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RubricUnit 4 AssignmentUnit 4 AssignmentCriteriaRatingsPtsThis criterion is linked to a Learning OutcomeOrganizationPRICE-P; PRICE-I12.5 ptsLevel 5All questions answered with information organized in a logical sequence.11.25 ptsLevel 4All questions answered with information generally organized in a logical sequence.10.0 ptsLevel 3All questions answered and information is intermittently organized.8.75 ptsLevel 2All questions answered but the information is disorganized.7.5 ptsLevel 1All questions not addressed.0.0 ptsLevel 0Did not submit the assignment.12.5 pts
This criterion is linked to a Learning OutcomeAnalysis & EvaluationNM424-CO2; NM424-CO4; NM424-CO7; PRICE-P; PRICE-R; PRICE-I12.5 ptsLevel 5Presents an insightful and thorough analysis of the issue; Support analysis with at least one scholarly source.11.25 ptsLevel 4Presents a thorough analysis of the issue; Support analysis with at least one scholarly source.10.0 ptsLevel 3Presents an incomplete analysis of the issue by failure to address one aspect: No scholarly support of analysis.8.75 ptsLevel 2Presents an incomplete analysis of the issue by failure to address multiple aspects; No scholarly support of analysis.7.5 ptsLevel 1Presents a superficial analysis of the issue; No scholarly support of analysis.0.0 ptsLevel 0Did not submit the assignment.12.5 pts
This criterion is linked to a Learning OutcomeWriting MechanicsPRICE-P; PRICE-I12.5 ptsLevel 5Demonstrates clarity, conciseness, and correctness Majority of the information is clear with some questions left to reader interpretation.11.25 ptsLevel 4Majority of the information is clear with some questions left to reader interpretation.10.0 ptsLevel 3Sentence structure proper but paragraph is disorganized.8.75 ptsLevel 2Poorly organized and does not follow proper sentence structure.7.5 ptsLevel 1Unfocused and rambling.0.0 ptsLevel 0Did not submit the assignment.12.5 pts
This criterion is linked to a Learning OutcomeFormatPRICE-P; PRICE-I12.5 ptsLevel 5APA formatted and free of grammar and spelling errors.11.25 ptsLevel 4APA formatted with 1-3 grammar and spelling errors.10.0 ptsLevel 3APA formatted with 4-5 grammar and spelling errors.8.75 ptsLevel 2APA formatted with greater than 5 grammar and spelling errors.7.5 ptsLevel 1Not in APA format.0.0 ptsLevel 0Did not submit the assignment.12.5 pts
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The following case study is worth 50 points. Complete the case study and submit it to the drop box. You can either type your answers directly into the study or you can write them, take a picture and u
As is known, the U.S. government began providing public health services in the 1700s, and public health nursing was first recognized 125 years ago (see Chapter 2). Although there were physicians in England in the 1600s and 1700s and in the United States since the 1700s, official recognition of the general practitioner (GP) occurred in England only in 1844. In the 1950s and 1960s in the United States, discussions were held to elevate the GP to a specialty practice in medicine. Thus family practice medicine became a reality in the 1960s (ABFM, 2005). After this development in medicine the first nurse practitioner program was begun in 1965 (Medscape, 2000). Then, in September 1978, an international conference was held in the city of Alma-Ata, which at that time was the capital of the Soviet Republic of Kazakhstan. During this conference, the Declaration of Alma-Ata and the primary health care model emerged (Appendix A.3). This declaration states that health is a human right and that the health of its people should be the primary goal of every government. One of the main themes of this declaration was the involvement of community health workers and traditional healers in a new health system (World Health Organization [WHO], 1978). A special thanks to Bonnie Jerome-D-Emilia for the many contributions to this chapter in edition 8 of the text. It was through this conference that the concept of primary health care (PHC) was introduced, defined, and described. In 2008, the WHO renewed its call for health care improvements and reemphasized the need for public policymakers, public health officials, primary care providers, and leadership within countries to improve health care delivery. The WHO said: “Globalization is putting the social cohesion of many countries under stress, and health systems … are clearly not performing as well as they could and should. People are increasingly impatient with the inability of health services to deliver. … Few would disagree that health systems need to respond better—and faster—to the challenges of a changing world. PHC can do that” (WHO, 2008; and see Chapter 4). As defined by the WHO, PHC reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities, and is based on the application of social, biomedical, and health services research and public health experience. It addresses the main health problems in the community, providing for health promotion, disease prevention, and curative and rehabilitative services (WHO, 1978). Defined differently than primary care or public health, PHC promotes the integration of all health care systems within a community to come together to improve the health of the community, including primary care and public health. Health Care in the United States Despite the fact that health care costs in the United States are the highest in the world and comprise the greatest percentage of the gross domestic product, the indicators of what constitutes good health do not document that Americans are really getting their money’s worth. In the first decade of the twenty-first century there have been massive and unexpected changes to health, economic, and social conditions as a result of terrorist attacks, hurricanes, fires, floods, infectious diseases, and an economic turndown in 2008. New systems have been developed to prevent and/or deal with the onslaught of these horrendous events. Not all of the systems have worked, and many are regularly criticized for their inefficiency and costliness. Simultaneously, new, nearly miraculous advances have been made in treating health-related conditions. Organs and joints are being replaced and medicines are keeping people alive who only a few years ago would have suffered and died. These advances and “wonder drugs” save and prolong lives, and a number of deadly and debilitating diseases have been eliminated through effective immunizations and treatments. In addition, sanitation, water supplies, and nutrition have been improved, and animal cloning has begun. However, attention to all of these advances may overshadow the lack of attention to public health and prevention. Several of the most destructive health conditions can be prevented either through changes in lifestyle or interventions such as immunizations. The increasing rates of obesity, especially among children; substance use; lack of exercise; violence; and accidents are alarmingly expensive, particularly when they lead to disruptions in health. This chapter describes a health care system in transition as it struggles to meet evolving global and domestic challenges. The overall health care and public health systems in the United States are described and differentiated, and the changing priorities are identified. Nurses play a pivotal role in meeting these needs, and the role of the nurse is described. Forces Stimulating Change in the Demand for Health Care In recent years, enormous changes have occurred in society, both in the United States and most other countries of the world. The extent of interaction among countries is stronger than ever, and the economy of each country depends on the stability of other countries. The United States has felt the effects of rising 46labor costs as many companies have shifted their production to other countries with lower labor costs. It is often less expensive to assemble clothes, automobile parts, and appliances and to have call distribution centers and call service centers in a less industrialized country and pay the shipping and other charges involved than to have the items fully assembled in the United States. In recent years the vacillating cost of fuel has affected almost every area of the economy, leading to both higher costs of products and layoffs as some industries have struggled to stay solvent. This has affected the employment rate in the United States. The economic downturn of 2008 left many people unemployed, and many lost their homes because they could not pay their mortgages. When the unemployment rate is high, more people lack comprehensive insurance coverage, since in the United States this has been typically provided by employers. In late November 2008, the U.S. unemployment rate was 6.7%. This represented an increase from 4.6% in 2007. In July 2012 the unemployment rate had increased to 8.2%, close to double the rate in 2007. In recent years the economy has begun to recover. In 2014, for example, the unemployment rate decreased to 6.1%—down by 2.1 percentage points from 2012 (Bureau of Labor Statistics [BLS], 2014a). Also, health care services and the ways in which they are financed are changing, with the continuing implementation of the Patient Protection and Affordable Care Act (ACA, enacted in 2010). Demographic Trends The population of the world is growing as a result of increased fertility and decreased mortality rates. The greatest growth is occurring in underdeveloped countries, and this is accompanied by decreased growth in the United States and other developed countries. The year 2000, however, marked the first time in more than 30 years that the total fertility rate in the United States was above the replacement level. Replacement means that for every person who dies, another is born (Hamilton et al, 2010). Both the size and the characteristics of the population contribute to the changing demography. Seventy-seven million babies were born between the years of 1946 and 1963, giving rise to the often discussed baby boomer generation (Office of National Statistics, 2014) The oldest of these boomers reached 65 years of age in 2011, and they are expected to live longer than people born in earlier times (see Chapter 5). The impact on the federal government’s insurance program for people 65 years of age and older, Medicare, is expected to be enormous, and this population is expected to double between the years 2000 and 2030, representing 20% of the total population (CDC, 2013a). In 2014, the U.S. population was 318,804 million people, representing the third most populated country in the world. From 1990 to 2012, the U.S. foreign-born immigrant population grew from about 19 million to about 41 million and is continuing to increase every year (US Census Bureau, 2014). At the time of the 1990 census, African Americans were the largest minority group in the United States (U.S. Census Bureau, 1996). However, in 2014, the U.S. Census Bureau announced that Hispanic persons outnumbered African Americans, with non-Hispanic whites being the largest single ethnic group in the United States (Office of National Statistics [ONS], 2014). The nation’s foreign-born population is growing, and it is projected that from now until 2050 the largest population growth will be due to immigrants and their children. States with the largest percentage of foreign-born populations are California, New York, Hawaii, Florida, and New Jersey. The states with the fastest-growing immigrant populations in 2012 were Nevada, Texas, Maryland, Illinois, and Arizona (Migration Policy Institute, 2014; Pew Research Center, 2012). The composition of the U.S. household is also changing (see Chapter 25 for changes in families). From 1935 to 2010, mortality for both genders in all age groups and races declined (Hoyert, 2012) as a result of progress in public health initiatives, such as antismoking campaigns, AIDS prevention programs, and cancer screening programs. The leading causes of death have changed from infectious diseases to chronic and degenerative diseases (NCHS, 2014). New infectious diseases are emerging, such as Ebola virus, which affected the United States in 2014 with the first case in Dallas, Texas (CDC, 2014a). New treatments for infectious diseases have resulted in steady declines in mortality among children, as long as parents participate in immunization programs. A recent measles outbreak in Orange County, California shows that continuous focus on control of infectious diseases is essential (Orange County Health Care Agency, 2014). The mortality for older Americans has also declined. However, people 50 years of age and older have higher rates of chronic and degenerative illness and they use a larger portion of health care services than other age groups. Social and Economic Trends In addition to the size and changing age distribution of the population, other factors also affect the health care system. Several social trends that influence health care include changing lifestyles, a growing appreciation of the quality of life, the changing composition of families and living patterns, changing household incomes, and a revised definition of quality health care. Americans spend considerable money on health care, nutrition, and fitness (Bureau of Labor Statistics, 2012), because health is seen as an irreplaceable commodity. To be healthy, people must take care of themselves. Many people combine traditional medical and health care practices with complementary and alternative therapies to achieve the highest level of health. Complementary therapies are those that are used in addition to traditional health care, and alternative therapies are those used instead of traditional care. Examples include acupuncture, herbal medications, and more (National Center for Complementary and Alternative Medicine, 2014). People often spend a considerable amount of their own money for these types of therapies because few are covered by insurance. In recent years, some insurance plans have recognized the value of complementary therapies and have reimbursed for them. State offices of insurance are good sources to determine whether these services are covered and by which health insurance plans. About 65 years ago, income was distributed in such a way that a relatively small portion of households earned high incomes; families in the middle-income range made up a 47somewhat larger proportion and households at the lower end of the income scale made up the largest proportion. By the 1970s, household income had risen, and income was more evenly