Explore the vast range of titles available.

The author traces the development of the concept of health promotion from 1980s policies of the World Health Organization. Two approaches that signify the modernization of public health are outlined in detail: the European Health for All targets and the settings approach. Both aim to reorient health policy priorities from a risk factor approach to strategies that address the determinants of health and empower people to participate in improving the health of their communities. These approaches combine classic public health dictums with “new” strategies, some setting explicit goals to integrate public health with general welfare policy. Health for All, health promotion, and population health have contributed to this reorientation in thinking and strategy, but the focus of health policy remains expenditure rather than investment.

The first WHO essential drugs list, published in 1977, was described as a peaceful revolution in international public health. The list helped to establish the principle that some medicines were more useful than others and that essential medicines were often inaccessible to many populations. Since then, the essential medicines list (EML) has increased in size; defining an essential medicine has moved from an experience to an evidence-based process, including criteria such as public-health relevance, efficacy, safety, and cost-effectiveness. High priced medicines such as antiretrovirals are now included. Differences exist between the WHO model EML and national EMLs since countries face varying challenges relating to costs, drug effectiveness, morbidity patterns, and rationality of prescribing. Ensuring equitable access to and rational use of essential medicines has been promoted through WHO's revised drug strategy. This approach has required an engagement by WHO on issues such as the effect of international trade agreements on access to essential medicines and research and development to ensure availability of new essential medicines.

The economic effect of ill health has long been a cause of bankruptcies in the USA,23 but in the 1990s, ill health became a leading cause of household impoverishment in transitional economies, such as rural China,13 and some of the Asiatic republics of the former USSR.15 Poor households reporting illness in a rural area in northern Vietnam, spent an average 22% of their household budget on health-care costs, whereas rich households spent 8%.14 Moreover, poor people tended to pay more than rich people at a health centre, and poor communes charged more than rich communes.24 In Thailand, poor people also pay proportionally more for health care than rich people.25 So-called free maternity services in Dhaka, Bangladesh, have hidden and unofficial payments that necessitate more than a fifth of families spending the equivalent of 50-100% of their monthly income on maternity care.16 In Vietnam, the average cost of hospital admission is the equivalent of 2 months' wages,14 and in rural China, hospital care costs up to seven times the net monthly income of a poor household.26

The research programs of the National Institutes of Health (NIH) have been remarkably successful over the past 50 years. NIH-funded scientists have made substantial progress in understanding the basic mechanisms of disease and have vastly improved the preventive, diagnostic, and therapeutic options available. 1 However, the NIH is able to fund less than 30 percent of extramural grant applications; this fact has led scientists, patients, and other advocates of biomedical research to question how research funds are allocated to research on various diseases. 2 – 6 The NIH working group on the setting of priorities has listed five major criteria for the allocation . . .

The Mexican health system has evolved through three generations of reform. The creation of the Ministry of Health and the main social security agency in 1943 marked the first generation of health reforms. In the late 1970s, a second generation of reforms was launched around the primary health-care model. Third-generation reforms favour systemic changes to reorganise the system through the horizontal integration of basic functions—stewardship, financing, and provision. The stability of leadership in the health sector is emphasised as a key element that allowed for reform during the past 60 years. Furthermore, there has been a transition in the second generation of reforms to a model that is increasingly based on evidence; this has been intensified and extended in the third generation of reforms. We also examine policy developments that will provide social protection in health for all. These developments could be of interest for countries seeking to provide their citizens with universal access to health care that incorporates equity, quality, and financial protection.

To improve the dietary offering in schools, the French authorities published recommendations on nutrition in 1999, which were then revised in 2007. The aim of the present study was to assess the nutritional offering in secondary school meals and the extent to which the recommendations promote balanced nutritional offerings. In 2005, a national survey was conducted on a representative sample of secondary schools, either administrated by the Ministry of Education (ES) or the Ministry of Agriculture (AS). Information on school-catering organisation and twenty consecutive meals was collected from each of the 707 secondary schools surveyed. Nutritional composition was estimated according to the French food composition database. Univariate and multivariate analyses were used to investigate the impact of food-group frequency guidelines (FFG) on nutritional offering. It was found that 15 and 26 % of ES and AS schools, respectively, had high compliance with the FFG, at lunch. Macronutrient content was unbalanced in ES school lunches in which 42·8 % lipids, 21·5 % proteins and 35·7 % carbohydrates contributed to the energy. Nevertheless, proper offerings in Fe, Ca and vitamin C content were observed. In addition, a lower offering in lipids and a higher offering in proteins, Ca, vitamin C and Fe were found when the FFG were applied (P < 0·001). Similar results were found for AS schools. This paper confirms the effectiveness of FFG in providing nutritionally balanced school meals. However, others measures such as nutrition promotion and actions to improve children's food habits have to be introduced to make the recommendations more effective and easier to understand.

Under managed care, the financing and delivery of health care are organized by a single entity. Managed-care plans are classified as health maintenance organizations (HMOs), preferred-provider organizations (PPOs), or various mixes of the two. 1 There are two major forms of HMO: group-model or staff-model HMOs and network or independent-practice–association (IPA) HMOs. Both types are usually at risk for the costs of care and therefore often control costs by requiring patients to be referred to specialists by primary care doctors. The doctors in network or IPA HMOs are usually in independent practice. A PPO, in contrast, consists of a group of . . .

