Global health disparities were the topic of a special event November 11th co-sponsored by the Asia Health Policy Program of the Shorenstein Asia-Pacific Research Center and the Center for Health Policy / Primary Care and Outcomes Research.

Sir Michael Marmot, internationally renowned Principal Investigator of the Whitehall Studies of British civil servants (investigating explanations for the striking inverse social gradient in morbidity and mortality), spoke about research on the social determinants of health and taking action to promote policy change. Pointing out the extreme disparities in life expectancy for peoples in different parts of the world – including the “haves” and “have-nots” within the high-income world – he presented an overview of “Closing the gap in a generation: Health equity through action on the social determinants of health” (http://www.who.int/social_determinants/en/). That report was commissioned by the World Health Organization (WHO) and released last year; Sir Marmot served as the Chair of the Commission on Social Determinants of Health.

Criticizing those who justify initiatives in global health solely on economic grounds, Sir Marmot argued that addressing the social determinants of health is a matter of social justice.

He presented data and discussed the report’s three primary recommendations: 1. Improve daily living conditions; 2. Tackle the inequitable distribution of power, money, and resources; and 3. Measure and understand the problem and assess the impact of action.
Stating that the World Health Assembly resolution on the social determinants of health was only meaningful as a first “baby step,” Marmot urged the audience to consider how research and policy advocacy can address the social determinants of health so that all individuals can lead flourishing lives.

Examples from Asia include

• the high risk of maternal mortality (1 in 8) in Afghanistan;
• the steep gradient in under-5 mortality in India (with the rate almost three times higher for the poorest quintile than for the wealthiest quintile);
• less than half of women in Bangladesh have a say in decision-making about their own health care;
• a large share of the world’s population living on less than US$2 a day reside in Asia;
• social protection systems like pensions are possible in lower and middle-income countries, with Thailand as an example;
• more can be done to address the millions impoverished by catastrophic health expenditures, such as in southeast Asia; and
• conflict-ridden areas and internally displaced people, such as in Pakistan and Myanmar, are among the most vulnerable.

He also responded to questions about the role of freedom and liberty in social development – contrasting India and China – and commented on the peculiar contours of the US health reform debate.

Professor Marmot closed by noting that, in exhorting everyone to strive for social justice and close the gaps in health inequalities all too apparent in our 21st century world, he hoped he was not too much like Don Quixote, going around “doing good deeds but with people all laughing at him.” 
Professor Sir Michael Marmot MBBS, MPH, PhD, FRCP, FFPHM, FMedSci, is Director of the International Institute for Society and Health and MRC Research Professor of Epidemiology and Public Health at University College, London. In 2000 he was knighted by Her Majesty The Queen for services to Epidemiology and understanding health inequalities.

In April, China announced an ambitious health care reform plan that aims to provide universal access to basic care for all Chinese while enhancing population health initiatives, strengthening service delivery, improving risk pooling, and significantly increasing government funding for the health sector. China Radio International interviewed Karen Eggleston, Asia Health Policy Program Director, about China's health care reform for the radio program "People in the Know." The program, aired on August 21, can be heard online.

"The Role of the Private Sector in Health" was the topic of a full day symposium held July 11th at the Beijing International Convention Center. Convened one day before the World Congress of the International Health Economics Association, the private sector symposium attracted over a hundred participants from nations around the world. Aiming to foster dialogue between researchers interested in the private sector and policymakers, the event is one in a series with the long-term goal of promoting greater research interest and knowledge generation regarding the private sector to benefit health systems development. The program featured several scientific paper presentations and panels as well as keynote addresses by representatives from the Chinese Ministry of Health and the World Bank.

Karen Eggleston of the Asia Health Policy Program worked alongside several others on the organizing committee for this ongoing collaboration about the role of the private sector in health policy. Other committee members included Ruth Berg, PSP ONE, Abt Associates; Peter Berman, World Bank; Birger Forsberg, Karolinska Institutet; Gina Lagomarsino, Results for Development; Qingyue Meng, Shandong University; Dominic Montagu, University of California, San Francisco; Sara Bennett, Alliance for Health Systems and Policy Research; and Stefan Nachuk, Rockefeller Foundation.