distributed, largely as a result of dual-income families. Since 1970 and to 2008, two trends in income distribution have emerged. The first is that the average per-person income in America has increased. Income of households in the top 1% of earners grew by 275%, compared with 65% for the next 19%, just under 40% for the next 60%, and 18% for the bottom fifth of households (Congressional Budget Office [CBO], 2011). However, as a result of what is being called the Great Recession, which began in 2008, and in recent years with layoffs, outsourcing, and other economic forces, many families are seeing decreases in wages. The second trend is that the gap between the richest 25% and the poorest 25% is widening because of the percent wage increase in the higher income levels (CBO, 2011). Chapter 5 provides a detailed discussion of the economics of health care and how financial constraints influence decisions about public health services. Health Workforce Trends The health care workforce ebbs and flows. The early years of the twenty-first century saw the beginning of what is expected to be a long-term and sizable nursing shortage. Similarly, most other health professionals are documenting current and future shortages. Historically, nursing care has been provided in a variety of settings, primarily in the hospital. Approximately 56% of all registered nurses (RNs) continue to be employed in hospitals (American Nurses Association, 2012). A few years ago hospitals began reducing their bed capacity as care became more community based. Now they are expanding, including building for both acute and longer term chronic care. This growth is due to the factors previously discussed: the ability to treat and perhaps cure more diseases, the complexity of the care and the need for inpatient services, and the growth of the older age group. The nursing shortage has been discussed in recent years, yet new graduates often have difficulty finding positions on graduation (American Association of Colleges of Nursing [AACN], 2014). Participating in a nurse internship program and being a bachelor of science in nursing (BSN) graduate or higher provides more opportunities for the new graduate. By 2016 there are expected to be 527,000 new nursing positions (BLS, 2014b). In addition, 55% of nurses reported in a recent survey that they intended to retire between 2011 and 2020, which will open positions for others (Fears, 2010). There tend to be periodic shortages, especially in the primary care workforce in the United States, as providers choose to be specialists in fields such as medicine and nursing. Primary care providers include generalists who are skilled in diagnostic, preventive, and emergency services. The health care personnel trained as primary care generalists include family physicians, general internists, general pediatricians, nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants, and certified nurse-midwives (CNMs) (Steinwald, 2008). NPs, CNSs, and CNMs, considered advanced practice nursing (APN) specialties, are vital members of the primary care teams (see Chapter 39). Although there is a shortage of primary care physicians, nurse practitioners may or may not be able to fill the gap because of state nurse practice acts and medical practice acts, which influence the practice of both groups. In terms of the nursing workforce, increasing the number of minority nurses remains a priority and a strategy for addressing the current nursing shortage. In 2013 minority nurses represented about 22% of the registered nurse population. It is thought that increasing the minority population will help close the health disparity gap for minority populations (AACN, 2014). For example, persons from minority groups, especially when language is a barrier, often are more comfortable with and more likely to access care from a provider from their own minority group. Technological Trends The development and refinement of new technologies such as telehealth have opened up new clinical opportunities for nurses and their clients, especially in the areas of managing chronic conditions, assisting persons who live in rural areas, and in providing home health care, rehabilitation, and long-term care. On the positive side, technological advances promise improved health care services, reduced costs, and more convenience in terms of time and travel for consumers (see Chapter 5). Reduced costs result from a more efficient means of delivering care and from replacement of people with machines. It also reduces paperwork, gets accurate information to providers and clients and agencies, assists with care coordination and safety, and provides direct access to health records between agencies and to clients (HealthIT.gov, 2013). Contradictory as it may seem, cost is also the most significant negative aspect of advanced health care technology. The more high-technology equipment and computer programs become available, the more they are used. High-technology equipment is expensive, quickly becomes outdated when newer developments occur, and often requires highly trained personnel. There are other drawbacks to new technology, particularly in the area of home health care. These include increased legal liability, the potential for decreased privacy, too much reliance on technological advances, and the inconsistent quality of resources available on the Internet and other places (Palma, 2014). Advances in health care technology will continue. One example of an effective use of technology is the funding provided by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) to health centers so they can adopt and implement electronic health records (EHRs) and other health information technology (HRSA, 2008). HRSA’s Office of Health Information Technology (HIT) was created in 2005 to promote the effective use of HIT as a mechanism for responding to the needs of the uninsured, underinsured, and special-needs populations (HRSA, 2014). Specifically, in December 2012, an award of $18 plus million through the Affordable Care Act was announced to expand health information technology in 600 health centers (HRSA, 2012). One innovative use of the EHR in public health is to embed reminders or guidelines into the system. For 48example, the CDC published health guidelines that contain clinical recommendations for screening, prevention, diagnosis, and treatment. To find and keep current on these guidelines, clinicians must visit the CDC website. The availability of an EHR system allows the embedding of reminders so that the clinician can have access to practice guidelines at the very point of care. Some additional benefits in public health (and these are some of the uses health centers make of such records) include the following: • 24-hour availability of records with downloaded laboratory results and up-to-date assessments • Coordination of referrals and facilitation of interprofessional care in chronic disease management • Incorporation of protocol reminders for prevention, screening, and management of chronic disease • Improvement of quality measurement and monitoring • Increased client safety and decline in medication errors Two federal programs, Medicaid and the State Children’s Health Insurance Program (SCHIP), have effectively used health information technology (HIT) in several key functions including outreach and enrollment, service delivery, and care management, as well as communications with families and the broader goals of program planning and improvement. In early 2009, the surgeon general’s office reopened a web site that had been tried first in 2004, and then closed: an electronic family tree for your health (National Institutes of Health [NIH], 2010). This is described as an easy-to-use computer application for people to keep a personal record of their family health history (https://familyhistory.hhs.gov/FHH/html/index.html). Before the initiative described above, the CDC began a family history public health initiative through the Office of Public Health Genomics to increase awareness of family history as an important risk factor for common chronic diseases. This initiative had four main activities: 1. Research to define, measure, and assess family history in populations and individuals 2. Development and evaluation of tools for collecting family history 3. Evaluation of how family history-based strategies work 4. Promotion of evidence-based applications of family history to health professionals and the public (CDC, 2013b). Current Health Care System in the United States Despite the many advances and the sophistication of the U.S. health care system, the system has been plagued with problems related to cost, access, and quality (see more discussion in Chapters 5, 21, and 26). These problems are different for each person and have been affected by the ability of individuals to obtain health insurance. Most industrialized countries want the same things from their health care system. Several give their government a greater role in health care delivery and eliminate or reduce the use of market forces to control cost, access, and quality. Seemingly, there is no one perfect health care system in the world. Cost Beginning in 2008, a historic weakening of the national and global economy—the “Great Recession”—led to the loss of 7 million jobs in the United States (Economic Report, 2010). Even as the gross domestic product (GDP), an indicator of the economic health of a country, declined in 2009, health care spending continued to grow and reached $2.5 trillion in the same year (Truffer et al, 2010). In the years between 2010 and 2019, national health spending is expected to grow at an average annual rate of 6.1%, reaching $4.5 trillion by 2019, for a share of approximately 19.3% of the GDP. This translates into a projected increase in per capita spending (see Chapter 5). In Chapter 5, additional discussion illustrates how health care dollars are spent. The largest share of health care expenditures goes to pay for hospital care, with physician services being the next largest item. The amount of money that has gone to pay for public health services is much lower than for the other categories of expenditures. Other significant drivers of the increasingly high cost of health care include prescription drugs, technology, and chronic and degenerative disease. Following the “Great Recession,” the economic rebound will likely coincide with the burgeoning Medicare enrollment of the aging baby boomer population. It was projected that these new Medicare enrollees will increase Medicare expenditures for the foreseeable future. Medicaid recipients can be expected to decline as jobs are added to the economy, and the percentage of workers covered by employer-sponsored insurance should rise to reflect that growth. Although workers’ salaries have not kept pace, employer-sponsored insurance premiums have grown 119% since 1999 (Kaiser Family Foundation, 2009a), and the inability of workers to pay this increased cost has led to a rise in the percentage of working families who are uninsured. It is essential to read about the changes in the above facts as the American Affordable Care Act is implemented. Access Another significant problem is poor access to health care (case study in Box 3-1). The American health care system is described as a two-class system: private and public. People with insurance or those who can personally pay for health care are viewed as receiving superior care; those who receive lower quality care are 49(1) those whose only source of care depends on public funds or (2) the working poor, who do not qualify for public funds either because they make too much money to qualify or because they are illegal immigrants. Employment-provided health care is tied to both the economy and to changes in health insurance premiums. By 2009, 61% of the nonelderly population continued to obtain health insurance through their employer as a benefit; however, employment did not guarantee insurance (Rowland et al, 2009). This became clear when considering that 9 in 10 (91%) of the middle-class uninsured came from families with at least one full-time worker in jobs that did not offer health insurance or where coverage was unaffordable (Rowland et al, 2009). Box 3-1 Case Study Public health nurses who worked with local Head Start programs noted that many children had untreated dental caries. Despite qualifying for Medicaid, only two dentists in the area would accept appointments from Medicaid patients. Dentists asserted that Medicaid patients frequently did not show up for their appointments and that reimbursement was too low compared with other third-party payers. They also said the children’s behavior made it difficult to work with them. So the waiting list for local dental care was approximately 6 years long. Although some nurses found ways to transport clients to dentists in a city 70 miles away, it was very time consuming and was feasible for only a small fraction of the clients. When decayed teeth abscessed, it was possible to get extractions from the local medical center. The health department dentist also saw children, but he, too, was booked for years. Created by Deborah C. Conway, Assistant Professor, University of Virginia School of Nursing. In 2012, the total number of uninsured persons in the United States was 48 million. As discussed, there was a strong relationship between health insurance coverage and access to health care services. Insurance status determines the amount and kind of health care people are able to afford, as well as where they can receive care. During this same year 15% of the total population was uninsured and 48% were covered by employer health insurance. All but 5% of the remaining, or 32%, were covered by government insurance programs (Kaiser Health News 2012; Kaiser Family Foundation, 2014). The uninsured receive less preventive care, are diagnosed at more advanced disease states, and once diagnosed tend to receive less therapeutic care in terms of surgery and treatment options. There is a safety net for the uninsured or underinsured. As discussed later in this chapter, there are more than 1300 federally funded community health centers throughout the country. Federally funded community health centers provide a broad range of health and social services, using nurse practitioners and RNs, physician assistants, physicians, social workers, and dentists. Community health centers serve primarily in medically underserved areas, which can be rural or urban. These centers serve people of all ages, races, and ethnicities, with or without health insurance. Quality