Background : A common way of describing UK National Institute for Health and Clinical Excellence (NICE) decisions is to distinguish between cases where NICE recommended use of a healthcare technology by all relevant patients (‘yes’); those where it did not recommend use (‘no’); and those where its decisions are a mixture of ‘yes’ to some patient subgroups, and ‘no’ to others. Over half of NICE’s decisions are of this mixed type, which involve restricting (or‘optimizing’) patient use in some way. Objective : To report an attempt to develop a robust and defensible means of measuring and describing the degree of patient access in mixed NICE decisions. Methods : A list of mixed decisions made from 2006 to the end of 2009 was identified using HTAinSite™. The following calculation was used: M= (p/P) × 100, where M is a measure of the level of patient access (0 = no access, 100 = full access), P is the set of patients considered in the guidance as P otential candidates for treatment (given the licensed use and the scope of NICE’s appraisal), and p is a subset of those p atients, for whom NICE did recommend treatment.Mcan be estimated either for a specific product or for a group of technologies (Multiple Technology Appraisals). Both productspecific and overall M were estimated, using estimates of p obtained from NICE costing templates. These data are subject to some important limitations, so the results should be regarded as illustrative. Results : Of the 69 medicines that have received a mixed decision since January 2006, 34 included details that allowed the estimation of M. Of these 34 decisions, 24 (71%) had a product-specific M ≤50, 16 (47%) M ≤25 and 11 (32%) M ≤10. That is, in just under three-quarters of the mixed decisions for which P and p were available, NICE recommended use for less than half of patients for whom the medicine is licensed, and in nearly one-third of these sorts of decisions, NICE recommended use in ≤10% of potential patients. The estimates of M for groups of technologies provide a slightly different picture: for example, grouped M was ≤10 in <20% of decisions. Conclusions : The measure of patient access, M, proposed here has the potential to provide a more informative way of reporting all NICE decisions, particularly ‘restricted’ (or ‘optimized’) decisions.

In the UK, as elsewhere in the world, there is abundant evidence of unacceptable inequalities and inefficiencies in health care. These failures are manifest in various ways including inappropriate variations in the uptake and use of health technologies of proven value, the too frequent failure to provide patients with optimum care for the treatment of common diseases, and the too ready adoption of health technologies with no established clinical benefits. Healthcare systems worldwide are therefore struggling to find ways to ensure that their health professionals are able to provide patients with the highest possible and affordable–standards of clinical care. The British government has committed itself to a programme of enhancing the quality of care given to National Health Service (NHS) patients. The new National Institute for Clnical Excellence (NICE) has been charge with providing NHS staff with clear and robust advice that will help them meet their own, and their patients', aspirations. The Institute's guidance will cover individual technologies as well as the management of a wide range of conditions. NICE will also advise on appropriate methods of clinical audit in those areas where it has provided guidance.

The National Institute for Health and Clinical Excellence (NICE) invited the manufacturer of dabigatran etexilate (Boehringer Ingelheim Ltd, UK) to submit evidence for the clinical and cost-effectiveness of this drug for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF) as part of the NICE single technology appraisal process. The Centre for Reviews and Dissemination and the Centre for Health Economics at the University of York were commissioned to act as the evidence review group (ERG). This article presents a summary of the manufacturer’s submission, the ERG report and the subsequent development of NICE guidance for the use of dabigatran within the UK National Health Service. Dabigatran was granted marketing authorisation by the European Medicines Agency for a sequential dosing regimen (DBG sequential), in which patients under 80 years are treated with dabigatran 150 mg twice daily (DBG150) and patients 80 years and over are given dabigatran 110 mg twice daily (DBG110). NICE decisions are bound by the marketing authorisation; therefore, the decision problem faced by the committee was whether the DBG sequential regimen was effective and cost-effective compared with warfarin or aspirin for patients with non-valvular AF and one or more risk factors. The RE-LY trial, a large multi-centre non-inferiority randomised clinical trial, was the primary source of clinical evidence. DBG150 was shown to be non-inferior, and subsequently superior to warfarin, for the primary outcome of all stroke/systemic embolism. DBG110 was found to be non-inferior to warfarin. Results were presented for a post hoc subgroup analysis for patients under and over 80 years of age, where DBG110 showed a statistically significant reduction of haemorrhagic stroke and intracranial haemorrhage in comparison to warfarin in patients over 80 years of age. This post hoc subgroup analysis by age was the basis for the licensed DBG sequential regimen. The economic evaluation compared the costs and outcomes of DBG110, DBG150 and DBG sequential against warfarin, aspirin, and aspirin plus clopidogrel. Across the three dosing regimens, dabigatran was associated with greater costs and better health outcomes than warfarin; however, DBG150 offered the most benefits and dominated DBG110 and DBG sequential (i.e. less costly and more effective). The cost-effectiveness of DBG150 was less favourable for patients well controlled on warfarin. In the first appraisal meeting, the committee issued a ‘minded no’ decision until additional analyses on the licensed DBG sequential regimen were presented by the manufacturer. These additional analyses indicated that the incremental cost-effectiveness ratio (ICER) of the DBG sequential regimen compared with warfarin ranged from £8,388 to £18,987 per quality-adjusted life year (QALY) gained depending on the level of monitoring costs assumed for warfarin. Patients on warfarin would need to be within therapeutic range 83–85 % of the time for the ICER to exceed £30,000 per additional QALY. Following consideration of the additional evidence and the responses from a large number of consultees and commentators, the committee recommended dabigatran as DBG sequential as an option for the prevention of stroke and systemic embolism in people with non-valvular AF with one or more risk factors for ischaemic stroke.