ECHO: health care performance assessment in several European health systems.

BACKGROUND: Strengthening health-care effectiveness, increasing accessibility and improving resilience are key goals in the upcoming European Union health-care agenda. European Collaboration for Health-Care Optimization (ECHO), an international research project on health-care performance assessment funded by the seventh framework programme, has provided evidence and methodology to allow the attainment of those goals. This article aims at describing ECHO, analysing its main instruments and discussing some of the ECHO policy implications. METHODS: Using patient-level administrative data, a series of observational studies (ecological and cross-section with associated time-series analyses) were conducted to analyze population and patients' exposure to health care. Operationally, several performance dimensions such as health-care inequalities, quality, safety and efficiency were analyzed using a set of validated indicators. The main instruments in ECHO were: (i) building a homogeneous data infrastructure; (ii) constructing coding crosswalks to allow comparisons between countries; (iii) making geographical units of analysis comparable; and (iv) allowing comparisons through the use of common benchmarks. CONCLUSION: ECHO has provided some innovations in international comparisons of health-care performance, mainly derived from the massive pooling of patient-level data and thus: (i) has expanded the usual approach based on average figures, providing insight into within and across country variation at various meaningful policy levels, (ii) the important effort made on data homogenization has increased comparability, increasing stakeholders' reliance on data and improving the acceptance of findings and (iii) has been able to provide more flexible and reliable benchmarking, allowing stakeholders to make critical use of the evidence.

A pilot study of the safety and performance of the Otologics fully implantable hearing device: transducing sounds via the round window membrane to the inner ear.

OBJECTIVES: The safety and performance of the Otologics fully implantable hearing device were assessed in adult patients with mixed conductive and sensorineural hearing loss. METHODS: The subcutaneous microphone of this fully implantable device picks up ambient sounds, converts them into an electrical signal, amplifies the signal according to the user's needs, and sends it to an electromechanical transducer. The transducer tip is customized with a prosthesis in order to be in contact with the round window membrane and is protected by fascia; this translates the electrical signal into a mechanical motion that directly stimulates the round window membrane and enables the user to perceive sound. The implanted battery is recharged daily via an external charger and the user can turn the implant on and off as well as adjust the volume with a hand-held remote control. In this pilot study, 6 patients with mixed conductive and sensorineural hearing loss were implanted with the Otologics fully implantable hearing device. Pre- and postoperative air conduction, bone conduction, as well as aided and unaided thresholds and speech scores were measured. RESULTS: No significant differences between preoperative and postoperative pure-tone averages were noted. Average improvement ranged from 19.16 to 35.8 dB of functional gain across audiometric frequencies with a mean of 26.17 +/- 5.15 dB. Long-term average functional gain at 12 months was 20.83 +/- 6.22 dB. Word recognition scores demonstrated significant differences between unaided and implant-aided conditions. CONCLUSIONS: Preliminary results of this trial of the Otologics fully implantable hearing device provide evidence that this fully implantable device is capable of efficiently transferring the sound to the inner ear via the round window membrane in patients with mixed hearing loss.

Health, nutrition and population

As countries refine their poverty reduction strategies, the role of human capital, including health and nutrition, is receiving considerable attention. People become poorer as a result of bad health or health crises, but being poor also makes people less healthy and more exposed to riskProjects are tools used in all countries and organizations to achieve specific short-term goals. In health, they provide a means of developing targeted interventions to reach the poor or to address specific health problems and to prove that the interventions succeed at reasonable cost. (Au)

The impact of alternative cost recovery schemes on access and equity in Niger.

The authors examine accessibility and the sustainability of quality health care in a rural setting under two alternative cost recovery methods, a fee-for-service method and a type of social financing (risk-sharing) strategy based on an annual tax+fee-for-service. Both methods were accompanied by similar interventions aimed at improving the quality of primary health services. Based on pilot tests of cost recovery in the non-hospital sector in Niger, the article presents results from baseline and final survey data, as well as from facility utilization, cost, and revenue data collected in two test districts and a control district. Cost recovery accompanied by quality improvements increases equity and access to health care and the type of cost recovery method used can make a difference. In Niger, higher access for women, children, and the poor resulted from the tax+fee method, than from the pure fee-for-service method. Moreover, revenue generation per capita under the tax+fee method was two times higher than under the fee-for-service method, suggesting that the prospects of sustainability were better under the social financing strategy. However, sustainability under cost recovery and improved quality depends as much on policy measures aimed at cost containment, particularly for drugs, as on specific cost recovery methods.

PIP: In Niger the Ministry of Public Health in 1989 carried out a pilot test on a pure fee-for-service financing mechanism and a local social financing mechanism, a tax + fee-for-service, for a national cost recovery health policy. Three health districts were selected: the District of Say, the District of Boboye, and the District of Illela. The fee-per-episode of illness method was instituted in the District of Say where fees were set at 200 FCFA ($0.66) per user 5 years and older and 100 FCFA ($0.33) for children under 5. The second method was implemented in the District of Boboye in the form of a local, annual tax of 200 FCFA ($0.66) to be paid by the district taxpayers and a small fee-per-episode to be paid by users of public health facilities. A baseline survey collected information on the curative health behavior of 2710 individuals who reported illness during the last 2 weeks preceding the survey. Information was also collected on preventive care behavior from 1770 childbearing women for the baseline survey and 1615 childbearing women for the final survey. Information on monthly activities and utilization of the 23 health facilities was collected for the year preceding the launching of fee collection, the base year, May 1992-April 1993, and the year following the launching of charges at public facilities, the test year, May 1993-April 1994. In the District of Say the number of visits declined slightly, but the total quantity of care increased significantly. In contrast, the number of initial visits increased by nearly 40% in the District of Boboye, and significant improvement was observed in the utilization of public health facilities among children and women. Overall, people spent less on health care across the 3 districts during the test period than they did before. Furthermore, drug consumption at public health facilities in the 2 test districts was well below current needs.

Research note: does cost recovery for curative care affect preventive care utilization?

PIP: Findings are presented from cost recovery pilot tests implemented by the government of Niger, with technical assistance from USAID's Health Financing and Sustainability (HFS) Project, in the primary health care sector in Boboye and Say districts during 1993-94. The tests focused upon the use of free prenatal care for pregnant women. Two different payment methods were tested along with interventions to improve the quality of care. An annual adult tax plus a small fee-per-episode at the time of use were assessed in Boboye, while a straight fee-per-episode of illness was implemented in Say. The difference in the financial burden to the consumer between the two schemes depended upon the number of illnesses experienced. Preventive services remained free of charge in all public facilities. Together with the introduction of cost recovery, health facility staff in the two test districts were trained on diagnostic and treatment protocols, an initial stock of generic drugs was provided to the involved health facilities, and a drug inventory and financial management system were established. Far from suffering with the introduction of cost recovery and quality improvements, the use of preventive services actually increased. Additional research is needed on the effect of cost recovery upon the use of preventive services.^ieng