The quality of health care leaped to the forefront of concern following the 1999 release of the Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System (IOM, 2000). As indicated in this groundbreaking report, as many as 98,000 deaths a year could be attributed to preventable medical errors. Some of the untoward events categorized in this report included adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken client identities. It was further determined that high rates of errors with serious consequences were most likely to occur in intensive care units, operating rooms, and emergency departments. Beyond the cost in human lives, preventable medical errors result in the loss of several billions of dollars annually in hospitals nationwide. Categories of error include diagnostic, treatment, and prevention errors as well as failure of communication, equipment failure, and other system failures. Significant to nurses, the IOM estimated the number of lives lost to preventable errors in medication alone represented more than 7000 deaths annually, with a cost of about $2 billion nationwide. Although the IOM report made it clear that the majority of medical errors today were not produced by provider negligence, lack of education, or lack of training, questions were raised about the nurse’s role and workload and its effect on client safety. In a follow-up report, Keeping Patients Safe: Transforming the Work Environment of Nurses, the IOM (2003) stated that nurses’ long work hours pose a serious threat to patient safety, because fatigue slows reaction time, saps energy, and diminishes attention to detail. The group called for state regulators to pass laws barring nurses from working more than 12 hours a day and 60 hours a week—even if by choice (IOM, 2003). Although this information is largely related to acute care, many of the patients who survive medical errors are later cared for in the community. The culture of quality improvement and safety has made providers and consumers more conscious of safety, but medical errors and untoward events continue to occur. As a means to improve consumer awareness of hospital quality, the Centers for Medicare and Medicaid Services (CMS) began publishing a database of hospital quality measures, Hospital Compare, in 2005. Hospital Compare, a consumer-oriented website that provides information on how well hospitals provide recommended care in such areas as heart attack, heart failure, and pneumonia, is available through the CMS website (www.cms.gov). In a further effort, the CMS, in 2008, announced that it will no longer reimburse hospitals, under Medicare guidelines, for care provided for “preventable complications” such as hospital-acquired infections. This reimbursement policy was extended to Medicaid reimbursement in 2011 (Galewitz, 2011; CMS, 2009). The accreditation process for public health is new and the impact of quality and safety monitoring has not yet been determined. The ability of a public health agency or a community to respond to community disasters is one event that will be monitored. In December 2014, 60 of 303 local, tribal, and state centralized integration systems, and multijurisdictional health departments, have received accreditation in this new process. The accredited health departments served a 111 million population base. The purpose of this process is to • Assist and identify quality health departments to improve performance and quality, and to develop leadership • Improve management • Improve community relationships (Public Health Accreditation Board [PHAB], 2014) Organization of the Health Care System An enormous number and range of facilities and providers make up the health care system. These include physicians’ and dentists’ offices, hospitals, nursing homes, mental health facilities, ambulatory care centers, freestanding clinics and clinics inside stores such as drugstores, as well as free clinics, public health, and home health agencies. Providers include nurses, advanced practice nurses, physicians and physician assistants, dentists and dental hygienists, pharmacists, and a wide array of essential allied health providers such as physical, occupational, and recreational therapists; nutritionists; social workers; and a range of technicians. In general, however, the American health 50care system is divided into the following two, somewhat distinct, components: a private or personal care component and a public health component, with some overlap, as discussed in the following sections. It is important to discuss primary health care and examine the interest in developing such a system. Primary Care System Primary care, the first level of the private health care system, is delivered in a variety of community settings, such as physicians’ offices, urgent care centers, in-store clinics, community health centers, and community nursing centers. Near the end of the past century, in an attempt to contain costs, managed care organizations grew. Managed care is defined as a system in which care is delivered by a specific network of providers who agree to comply with the care approaches established through a case management approach. The key factors are a specified network of providers and the use of a gatekeeper to control access to providers and services. This form of care has not become as prominent as the original concept outlined. The government tried to reap the benefits of cost savings by introducing the managed care model into Medicare and Medicaid, with varying levels of success. The traditional Medicare plan involves Parts A and B. Part C, the Medicare Advantage program, incorporates private insurance plans into the Medicare program including HMO (health maintenance organization) and PPO (preferred provider organization) managed care models and private fee-for-service plans. In addition, Medicare Part D has been added to cover prescriptions (see Chapter 5). Public Health System The public health system is mandated through laws that are developed at the national, state, or local level. Examples of public health laws instituted to protect the health of the community include a law mandating immunizations for all children entering kindergarten and a law requiring constant monitoring of the local water supply. The public health system is organized into many levels in the federal, state, and local systems. At the local level, health departments provide care that is mandated by state and federal regulations. The Federal System The U.S. Department of Health and Human Services (USDHHS; or simply HHS) is the agency most heavily involved with the health and welfare concerns of U.S. citizens. The organizational chart of the HHS (Figure 3-1) shows the office of the secretary, 11 agencies, and a program support center (USDHHS, 2014a). Ten regional offices are maintained to provide more direct assistance to the states. Their locations are shown in Table 3-1. The HHS is charged with regulating health care and overseeing the health status of Americans. See Box 3-2 for the goals and objectives of the HHS strategic plan for fiscal years 2010-2015. Newer areas in the HHS are the Office of Public Health Preparedness, the Center for Faith-Based and Neighborhood Partnerships and the Office of Global Affairs. The Office of Public Health Preparedness was added to assist the nation and states to prepare for bioterrorism after September 11, 2001. The Faith-Based Initiative Center was developed by President George W. Bush to allow faith communities to compete for federal money to support their community activities. The goal of the Office of Global Affairs is to promote global health by coordinating HHS strategies and programs with other governments and international organizations (USDHHS, 2014a). image FIG 3-1 Organization of the U.S. Department of Health and Human Services. (From U.S. Department of Health and Human Services; Available at http://www.hhs.gov/about/orgchart/.) TABLE 3-1 Regional Offices of the U.S. Department of Health and Human Services Region Location Territory 1 Boston Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont 2 New York New Jersey, New York, Puerto Rico, Virgin Islands 3 Philadelphia Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia 4 Atlanta Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee 5 Chicago Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin 6 Dallas Arkansas, Louisiana, New Mexico, Oklahoma, Texas 7 Kansas City Iowa, Kansas, Missouri, Nebraska 8 Denver Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming 9 San Francisco Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Republic of the Marshall Islands, Republic of Palau 10 Seattle Alaska, Idaho, Oregon, Washington U.S. Department of Health and Human Services: HHS Regional Offices. Retrieved December 2014 from http://www.hhs.gov/about/regions/ Box 3-2 USDHHS Strategic Plan Goals and Objectives—Fiscal Years 2010-2015* GOAL 1: Strengthen Health Care Objective A Make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured. Objective B Improve health care quality and patient safety. Objective C Emphasize primary and preventive care linked with community prevention services. Objective D Reduce the growth of health care costs while promoting high-value, effective care. Objective E Ensure access to quality, culturally competent care for vulnerable populations. Objective F Promote the adoption and meaningful use of health information technology. GOAL 2: Advance Scientific Knowledge and Innovation Objective A Accelerate the process of scientific discovery to improve patient care. Objective B Foster innovation to create shared solutions. Objective C Invest in the regulatory sciences to improve food and medical product safety. Objective D Increase our understanding of what works in public health and human service practice. GOAL 3: Advance the Health, Safety, and Well-Being of the American People Objective A Promote the safety, well-being, resilience, and healthy development of children and youth. Objective B Promote economic and social well-being for individuals, families, and communities. Objective C Improve the accessibility and quality of supportive services for people with disabilities and older adults. Objective D Promote prevention and wellness. Objective E Reduce the occurrence of infectious diseases. Objective F Protect Americans’ health and safety during emergencies, and foster resilience in response to emergencies. GOAL 4: Increase Efficiency, Transparency, Accountability and Effectiveness of HHS Programs Objective A Ensure program integrity and responsible stewardship of resources. Objective B Fight fraud and work to eliminate improper payments. Objective C Use HHS data to improve the health and well-being of the American people. Objective D Improve HHS environmental, energy, and economic performance to promote sustainability. GOAL 5: Strengthen the Nation’s Health and Human Service Infrastructure and Workforce Objective A Invest in the HHS workforce to meet America’s health and human service needs today and tomorrow. Objective B Ensure that the Nation’s health care workforce can meet increased demands. Objective C Enhance the ability of the public health workforce to improve public health at home and abroad. Objective D Strengthen the Nation’s human service workforce. Objective E Improve national, state, local, and tribal surveillance and epidemiology capacity. *In process of being updated for 2014-2018. From the U.S. Department of Health and Human Services, 2014. Retrieved July 2, 2014, from http://www.hhs.gov/secretary/about/priorities.html. The U.S. Public Health Service (USPHS; or simply PHS) is a major component of the Department of Health and Human Services. The PHS consists of eight agencies: Agency for Healthcare Research and Quality, Agency for Toxic Substances and Diseases Registry, Centers for Disease Control and Prevention, Food and Drug Administration, Health Resources and Services Administration, Indian Health Service, National Institutes of Health, and Substance Abuse and Mental Health Services Administration. Each has a specific purpose (see Chapter 8 for relevancy of the agencies to policy and providing health care). The PHS also has a Commissioned Corps, which is a uniformed service of more than 6500 health professionals who serve in many HHS and other federal agencies. The surgeon general is head of the Commissioned Corps. The corps fills essential services for public health, clinic and provides leadership within the federal government departments and agencies to support the care of the underserved and vulnerable populations (USPHS, 2014). An important agency and a recent addition to the federal government, the U.S. Department of Homeland Security (USDHS, or simply DHS), was created in 2003 (USDHS, 2014). The mission of the DHS is to prevent and deter terrorist attacks and protect against and respond to threats and hazards to the nation. The goals for the department include awareness, prevention, protection, response, and recovery. The DHS works with first responders throughout the United States, and through the development of programs such as the Community 52Emergency Response Team (CERT) program trains people to be better prepared to respond to emergency situations in their communities. Nurses working in state and local public health departments as well as those employed in hospitals and other health facilities may be called on to respond to acts of terrorism or natural disaster in the course of their careers, and the DHS, along with the Food and Drug Administration (FDA) and CDC, is developing programs to ready nurses and other health care providers for an uncertain future (USDHS, 2014). The State System When the United States faced a pandemic flu outbreak in 2009, the federal government and the public health community quickly prepared to meet the challenge of educating the public and health professionals about the H1N1 flu and making vaccinations available. In 2014 public health within the states was responding to an enterovirus affecting large numbers of children with systems of upper respiratory disease and weakness in arms and legs. The virus was considered life-threatening (CDC, 2014b). In addition to standing ready for disaster prevention or response, state health departments have other equally important functions, such as health care financing and administration for programs such as Medicaid, providing mental health and professional education, establishing health codes, licensing facilities and personnel, and regulating the insurance industry. State systems also have an important role in direct assistance to local health departments, including ongoing assessment of health needs (see Chapter 46). image Levels of Prevention Related to the Public Health Care System Primary Prevention Implement a community-level program such as walking for exercise to assist citizens in improving health behaviors related to lifestyle. Secondary Prevention Implement a family-planning program to prevent unintended pregnancies for young couples who attend the local community health center. Tertiary Prevention Provide a self-management asthma program for children with chronic asthma to reduce their need for hospitalization. 