Selected papers about the private health sector in Asia presented at the symposium will appear in the Asia Health Policy Program's working paper series on health and demographic change in the Asia-Pacific.

AHPP sponsors special journal issue on health service provider incentives

The Director of the Asia Health Policy Program, Karen Eggleston, served as guest editor of the International Journal of Healthcare Finance and Economics for the June 2009 issue. The eight papers of that issue evaluate different provider payment methods in comparative international perspective, with authors from Hungary, China, Thailand, the US, Switzerland, and Canada. These contributions illustrate how the array of incentives facing providers shapes their interpersonal, clinical, administrative, and investment decisions in ways that profoundly impact the performance of health care systems.

The collection leads off with a study by János Kornai, one of the most prominent scholars of socialism and post-socialist transition, and the originator of the concept of the soft budget constraint. Kornai’s paper examines the political economy of why soft budget constraints appear to be especially prevalent among health care providers, compared to other sectors of the economy.

Two other papers in the issue take up the challenge of empirically identifying the extent of soft budget constraints among hospitals and their impact on safety net services, quality of care, and efficiency, in the United States (Shen and Eggleston) and – even more preliminarily – in China (Eggleston and colleagues, AHPP working paper #8).

The impact of adopting National Health Insurance (NHI) and policies separating prescribing from dispensing are the subject of Kang-Hung Chang’s article entitled “The healer or the druggist: Effects of two health care policies in Taiwan on elderly patients’ choice between physician and pharmacist services” (AHPP working paper #5).

In “Does your health care depend on how your insurer pays providers? Variation in utilization and outcomes in Thailand” (AHPP working paper #4), Sanita Hirunrassamee of Chulalongkorn University and Sauwakon Ratanawijitrasin of Mahidol University study the impact of multiple provider payment methods in Thailand, providing striking evidence consistent with standard predictions of how payment incentives shape provider behavior. For example, patients whose insurers paid on a capitated or case basis (the 30 Baht and social security schemes) were less likely to receive new drugs than those for whom the insurer paid on a fee-for-service basis (civil servants). Patients with lung cancer were less likely to receive an MRI or a CT scan if payment involved supply-side cost sharing, compared to otherwise similar patients under fee-for-service. (This article is open access.)

The fourth paper in this special issue is entitled “Allocation of control rights and cooperation efficiency in public-private partnerships: Theory and evidence from the Chinese pharmaceutical industry” (AHPP working paper #6). Zhe Zhang and her colleagues use a survey of 140 pharmaceutical firms in China to explore the relationships between firms’ control rights within public-private partnerships and the firms’ investments.

Hai Fang, Hong Liu, and John A. Rizzo delve into another question of health service delivery design and accompanying supply-side incentives: requiring primary physician gatekeepers to monitor patient access to specialty care (AHPP working paper #2).

Direct comparisons of payment incentives in two or more countries are rare. In “An economic analysis of payment for health care services: The United States and Switzerland compared,” Peter Zweifel and Ming Tai-Seale compare the nationwide uniform fee schedule for ambulatory medical services in Switzerland with the resource-based relative value scale in the United States.

Several of the papers featured in this special issue were presented at the conference “Provider Payment Incentives in the Asia-Pacific” convened November 7-8, 2008 at the China Center for Economic Research (CCER) at Peking University in Beijing. That conference was sponsored by the Asia Health Policy Program of the Shorenstein Asia-Pacific Research Center at Stanford University and CCER, with organizing team members from Stanford University, Peking University, and Seoul National University.

As Eggleston notes in the guest editorial to the special issue, AHPP and the other scholars associated with the issue “hope that these papers will contribute to more intellectual effort on how provider payment reforms, carefully designed and rigorously evaluated, can improve ‘value for money’ in health care.”