need to be tracked carefully and acknowledged. Value generation should serve as the goal of ongoing EMS reform efforts.

Munk MD. Value generation and health reform in emergency medical services. Prehosp Disaster Med. 2012;27(2):1-4.

The establishment of primary care trusts (PCTs) is a radical reorganization of the NHS. This paper examines primary care groups (PCGs) making an early change to trust status, comparing them with those adopting a longer timetable for the change. The data are derived from the National Tracker Survey of primary care groups and trusts (random sample of 72 PCGs, 15% of the 481 PCGs in England, and five purposively sampled early PCTs) conducted in 1999 and 2000. The main source of data consisted of interviews with Chief Officers (response rates: 1999, 100%; 2000, 97%). In total, 43% of PCGs had become PCTs by April 2001, and 90% expect to become PCTs by April 2002. Integration of primary and community health services, focusing on local needs and innovation in service development, were common reasons for wanting to become a PCT. These trusts were more likely to cite autonomy as a reason, and were also more likely to believe that they had the support of professional stakeholders, but a substantial minority reported that they did not have the active support of GPs and other primary care staff. Although early trusts had slightly more experience of GP-led commissioning, there was no evidence that they were performing better than later trusts in their core functions of developing primary care, improving quality and commissioning services. The rapid progress from PCGs to PCTs does not seem to reflect the process of developmental learning and building on experience initially envisaged by government. Evidence from earlier NHS reforms indicates that time taken to build capacity, develop relationships and secure stakeholder support is associated with success. There appears to be a tension between central control over the implementation of NHS reforms and the desire to devolve budgets and responsibilities to local level.

Jurisdictions around the world have articulated the need for the development of an integrated health care system with an increased emphasis on primary health care that incorporates the principles/practices of health promotion. Over the past century, the medical model has been the default model of care in many countries, and yet treatment alone is unlikely to have marked effects on health inequities or health status. This article presents and discusses three fundamental dimensions (strategies, processes and outcomes) of health promotion in primary health care (HP in PHC) settings. We argue that the three dimensions are founded on the values and structures of health promotion (Frankish et al., 2006). Our work is based on a comprehensive literature review, validation by key informants and a national survey of Canadian primary health care settings. We suggest that the strategies (types of interventions), processes (client and community centred care), and desired health promotion outcomes (intended or unintended results) need to be better articulated and understood. Identification and discussion of the domains of HP in PHC settings is a crucial first step. It is a step toward the subsequent identification of related indicators and measures of health promotion that can be used for planning, implementation and evaluation of important health promotion initiatives.

Jurisdictions around the world have articulated a need for development of an integrated health care system with increased emphasis on primary health care and incorporation of the principles and practices of health promotion. To date, the medical model has been the default model of care. Yet, treatment alone is unlikely to have marked effects on health inequities or health status. This article presents and discusses two foundational dimensions (values, structures) of a health promotion philosophy and approach in primary health care settings. We propose a strategy and framework to support practical and attainable action. Our article (the first of a series of two) is based on a literature review, validation by key experts and a national survey of Canadian primary health care settings. We argue that fundamental philosophical values provide a foundation for health promotion in primary health care. These values should be reflected in the structures that create a supportive environment for health promotion. Our remaining three domains (strategies, processes, outcomes) are presented in a second following article. Based on values and structures, we conclude that subsequent strategies (interventions), processes (client- and community-centred care), and desired health promotion outcomes (intended or unintended) may be achieved.

In this paper, we discuss the complex relationship between health technology assessment (HTA) and the regulation of medical devices and procedures. The relationship is first examined through a conceptual framework describing the itinerary from research to three levels of policy making: micro (standards of medical practice), meso (institutional rules), and macro (health policies). Four reports from the Quebec Health Technology Assessment Council (CÉTS) are used to illustrate how HTA activities can influence the regulatory mechanisms operating at each decision-making level. We then discuss the skillful balancing act required from HTA agencies to constantly negotiate the right distance from the regulatory process at which to operate. We propose that HTA agencies should not be incorporated into any regulatory, auditing, or monitoring process. Finally, the relationship between health technology assessment and health care reform is discussed. It is suggested that HTA activities will contribute most during the data-driven preparation and consolidation phases of a reform process. The fast pace of events and the political turmoil characteristic of the implementation phase provide a less receptive environment for HTA contributions.