53 Nurses serve in many capacities in state health departments; they are consultants, direct service providers, researchers, teachers, and supervisors. They also participate in program development, planning, and the evaluation of health programs. The Local System The local health department has direct responsibility to the citizens in its community or jurisdiction. Services and programs offered by local health departments vary depending on the state and local health codes that must be followed, the needs of the community, and available funding and other resources. For example, one health department might be more involved with public health education programs and environmental issues, whereas another health department might emphasize direct client care. Local health departments vary in providing sick care or even primary care (see Chapter 46). More often than at other levels of government, public health nurses at the local level provide population level or direct services. Some of these nurses deliver special or selected services, such as follow-up of contacts in cases of tuberculosis or venereal disease or providing child immunization clinics. Others provide more general care, delivering services to families in certain geographic areas. This method of delivery of nursing services involves broader needs and a wider variety of nursing interventions. The local level often provides an opportunity for nurses to take on significant leadership roles, with many nurses serving as directors or managers. Since the tragedy of September 11, 2001, state and local health departments have increasingly focused on emergency preparedness and response. In case of an event, state and local health departments in the affected area will be expected to collect data and accurately report the situation, to respond appropriately to any type of emergency, and to ensure the safety of the residents of the immediate area, while protecting those just outside the danger zone. This level of knowledge—to enable public health agencies to anticipate, prepare for, recognize, and respond to terrorist threats or natural disasters such as hurricanes or floods—has required a level of interstate and federal-local planning and cooperation that is unprecedented for these agencies. Whether participating in disaster drills or preparing a local high school for use as a shelter, nurses play a major role in meeting the challenge of an uncertain future. Forces Influencing Changes in the Health Care System Although most people are personally satisfied with their own physicians or nurse practitioners, at present few people are satisfied with the health care system in general. Costs have been high and have continued to rise while quality and access have been uneven across the country and within communities, depending on the ability to pay. What, then, were some of the factors that might influence health care to change? First, as a nation, citizens must decide what has to be provided for all people, who will be in charge of the system, and who will pay for what. In recent years, federal and state services have been reduced and more responsibility for health care delivery has been moved to the private sector. Health care has become big business. Health care company stocks are now traded by major stock exchanges, directors receive benefits when profits are high, and the locus of control had shifted from the provider to the payer. Many competing forces have influenced the changing design of the health care system, some of which are consumers, employers (purchasers), care delivery systems, and state and federal legislation. First, consumers want lower costs and high-quality health care without limits and with an improved ability to choose the providers of their choice. Second, employers (purchasers of health care) want to be able to obtain basic health care plans at reasonable costs for their employees. Many employers have seen their profits diminish as they put more money into providing adequate health care coverage for employees. Third, health care systems want a better balance between consumer and purchaser demands. Thus they continually watch their own budget and expenses. To maintain a profit while providing quality care, many health care delivery groups have downsized and created alliances, mergers, and other joint ventures. Finally, legislation, especially concerning access and quality, continues to be enacted, thus creating one more force helping shape a health care system. The goal of “evidence-based care” is to ensure quality. Many have said that solving the health care crisis requires the institution of a rational health care system that balances equity, cost, and quality. The fact that millions of people have been uninsured, that wide disparities have existed in access, and that a large proportion of deaths each year seem attributable to preventable causes (errors as well as tobacco, alcohol abuse, preventable injuries, and obesity) has indicated that the American system is currently not serving the best interests of the American population. The WHO has suggested that integrating primary care and public health into a primary health care system will be the basis for better health for all world citizens (WHO, 1986a). Integration of Public Health and the Primary Care Systems Although primary care and public health share a goal of promoting the health and well-being of all people, these two disciplines historically have operated independently of one another. Problems that stem from this separation have long been recognized, but new opportunities are emerging for bringing these systems together to promote lasting improvements in the health of individuals, communities, and populations (IOM, 2012). In recognition of this potential, the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA), both agencies of the Department of Health and Human Services (HHS), asked the Institute of Medicine (IOM) to convene a committee of experts, including input from nursing, to examine the integration of primary care and public health (IOM, 2012). To recognize the differences in these two systems, definitions were used to guide the work of the experts. Primary care was defined as “the providing of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, while developing partnerships with patients and practicing in the context of family and community” (IOM, 1996, p. 1). Public health was defined as “fulfilling society’s interest in assuring conditions in 54which people can be healthy” (IOM, 1988, p. 140). The purpose of the integration is to achieve the WHO goal of primary health care. Potential Barriers to Integration Contrasting the two systems, primary care, which can be either a public or a private entity, is person focused, provides a point of first contact for individuals to address health problems, and is considered comprehensive and provides coordination of individual care; public health can also be delivered through public and private entities to contribute to the health of society, but government plays a major role in public health. Health departments are legally bound to provide essential public health services, and to work with the total community and multiple stakeholders to address community-level health problems. Public health also has specific functions of assurance, assessment, and policy development to address community-level health issues and has a charge to create healthy communities (see Chapter 1). In addition to differing roles and functions and issues related to funding, different clients and different foci will need to be addressed to form a solid foundation for a partnership. Primary care is largely funded through individual client payments, health insurance, and sometimes through federal grants. Public health is largely funded through tax dollars, federal and state grants, and sometimes health insurance payments through Medicare and Medicaid. Primary care serves the individuals who present to the practice while public health serves to assess the health problems of the population. Both focus on meeting the most prevalent health needs of the population. Primary care focuses more on the curative aspect of care while public health focuses more on the prevention of health problems (Levesque et al, 2013). The common goal of public health and primary care, although these systems operate independently, is to ensure a healthier population. Integration of these two systems has the potential to produce a greater impact on the health of populations than either could have working alone, said the committee of experts convened by the IOM (2012). The Healthy People initiatives, beginning with the U.S. surgeon general’s 1979 report, indicate the long-standing desire to improve population health in the United States. Primary Health Care Primary health care (PHC), the goal of the integration of public health and primary care, includes a comprehensive range of services including public health and preventive, diagnostic, therapeutic, and rehabilitative services. This system is composed of public health agencies, community-based agencies and primary care clinics, and health care providers. From a conceptual point of view, PHC is essential care made universally accessible to individuals, families, and the community. Health care is made available to them with their full participation and is provided at a cost that the community and country can afford. This care is not uniformly available and accessible to all people in many countries including the United States. Full community participation means that individuals within the community help in defining health problems and in developing approaches to address the problems. The setting for primary health care is within all communities of a country and involves all aspects of society (WHO, 1978). The primary health care movement officially began in 1977 when the 30th World Health Organization (WHO) Health Assembly adopted a resolution accepting the goal of attaining a level of health that permitted all citizens of the world to live socially and economically productive lives. At the international conference in 1978 in Alma-Ata, in the former Soviet Union (Russia), it was determined that this goal was to be met through PHC. This resolution, the Declaration of Alma-Ata, became known by the slogan “Health for All (HFA) by the Year 2000,” which captured the official health target for all the member nations of the WHO. In 1998 the program was adapted to meet the needs of the new century and was deemed “Health for All in the 21st Century.” In 1981 the WHO established global indicators for monitoring and evaluating the achievement of HFA. In the World Health Statistics Annual (WHO, 1986b), these indicators are grouped into the following four categories: health policies, social and economic development, provision of health care, and health status. The indicators suggest that health improvements are a result of efforts in many areas, including agriculture, industry, education, housing, communications, and health care. Because PHC is as much a political statement as a system of care, each United Nations member country interprets PHC according to its own culture, health needs, resources, and system of government. Clearly, the goal of PHC has not been met in most countries including the United States. Promoting Health/Preventing Disease: Year 2020 Objectives for the Nation As a WHO member nation, the United States has endorsed primary health care as a strategy for achieving the goal of “Health for All in the 21st Century.” However, the PHC emphasis on broad strategies, community participation, self-reliance, and a multidisciplinary health care delivery team is not the primary strategy for improving the health of the American people. The national health plan for the United States identifies disease prevention and health promotion as the areas of most concern in the nation. Each decade since the 1980s has been measured and tracked according to health objectives set at the beginning of the decade. The U.S. Public Health Service of the HHS publishes the objectives after gathering data from health professionals and organizations throughout the country. Healthy People 2020, which was officially launched in December 2010 (USDHHS, 2010a), is composed of a large number of objectives related to 42 topic areas. These objectives are designed to serve as a road map for improving the health of all people in the United States during the second decade of the twenty-first century. These objectives are described by four main goals (USDHHS, 2010b): • Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death • Achieve health equity, eliminate disparities, and improve the health of all groups 55 • Create social and physical environments that promote good health for all • Promote quality of life, healthy development, and healthy behaviors across all life stages These goals provide the framework with which measurable health indicators can be tracked. The emphasis on the social and physical environment moves Healthy People 2020 from the traditional disease-specific focus to a more holistic view of health consistent with a public health frame of reference (Healthy People 2020, 2012). This in turn will encourage public health nurses to broaden their scope to all aspects of their clients’ lives that may need assessment and intervention, including where they live, the condition of their home, and how the appropriateness of their environment may change as the client ages. The Healthy People 2020 box presents indicators of Healthy People 2020 related to the strengthening of the public health infrastructure. These objectives will assist nurses in having data to show that their assessments and interventions are changing practice. image Healthy People 2020 Selected Objectives That Pertain to Strengthening the Public Health Infrastructure • PHI-7 (Developmental): Increase the proportion of population-based Healthy People 2020 objectives for which national data are available for all major population groups. • PHI-8: Increase the proportion of Healthy People 2020 objectives that are tracked regularly at the national level. From U. S. Department of Health and Human Services. Healthy People 2020. Available at http://www.healthypeople.gov/2020topicsobjectives2020/default.aspx. Accessed December 27, 2010. Evidence-Based Practice It is often said that the states are the laboratories of democracy. One state, Massachusetts, began an experiment in health reform in 2006. Two years after health reform legislation became effective, only 2.6% of Massachusetts residents were uninsured, the lowest percentage ever recorded in any state (Dorn et al, 2009). However, the program became one of the most successful and a model for the Affordable Care Act. After 5 years approximately 98% to 99% of all of the commonwealth’s citizens were covered by the plan. Although other states have experimented with various programs to decrease the number of uninsured, the Massachusetts plan has had the most success. The health reform plan rests on an individual mandate that requires everyone who can afford insurance to purchase coverage. Those unable to afford insurance receive subsidies that allow low-income individuals and families to purchase coverage. A new state-run program, Commonwealth Care (CommCare), provides benefits to adults who are not eligible for Medicaid but whose incomes fall below 300% of the federal poverty level. To understand how the state was so successful in this effort toward universal coverage, a group of evaluators met with 15 key informants representing hospitals, community health centers, insurance companies, Medicaid, and CommCare. Several factors, it was found, have contributed to the historic level of coverage seen in the state. Rather than requiring consumers to complete separate applications for programs such as Medicaid, the Children’s Health Insurance Program (CHIP), or CommCare, a single application system provides entry to all the state programs. If an uninsured client was admitted to a hospital or visited a community health center, his or her eligibility was automatically evaluated and, if eligible, the client would be automatically converted to CommCare coverage, even without completing an application. A “Virtual Gateway” has been developed through which staff of community-based organizations have been trained to complete online applications on behalf of consumers, and to provide education and counseling about insurance options to underserved communities. By holding back reimbursement to providers who do not help consumers sign up for one of the available insurance options, hospitals and health centers are motivated to dedicate staff to provide education and counseling to the formerly uninsured. The result is that at least half of the new enrollees in Medicaid and CommCare have been enrolled without filling out any forms on their own. In addition to these efforts, shortly after the reform legislation was enacted, the state financed a massive public education effort to inform consumers about their new options. Nurse Use As health reform begins on the national level, nurses can play a crucial role in driving down the number of uninsured. Nurses should educate themselves so that they can encourage clients to apply and take advantage of all available coverage options. Taking an active role in consumer educational programs is a natural extension of a nurse’s role as a client advocate. Nurses can promote legislation to simplify enrollment processes and encourage the development of shared databases for community health care providers, thus preventing consumers from falling through the cracks in our fragmented health care system. Dorn S, Hill I, Hogan S: The secrets of Massachusetts’success: why 97 percent of state residents have health coverage: state health access reform evaluation, Rommneycare-The truth about Massachusetts health care. 2014, accessed at mittromneycentral.com/resources/romneycare. 9/25/20142009, Robert Wood Johnson Foundation. Available at http://www.urban.org/uploadedpdf/411987_massachusetts_success_brief.pdf. Accessed September 19, 2012. Health Care Delivery Reform Efforts—United States Over the centuries, both health insurance and health care reform have been the focus of numerous discussions and political battles. As can be seen in Chapter 2, the first health insurance plan, established in about 1798 in the United States, was for the Merchant Marines to assist in treating infectious diseases and protecting the ports of entry into the United States. The United States has discussed national health care reform since the 1900s (see Chapter 5). In 1912 Theodore Roosevelt campaigned on a health insurance proposal for industry. Then in 1915 the “progressive reformers” campaigned for a state-based system of compulsory health insurance. In the 1920s, the Committee on the Costs of Medical Care suggested group medicine and voluntary insurance, and this movement was labeled as promoting “socialized medicine.” Since the 1930s, through surveys, Americans have generally shown support of the goals of guaranteed access to health care and health insurance, and a governmental role in financing of care. Some strides were made in improving access and defining the role of government financing through 56the passing of Medicare in 1965, with Medicaid as a part of the proposal for social security amendments, and the Children’s Health Insurance Program bill passed in 1996. Many proposals have been put forward over the decades for health care reform, as well as health insurance reform. Beginning in the 1970s Senator Ted Kennedy, President Richard Nixon, President Gerald Ford, and President Jimmy Carter all made health-related proposals, all followed by the Health Security Act of President Bill Clinton. None were accepted by Congress (Kaiser Family Foundation, 2009b). Nurses and the American Nurses Association have been involved in the debates about health care reform over time. In its 2005 Healthcare System Reform Agenda, the American Nurses Association (American Nurses Association, 2008) promoted a blueprint for reform that includes the following: • Health care is a basic human right, and so a restructured health care system with universal access to a standard package of essential health care services for all citizens and residents must be assured. • The development and implementation of health policies that reflect the aims put forth by the Institute of Medicine (safe, effective, patient centered, timely, efficient, equitable) and are based on outcomes research will ultimately save money. • The overuse of expensive, technology-driven, acute, hospital-based services must give way to a balance between high-tech treatment and community-based and preventive services, with emphasis on the latter. • A single-payer mechanism is the most desirable option for financing a reformed health care system. In 2010 the Affordable Care Act (ACA) was passed, after introduction by the Obama team and after much debate. This act reflects many of the tenets offered by the ANA in its Health System Reform Agenda and puts into place comprehensive health insurance reforms that are to be implemented by 2014 and beyond. The act was passed to improve quality and lower health care costs, provide access to care, and provide for consumer protection. Table 3-2 provides an overview of the key features of the act by year. The ACA has a major focus on prevention. This focus is designed to improve the health of Americans, but also help to reduce health care costs and improve quality of care. Through the Prevention and Public Health Fund, the ACA will address factors that influence health—housing, education, transportation, the availability of quality affordable food, and conditions in the workplace and the environment. By concentrating on the causes of chronic disease, the ACA will move the nation from a focus on sickness and disease to one based on wellness and prevention. TABLE 3-2 Overview of Key Features of the Affordable Care Act by Year 2010 New Consumer Protections • Putting information for consumers online. • Prohibiting denying coverage of children based on pre-existing conditions. • Prohibiting insurance companies from rescinding coverage. • Eliminating lifetime limits on insurance coverage. • Regulating annual limits on insurance coverage. • Establishing consumer assistance programs in the states. Improving Quality and Lowering Costs • Providing small business health insurance tax credits. • Offering relief for 4 million seniors who hit the Medicare prescription drug “donut hole.” • Providing free preventive care. • Preventing disease and illness. • Cracking down on health care fraud. Increasing Access to Affordable Care • Providing access to insurance for uninsured Americans with pre-existing conditions. • Extending coverage for young adults. • Expanding coverage for early retirees. • Rebuilding the primary care workforce. • Holding insurance companies accountable for unreasonable rate hikes. • Allowing states to cover more people on Medicaid. • Increasing payments for rural health care providers. • Strengthening community health centers. 2011 Improving Quality and Lowering Costs • Offering prescription drug discounts. • Providing free preventive care for seniors. • Improving health care quality and efficiency. • Improving care for seniors after they leave the hospital. • Introducing new innovations to bring down costs. Increasing Access to Affordable Care • Increasing access to services at home and in the community. Holding Insurance Companies Accountable • Bringing down health care premiums. • Addressing overpayments to big insurance companies and strengthening Medicare Advantage. 2012 Improving Quality and Lowering Costs • Linking payment to quality outcomes. • Encouraging integrated health systems. • Reducing paperwork and administrative costs. • Understanding and fighting health disparities. Increasing Access to Affordable Care • Providing new, voluntary options for long-term care insurance. 2013 Improving Quality and Lowering Costs • Improving preventive health coverage. • Expanding authority to bundle payments. Increasing Access to Affordable Care • Increasing Medicaid payments for primary care doctors. • Open enrollment in the health insurance marketplace begins. 2014 New Consumer Protections • Prohibiting discrimination due to pre-existing conditions or gender. • Eliminating annual limits on insurance coverage. • Ensuring coverage for individuals participating in clinical trials. Improving Quality and Lowering Costs • Making care more affordable. • Establishing the health insurance marketplace. • Increasing the small business tax credit. Increasing Access to Affordable Care • Increasing access to Medicaid. • Promoting individual responsibility. 2015 Improving Quality and Lowering Costs • Paying physicians based on value, not volume. For more detail about each of the bulleted statements please refer to HHS.gov/HealthCare (Key Features of the Affordable Care Act, 2014: http://www.hhs.gov/healthcare/facts/timeline/). To improve the health of Americans, ways to make the healthy choice in each community an easy and affordable choice must be found. In addition, within the law there are specific benefits for women, young adults, and families. It strengthens Medicare and holds insurance companies accountable (USDHHS, 2014b). Since the close of the first enrollment period for the ACA in early 2014, the numbers of uninsured have declined (see Chapter 1). Because of a lag in data, the effects of the health care reform will not be known until 2015. Discussions and debates will continue about the impact of the ACA, and the IOM’s discussions of integrating public health and primary care, reducing cost, increasing quality, and access for all Americans. It is important not to lose sight of the goal: to protect and improve the health of all populations. After spending 18 months in a public policy fellowship and working with the Ways and Means Committee in Congress, Nancy Ridenour, PhD, RN and dean of the College of Nursing at the University of New Mexico, described her opportunity to work with others as the ACA was being developed. At a board of nursing celebration in Kentucky in the summer of 2014, Dr. Ridenour explained to the audience that it would be important for nurses to be involved in the implementation of the ACA to promote the success of the health care changes proposed. It is all about the influence of nurses and the nursing profession! (Kentucky Board of Nursing, 2014). image Focus on Quality and Safety Education for Nurses Targeted Competency: Informatics—Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. Important aspects of Informatics include the following: Knowledge: Identify essential information that must be available in a common database to support interventions in the health care system. Skills: Use information management tools to monitor outcomes of intervention processes. Attitudes: Value technologies that support decision making, error prevention, and case coordination. Informatics Question: Updated informatics definitions focus on having access to the necessary client and system information at the right time, to make the best clinical decision. In the U.S. Department of Health and Human Services (USDHHS) Strategic Plan for 2010 to 2015, there are five overarching goals. Goal 1, Objective C focuses on “Emphasizing primary and preventive care linked with community prevention services.” Which community data would a public health nurse assess to determine the work that needs to be done in a community related to this USDHHS strategic goal? Answer: To assess future work that could be done to effectively address Goal 1, Objective C, public health nurses might gather data in the following areas: • How informed are members of the community about existing community services that support health promotion (e.g., exercise classes, educational classes, self-management training, and nutrition counseling)? • How relevant are the services offered by health centers to the needs of a community? • Do payment or insurance barriers exist for individuals to access preventive health services? • How accessible is entry to care for vulnerable populations such as pregnant women and infants? • What community-based prevention programs exist for individuals with and at risk for chronic diseases and conditions? • How available are substance abuse screening and intervention programs? • How linked are primary care and health promotions and wellness programs in a community? Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing. 57 Practice Application During a well-child clinic visit, Jenna Wells, RN, met Sandra Farr and her 24-month-old daughter, Jessica. The Farrs had recently moved to the community. Mrs. Farr stated that she knew that Jessica needed the last in a series of immunizations and because they did not have health insurance, she brought her daughter to the public health clinic. On initial assessment, Mrs. Farr told the nurse that her husband would soon be employed, but the family had no health care coverage for the next 30 days. The Farrs also needed to decide which health care package they wanted. Mr. Farr’s company offers a preferred provider organization (PPO), a health maintenance organization (HMO), and a community nursing clinic plan to all employees. Neither Mr. nor Mrs. Farr has ever used an HMO or a community nursing clinic, and they are not sure what services are provided. Mrs. Farr asks Nurse Wells what she should do. Nurse Wells should do which of the following? A. Encourage Mrs. Farr to choose the HMO because it will pay more attention to the family’s preventive needs, and direct Mrs. Farr to other sources of health care should the family need to see a provider while they are uninsured. B. Encourage Mrs. Farr to choose the PPO because it will have a greater number of qualified providers from which to 58choose, and direct Mrs. Farr to other sources of health care should the family need to see a provider while they are uninsured. C. Encourage Mrs. Farr to choose the local community nursing center because it is staffed with nurse practitioners who are well qualified to provide comprehensive health care with an emphasis on health education, and direct Mrs. Farr to other sources of health care should the family need to see a provider while they are uninsured. D. Explain the differences between a PPO, HMO, and community nursing clinic and encourage Mrs. Farr to discuss the options with her husband about signing up for a health insurance plan under the ACA plans, and direct Mrs. Farr to other sources of health care should the family need to see a provider while they are uninsured. Answers can be found on the Evolve site. Key Points • Health care in the United States is made up of a personal care system and a public health system, with overlap between the two systems. • Primary care is a personal health care system that provides for first contact and continuous, comprehensive, and coordinated care. • Primary health care is essential care made universally accessible to individuals and families in a community. Health care is made available to them through their full participation and is provided at a cost that the community and country can afford. • Primary care and the public health systems are part of primary health care. • Public health refers to organized community efforts designed to prevent disease and promote health. • Important trends that affect the health care system include demographic, social, economic, political, and technological trends. • More than 48 million people in the United States were uninsured in 2012, and many more simply lacked access to adequate health care. • With the implementation of the Affordable Care Act (ACA), by 2014 the numbers of uninsured dropped by 8%. • Many federal agencies are involved in government health care functions. The agency most directly involved with the health and welfare of Americans is the U.S. Department of Health and Human Services (USDHHS). • Most state and local jurisdictions have government activities that affect the health care field. • Health care and insurance reform measures seek to make changes in the cost and quality of and access to the present system, such as the ACA passed in 2010. • To achieve the specific health goals of programs such as Healthy People 2020, primary care and public health must work within the community for community-based care. • The most sustainable individual and system changes come when people who live in the community have actively participated. • Nurses are more than able to fill the gap between personal care and public health because they have skills in assessment, health promotion, and disease and injury prevention; knowledge of community resources; and the ability to develop relationships with community members and leaders. • Nurses are important to the success of the ACA. Clinical Decision-Making Activities 1. Compare local and state services. How have they been affected by the implementation of the ACA? What changes would you recommend to your local health department to improve public health and primary care? 2. Debate the following with a classmate. The major problem with the health care system is (choose one of the following topics): a. Escalating costs (including those from increased technology) b. Fragmentation of services c. Limited access to care d. Quality of care Explain your choice and give examples of reasons for the choice. 3. Visit your local health department and determine how its services fit into a primary care, public health, community-based health care system. Illustrate what you mean by your answer with examples. 4. Determine whether there is a federally funded health center in your community. If yes, learn what services are provided. Are there services that are needed in the community that are not being provided? 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WHO.: Geneva; 2008 [Retrieved December 2014 from] Chapter 4 This chapter presents an overview of the major public health problems of the world, along with a description of the role and involvement of nurses in global and community health care settings. It describes health care delivery from a global and population health perspective, illustrates how health systems operate in different countries, presents examples of organizations that address global health, and explains how economic development relates to health care throughout the world. Overview and Historical Perspective of Global Health Global warming and the melting of the polar ice caps; world-wide droughts and the natural disasters of blizzards, hurricanes, tornadoes, volcanoes, typhoons, and earthquakes; war; growing populations and the impoverished, destitute populations of the world make it imperative that nurses know about global health. Recent movements in the global arena identify the need for nurses to practice global health diplomacy, expanding beyond the tenets of health care and education we once provided (Hunter et al, 2013). Evidence indicates that contamination of water sources by heavy metals such as arsenic, copper, cadmium, mercury, and lead, to name a few, arising from the earth’s crust appears to be increasing around the globe because of the changing environmental conditions (Fernández-Luqueño et al, 2013; Bolender et al, 2012, 2013; World Health Organization. Heavy metals in children, 2011). What once were the unique health challenges of people in less developed countries, such as loss of human rights; and lack of access to food, housing, safety, and health care, are now common problems of people all over the world. Contamination of the water sources in many countries, abject poverty, increasing global violence, the declining global economy, and the depletion of food supplies all contribute to the current global health crisis. See the Evidence-Based Practice box to learn how diarrheal outbreaks in Botswana correlate with poor water quality. Evidence-Based Practice Alexander and Blackburn (2013) did a historical analysis surveying data (2006-2009) to examine the temporal pattern of recurrent diarrheal outbreaks in Chobe District in Botswana in patients less than 5 years of age; as well as had patients of all ages presenting with diarrheal disease and medical staff complete a questionnaire survey tool during two diarrheal outbreaks (2011-2012). Cluster analysis and classification and regression trees (CART) were used to evaluate patient attributes by outbreak. Results showed that peak outbreaks appeared to coincide with major hydrological phenomena (rainfall/flood recession), water shortages, and water quality deficiencies. Public health strategy should be directed at securing improved water service and correcting water quality deficiencies. Public health education should include increased emphasis on sanitation practices when providing care to household members with diarrhea. Nurse Use Being culturally sensitive and responsive means that nurses need to understand where patients come from, what barriers exist that contribute to the public health problems they develop, and what can reasonably be done to reduce the health consequences of poverty and access deprivation. Given this research study, how could you as a nurse help reduce the incidence of diarrhea contamination in a family and across the village? One example might be to gather all the women together who have sick children and teach them how to improve sanitation and provide clean water; then have them go and teach the remainder of the village and expand that teaching to other villages. What might be other examples? Preventable conditions such as malaria, malnutrition, communicable diseases, chronic health problems, and conditions related to environmental pollution are taxing the health care systems of many nations. Immigrants from developing nations often bring these conditions with them because of lack of access to health care services that could successfully diagnose or treat these issues in their home country. Understanding global health and factors that contribute to the immigrant’s health problems better prepares the nurse to develop interventions that are culturally congruent, culturally responsive, and culturally acceptable to the people for whom interventions are planned. It is well known that nurses provide more than 90% of all the health care services for people around the globe (Bryar et al, 2012), and the vision of the International Council of Nurses (ICN)’s Leadership for Change program is that nursing is to take a leadership role in helping achieve better health for all. Yet, in sub-Saharan Africa, reported to have 25% of the world’s disease burden, the patients are cared for by only 1.3% of the world’s trained health workforce, most of those being nurses (Bryar et al, 2012). In 1977 attendees at the annual meeting of the World Health Assembly stated that all citizens of the world should enjoy a level of health that would permit them to lead a socially and economically productive life. This goal was to have been 63achieved by the year 2000; however, man-made and natural disasters, political corruption, lack of infrastructure in less developed nations, and unforeseen obstacles have inhibited this goal from being achieved. The goals of Health for All by the Year 2000 (HFA2000) were extended into the next century with the document Health for All in the 21st Century (HFA21: http://www.euro.who.int/en/publications/policy-documents/health21-health-for-all-in-the-21st-century). The four main HFA21 strategies for action to ensure that scientific, economic, social and political sustainability were those designed as follows: 1. To tackle the determinants of health, taking into account physical, economic, social, cultural, and gender perspectives, and ensuring the use of health impact assessment 2. As health-outcome-driven programs and investments for health development and clinical care 3. For integrated family- and community-oriented primary health care, supported by a flexible and responsive hospital system 4. As a participatory health development process that involves relevant partners for health at home, school, and work and at local community and country levels, and that promotes joint decision making, implementation and accountability HFA laid the foundation for the Healthy People agendas of Healthy People 2020. image Healthy People 2020 Selected Objectives That Apply to Global Health Care • EH-4 Increase the proportion of persons served by community water systems who receive a supply of drinking water that meets the regulations of the Safe Drinking Water Act. • EH-5: Reduce waterborne disease outbreaks arising from water intended for drinking among persons served by community water systems. • FP-1: Increase the proportion of pregnancies that are intended. • GH-1: Reduce the number of cases of malaria reported in the United States. • HIV-1: Reduce the number of new HIV diagnoses among adolescents and adults. • MICH-3: Reduce the rate of child deaths. EH, Environmental Health; FP, Family Planning; GH, Global Health; HIV, Human Immunodeficiency Virus; MICH, Maternal, Infant, and Child Health. From U.S. Department of Health and Human Services: Healthy People: 2020 Topics and Objectives. Retrieved December 2014 from http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx. Accessed January 1, 2011. Each of the previous goals has relevance to the global arena. The millions of deaths related to unsafe water and poor hygiene is most pronounced in Africa and Southeast Asia. This relates to objectives EH-4 and EH-5 (see the Healthy People 2020 Box). Six in ten pregnancies in developing nations are unintended and relate to objective FP-1 (Kott, 2011). Malaria caused an estimated 627,000 deaths, mostly among African children (World Health Organization [WHO] Malaria Fact Sheet, 2013a), which relates to objective GH-1. Sub-Saharan Africa remains most severely affected with HIV/AIDS, with nearly 1 in every 20 adults (4.9%) living with HIV and accounting for 69% of the people living with HIV worldwide (WHO Fact Sheet on Global HIV/AIDS, 2012a), which relates to objective HIV-1. Last, the leading causes of death in under-five children are pneumonia, preterm birth complications, birth asphyxia, diarrhea, and malaria (about 45% of all child deaths are linked to malnutrition). Children in sub-Saharan Africa are about 16 times more likely to die before the age of five than children in developed regions (WHO Child Deaths Fact Sheet, 2013b); this relates to objective MICH-3. See the Quality and Safety in Nursing Education box for suggestions for how to deal with malaria through a team approach. image Focus on Quality and Safety Education for Nurses As described in earlier chapters of the text, including Chapter 2, there are six QSEN competencies for nursing. Because of the complex and multifaceted nature of providing public health nursing care in countries around the world, competency number two, teamwork and collaboration, is emphasized here. Teamwork and collaboration refer to the ability to function effectively with nursing and interprofessional teams and to foster open communication, mutual respect, and shared decision making in order to best provide safe and quality care. One of the United Nations Millennium Development Goals is to combat HIV/AIDS, malaria, and other diseases (see Box 4-1). The quality and safety question is as follows: How would nurses working in a country that is plagued by malaria develop a team to help control this mosquito-borne disease? Answer: The spread of malaria can be interrupted by prevention, treatment, and control measures such as using insecticide-treated bed nets and spraying in and near where people live, work, and go to school. Nurses would develop a team including representatives from funding agencies, environmental health, NGOs, medical practitioners, and local governments to locate funds and develop, implement, and evaluate prevention, control, and treatment measures. Because of the ease of global travel, contagious and preventable health conditions are not endemic in just an isolated country; they are prevalent around the world. Health professionals and world leaders want to be enlightened about these health issues and want answers on how to address them, which becomes problematic in the countries most afflicted but without the technological infrastructure to help their people. Many terms are used to describe nations that have achieved a high level of industrial and technological advancement (along with a stable market economy) and those that have not. For the purposes of this chapter, the term developed country refers to those countries with a stable economy and a wide range of industrial and technological development, low child mortality, high gross national income, and a high human asset index (e.g., the United States, Canada, Japan, the United Kingdom, Sweden, France, and Australia). A country that does not meet these criteria is referred to as a less developed country (e.g., Congo, Bangladesh, Somalia, Haiti, Guatemala, most countries in sub-Saharan Africa, and the island nation of Indonesia). Both developed and lesser-developed countries are found in all parts of the world and in all geographic and climatic zones (UN Department of Economic and Social Affairs [DESA], 2013c). 64 Health problems exist throughout the world, but the lesser-developed countries often have more unusual health care problems. There are more than 6000 rare diseases (Forman et al, 2012) and in developing countries such conditions as Buruli ulcers, leishmaniasis, river blindness, schistosomiasis, brucellosis, typhus, yellow fever, scurvy, and malaria are often unknown entities in the world of Western medicine (Molyneux and Sayioli, 2013). Ongoing health problems needing control in lesser-developed countries include measles, mumps, rubella, and polio; the current health concerns of the more-developed countries are problems such as hepatitis, infectious diseases, and new viral strains such as hantavirus, SARS (severe acute respiratory syndrome), H1N1, and avian flu. Chronic health problems such as hypertension, diabetes, cardiovascular disease, obesity, cancer, the resurgence of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) among adolescents and young adults, drug-resistant tuberculosis (TB); and the larger social, yet health-related, issues such as terrorism, warfare, violence, and substance abuse are now global issues (Shah, 2014). World travelers may expose themselves to diseases and environmental health hazards that are unknown or rare in their home country, and may serve as hosts to various types of disease agents. Two recent examples of diseases that were once fairly isolated and rare but are now widespread throughout the world are AIDS and drug-resistant TB (Institute of Medicine [IOM], 2010b; U.N. Global Health Report, 2013d) (Figure 4-1). image FIG 4-1 Open market in Uganda, where preventable diseases are rampant. (Courtesy A. Hunter.) In addition to direct health problems, increasing populations, migration within countries, political corruption, lack of natural resources, and natural disasters affect the health and well-being of populations. Dr. Paul Farmer in his book Pathologies of Power (2005) talks about the war on the poor; how many migrate to the city to find employment, where limited employment opportunities exist. Such migration leads to the development of shanty towns often built on the outskirts of cities, on unstable ground, and in areas vulnerable to natural disasters such as hurricanes, tsunamis, and earthquakes such as those in Haiti, Chile, and Indonesia. These environments are unsanitary, unsafe, and a breeding ground for TB, dysentery, malnutrition, abuse of women and children, and mosquito and other insect or animal-borne diseases. Nations plagued by civil war and political corruption are faced with chronic poverty, unstable leadership, and lack of economic development. The effects of war and conflict also have devastating effects on a country and the health of its population. The wars in Afghanistan, Iraq, and the West Bank of Palestine, to name a few, have had devastating mental and physical health consequences, leaving each country and its people with few health care services or other resources to sustain life. A recent research study about the long-term effects of children exposed to war (Asia, 2009) supports the negative health consequences of such exposure. For example, changes in biomarkers can lead to future chronic health conditions such as cardiovascular disease, autoimmune conditions, cancer, and mental health problems. As countries promote the objectives of HFA21, they realize that they need to improve their economies and infrastructures. They often seek funds and technological expertise from the wealthier and more-developed countries (World Bank, Concessional Finance and Global Partnership Report, 2013a). According to the WHO (2013c), HFA21 is not a single, finite goal but a strategic process that can lead to progressive improvement in the health of people. In essence, it is a call for social justice and solidarity. Unfortunately, the lesser-developed nations still lack the infrastructure necessary to achieve health promotion and living conditions, as many of these countries continue to deteriorate for the poor, and environments that breed infections are the norm (Figure 4-2). image FIG 4-2 The streets of a typical town in Uganda. (Courtesy A. Hunter.) The UN Millennium Development Goals (MDGs) were first agreed on by world leaders at the Millennium Summit in 2000 (see Resource Tool 4.A on the book’s Evolve site). The MDGs were developed to relieve poor health conditions around the world and to establish positive steps to improve living conditions by the year 2015 (UN, 2013a; see goals in Box 4-1). 65These goals have continued to evolve as natural disasters and internal strife continue to affect the poor and the vulnerable. The Millennium Report (UN Millennium Development Report, 2013a) describes the developed nations’ responsibility to the betterment of those in lesser-developed nations. The revised goals highlight the global responsibility to eradicate poverty and hunger; achieve universal primary education for all children; promote gender equality and empower women; reduce child mortality; improve maternal health; combat HIV/AIDS, malaria, and other diseases; ensure environmental sustainability; and develop a global partnership for development. Unfortunately, the 2013 report indicated that one in eight people worldwide remains hungry; death in childbirth is still a major problem; more than 2.5 billion people still lack improved sanitation facilities; and climate change has caused the loss of forests, species and fish stocks. The United States supports the Millennium Development Goals in its Global Health Initiatives (www.ghi.gov Accessed December 20, 2014) as has the ICN. Continued work to develop economic agreements between countries so as to remove financial and political barriers has stimulated growth and development; but, is it enough? Box 4-1 Millennium Goals Millennium Development Goals MDG 1: Eradicate extreme poverty and hunger. MDG 2: Achieve universal primary education. MDG 3: Promote gender equality and empower women. MDG 4: Reduce child mortality. MDG 5: Improve maternal health. MDG 6: Combat HIV/AIDS, malaria, and other diseases. MDG 7: Ensure environmental sustainability. MDG 8: Develop a global partnership for development. From United Nations: UN millennium development goals (MDGs). 2005. Available at http://www.un.org/millenniumgoals/. Accessed August 25, 2014. Despite efforts by individual governments and international organizations to improve the general economy and welfare of all countries, many health problems continue to exist, especially among poorer people. Many countries lack both political commitment to health care and recognition of basic human rights. They may fail to achieve equity in access to primary health care, demonstrate inappropriate use and allocation of resources for high-cost technology, and maintain a low status of women. At present, the lesser-developed countries experience high infant and child death rates (http://gamapserver.who.int/gho/interactive_charts/MDG4/atlas.html), with diarrheal and respiratory diseases as major contributory factors (under-five and infant mortality rates, by WHO region; WHO, 2013d). Other major worldwide health problems include nutritional deficiencies in all age groups, women’s health and fertility problems, sexually transmitted infections (STIs), and illnesses related to the human immunodeficiency virus (HIV), malaria, drug-resistant TB, neonatal tetanus, leprosy, occupational and environmental health hazards, and abuses of tobacco, alcohol, and drugs. Because of these continuing problems, the director general of the WHO has made a commitment to renew all of the policies and actions of HFA21. The WHO (2013c) continues to develop new and holistic health policies that are based on the concepts of equity and solidarity, with an emphasis on the individual’s, family’s, and community’s responsibility for health. Strategies for achieving the continuing goals of HFA21 include building on past accomplishments and the identification of global priorities and targets for the first 20 years of the new century. Nurses need to be informed about global health. Many of the world’s health problems directly affect the health of individuals who live in the United States. For example, the One Hundred Third U.S. Congress passed the North American Free Trade Agreement (NAFTA), which opened trade borders between the United States, Canada, and Mexico in 1994 and allowed increased movement of products and people. Along the United States–Mexico border, an influx of undocumented immigrants in recent years has raised concerns for the health of people who live in this area. For example, many immigrants have settled on unincorporated land, known as colonias, outside the major metropolitan areas in California, Arizona, New Mexico, and Texas. These colonies may have no developed roads, transportation, water, or electrical services (U.S. Geological Survey [USGS]: U.S.–Mexico Border Environmental Health Report, 2011) (Figures 4-3 and 4-4). image FIG 4-3 A community living in a dump in Miacatlán, Mexico. (Courtesy A. Hunter.) image FIG 4-4 Diseases in the colonias. (From PBS Online, The Forgotten Americans. Available at http://www.pbs.org/klru/forgottenamericans/focus/health.htm and http://abcnews.go.com/US/hidden-america-forgotten-struggle-survive-texas-barren-colonias/story?id=16213828 and http://www.cinelasamericas.org/special-events/1060-the-forgotten-americans-a-film-by-hector-galan (Accessed March 20, 2014).) Conditions in these settlements have led to an increase in disease conditions such as amebiasis and respiratory and diarrheal diseases. Environmental health hazards in the colonias are associated with poverty, poor sanitation, and overcrowded conditions (USGS: U.S.–Mexico Border Environmental Health Report, 2011). On a more positive note, NAFTA has provided an impetus and framework for the government of Mexico to modernize their medical system so that they can compete and respond to the demands of more global competition. Although some improvements have been made, there is still an overriding concern that environmental and health regulations in Mexico have not kept up with the pace of increased border trade (California Department of Public Health, Office of Binational 66Border Health, Border Health Status Report, 2011). The Mexican National Academy of Medicine continues to make health and environmental recommendations to the government, which illustrates the beneficial interactions that are occurring between Mexico, Canada, and the United States as part of this trade agreement. Nurses play a significant role in obtaining health for the indigent and undocumented persons who live along the border regions in Texas, New Mexico, Arizona, and California. Nurses supported by private foundations and by local and state public health departments often provide the only reliable health care in these areas. Interestingly, Canadian worker groups were concerned that NAFTA would eventually lead to worsened working conditions as manufacturing plants move to the lower-wage and largely non-unionized southern United States and Mexico; however, reports indicate that trade, standard of living, and employment opportunities have risen (Ibbitson, 2012). The Role of Population Health Population health refers to the health outcomes of a group of individuals, including the distribution of such outcomes within the group, and includes health outcomes, patterns of health determinants, and policies and interventions that link these two. It is an approach and perspective that focuses on the broad range of factors and conditions that have a strong influence on the health of populations (environment, genetics, ethnicity, pollution, and physical and mental stressors affecting a community). Using epidemiologic trends, population health emphasizes health for groups at the population level rather than at the individual level and focuses on reducing inequities, improving health in these groups to reduce morbidity and mortality, and assessing emerging diseases and other health risks to a community (IOM, 2010a). A population can be defined by a geographic boundary, by the common characteristics shared by a group of people such as ethnicity or religion, or by the epidemiologic and social conditions of a community. The factors and conditions that are important considerations in population health are called determinants. Population health determinants may include income and social factors, social support networks, education, employment, working and living conditions, physical environments, social environments, biology and genetic endowment, personal health practices, coping skills, healthy child development, health services, sex, and culture (WHO, Health Impact Assessment, 2014a). The determinants do not work independently of each other but form a complex system of interactions. Canada is a leader in promoting the population health approach. Canada has been implementing programs using this framework since the mid-1990s and builds on a tradition of public health and health promotion. Box 4-2 presents the development of the Healthy Cities movement in Toronto. This successful project has been adopted by the WHO and is being implemented in several countries around the world—most specifically Europe, Southeast Asia, Africa, and the Western Pacific 67(WHO, Healthy Cities, 2014b). A key to the success of this project has been the identification and definition of health issues and of the investment decisions within a population that were guided by evidence about what keeps people healthy. Therefore a population health approach directs investments that have the greatest potential to influence the health of that population in a positive manner. A Healthy City aims to create a health-supportive environment, achieve a good quality of life, provide basic sanitation and hygiene needs, and supply access to health care. The most successful Healthy Cities programs have a commitment of local community members, a clear vision, ownership of policies, a wide array of stakeholders, and a process for institutionalizing the program. Box 4-2 Examples of the Healthy Cities Movement Toronto, Ontario, Canada was one of the first cities in North America to become involved in the Healthy Cities movement. Toronto began with a strategic planning committee to develop an overall strategy for health promotion. The committee conducted vision workshops in the community and a comprehensive environmental scan to help identify health needs in Toronto. The outcome was a final report outlining major issues, and it included a strategic mission, priorities, and recommendations for action. The Toronto Healthy City program involved a number of projects. One of them, the Healthiest Babies Possible project, was an intensive antenatal education and nutritional supplement program for pregnant women who were identified by health and social agencies as being at high risk. The program included intensive contact and follow-up of women, along with food supplements. It has been successful in decreasing the incidence of low-birth-weight infants. Another example is Chengdu, China. Chengdu is located on the upper parts of the Yangtze River. It is surrounded on four sides by the Fu and Nan Rivers and was one of the most polluted cities in southwestern China. The pollution created severe environmental problems as a result of industrial waste, raw sewage, and the intensive use of fresh water. The proliferation of slum and squatter settlements exacerbated the social, economic, and environmental problems of the city. The Fu and Nan Rivers Comprehensive Revitalization Plan was started in 1993 as a Healthy Community and City initiative to deal with the growing environmental problems. The principles of participatory planning and partnership were used to raise awareness of the problem among the general public and to mobilize major stakeholders to invest in a sustainable future for Chengdu and its inhabitants. The plan resulted in providing 30,000 households living in the slum and squatter settlements with decent and affordable housing, and with projects to deal with sewage and industrial waste. In addition, the plan was able to improve parks and gardens, turning Chengdu into a clean and green city within the natural flow of its rivers. From Flynn B, Ivanov L: Health promotion through healthy communities and cities. In Community & Public Health Nursing, ed 6, St. Louis, 2004, Mosby, pp 396–411. Integration of health determinants into public policies is apparent on the global stage. At the 2009 Nairobi Global Conference on Health Promotion, more than 600 participants representing 100 countries adopted a Call to Action on addressing population health and finding ways to promote health at the global level. Health and development today face unprecedented threats by the financial crisis, global warming and climate change, and security threats. Since 1986, with the development of the first Global Conference, until 2009, a large body of evidence and experience has accumulated about the importance of health promotion as an integrative, cost-effective strategy, and as an essential component of health systems primed to respond adequately to emerging concerns (WHO, 2010a, 2014c). As nurses work with immigrants from global arenas or become active participants in health care around the world, understanding such concepts as population health and the determinants of health for a population becomes more important than the most advanced acute care skills. These skills, though important, are intended to help an individual; population health skill sets can help the world. Primary Health CARE The ultimate goal of primary health care (PHC) is to achieve better health for all. WHO (2014c) has identified five key elements to achieving that goal: 1. Reducing exclusion and social disparities in health 2. Organizing health services around people’s needs and expectations 3. Integrating health into all sectors 4. Pursuing collaborative models of policy dialogue 5. Increasing stakeholder participation These aims continue to be reinforced and modified and were recently updated to incorporate MDGs (WHO, 2014c). Such services included the following: • An organized approach to health education that involves professional health care providers and trained community representatives • Aggressive attention to environmental sanitation, especially food and water sources • Involvement and training of community and village health workers in all plans and intervention programs • Development of maternal and child health programs that include immunization and family planning • Initiation of preventive programs that are specifically aimed at local endemic problems such as malaria and schistosomiasis in tropical regions • Accessibility and affordability of services for the treatment of common diseases and injuries • Availability of chemotherapeutic agents for the treatment of acute, chronic, and communicable diseases • Development of nutrition programs • Promotion and acceptance of traditional medicine Global leaders have recognized the need to get nations committed to the health care agenda. An important effort is needed at the level of recruitment, education, and retention of primary health care workers, including primary care nurses, family physicians, and mid-level care workers. Professional organizations, clinical agencies, universities, and other institutions for higher education should continue to demonstrate their “social accountability” by training appropriate providers. It is well documented that PHC practiced in high-income countries exerts a positive influence on health costs, appropriateness of care, and outcomes for most of the major health indicators. They also have more equitable health outcomes than systems oriented toward specialty care. In low and middle income countries the research studies did find consistent evidence of the impact of PHC on improved health outcomes; however, there were problems with the research rigor and validity of instrumentation to make any further statement than that health outcomes did improve. Nursing and Global Health Nurses play a leadership role in health care throughout the world. Those with public health experience provide knowledge and skill in countries where nursing is not an organized profession, and they give guidance to the nurses as well as to the auxiliary personnel who are part of the primary health care team (Bryar et al, 2012). In many areas in the developed world, nurses provide direct client care and help meet the education and health promotion needs of the community. They are viewed as strong advocates for primary health care, through social commitment to equality of health care and support of the concepts that are contained in the Declaration of Alma-Ata (Bryar et al, 2012). Unfortunately, in the lesser-developed countries, the role of the nurse is defined poorly, if at all, and care often depends on and is directed by physicians. I have seen health care systems in Africa, Mexico, and the Dominican Republic in which nursing is not valued and the ability of nurses to contribute to improving an individual’s health, much less a community’s health, is minimal. Much work is needed to raise the bar in the education of nurses in these countries so they have the skills necessary to make a difference; however, overcoming some of the cultural and gender-role barriers makes this process laborious (Figure 4-5). image FIG 4-5 Uganda hospital information for nurses assisting in labor and delivery. (Courtesy A. Hunter.) Nurses have led in care delivery after the devastating tsunami in South Asia, and more recently after the earthquakes in Haiti and Chile in 2010. Other health interventions have been the interprofessional work of nursing and science to build and open a dedicated children’s hospital in Uganda (Bolender and Hunter, 682010; Bolender, McDonald and Hunter, 2013), the nurse-developed Ghana Health Mission (Hunter and McKenry, 2005; https://ghanahealthmission.wordpress.com/), a nurse-led chronic illness management program in Thailand (Sindhu et al, 2010), and a nurse-led mental health program for Chinese patients (Chien et al, 2012) are just a few examples of nurse-initiated health programs around the globe. The role of nursing in China and Taiwan is noteworthy. Nursing in China is undergoing a dramatic change, largely because of an evolving political and economic environment. In the past, nursing was viewed as a trade, and the acquisition of nursing skills and knowledge took place in the equivalent of a middle school or junior high school in the United States. Increasing pressure on the health care system in China is providing an impetus for education at the university level. The Chinese government has sent many nurses to the United States, Europe, and Australia to receive university-level education in nursing at the undergraduate and graduate levels in hopes that these individuals will return to China to provide the nursing and nursing education needed there; but very few do, and a recent poll in China indicated that if the nurses could leave China to practice elsewhere, they would (Global Times, 2011). I, in conjunction with a colleague (Dr. Mary Jo Clark), have consulted in Taiwan, helping them establish their nurse practitioner programs and to implement their doctoral programs in nursing. Part of that consultation involved the use of standardized clients as a component for certification and license to practice as a nurse practitioner. The United States has entertained this idea. In some countries, such as Chile, the physician-to-population ratio is higher than the nurse-to-population ratio. In these cases, physicians influence nursing practice and place economic and political pressure on local, regional, and national governments to control the services that nurses provide. In Chile, nurses have set up successful and cost-effective clinics to deliver quality primary care services. However, the nurses often are being threatened by physicians who want to remove the nurses and replace them with the more costly services of physicians (Organization for Economic Cooperation and Development [OECD], Health at a Glance, 2011). Box 4-3 describes nursing and health care efforts in Zambia. Box 4-3 Community Health Nursing in Zambia The Ministry of Health, Churches Health Association, the private Medical Practitioners, and the Traditional Healer Services provide health care in Zambia. By 1995 there were 86 hospitals and 1345 health centers in the country. About 60% of the bed capacity is provided by the government hospitals and health centers, 26% by mission hospitals, and 13% by the Zambia Consolidated Copper Mines. At the time of independence, the population of Zambia was sparsely distributed, especially in the rural area, and there were inadequate health facilities. Health facilities were concentrated along the line of rail, and the provision of care was poor. This prompted the government to review the health care provision system after independence in 1964. The government then declared that health care services would be free for all, with the main health care services being curative rather than preventive. This policy was detrimental to Zambia, whose population was increasing. In 1991 the government of the Republic of Zambia, under the leadership of the Movement for Multiparty Democracy, introduced the concept of National Health Reforms, the vision being to provide equitable access to high-quality, cost-effective health care intervention as close to the family as possible. Health reforms stress the need for families and communities to be self-reliant and to participate in their own health care provision and development. The major component of the health policy reform is the restructured primary health care (PHC) program. This has been defined as the essential health care made universally accessible to individuals and families by means acceptable to them through their full participation and at a cost that the community and country can afford. The principles of PHC include community participation and intersectoral collaboration. Families are considered a unit of service, as most health care provision starts with the family setting. The Zambian government is committed to the fundamental and humane principle in the development of the health care system to provide Zambians with the equity of access to cost-effective quality health care as close to the family as possible. The National Health Reforms decentralized power to districts, and home-based care (HBC) was introduced. HBC was adopted and implemented in all districts as a way of cost sharing between the government, families, and community. HBC led to reduced congestion in hospitals, and government resources were not overstrained as families also took part in supplying the needed resources, time, and personnel (caregivers) when the clients were cared for at home. Nurses provide about 75% of the health force in Zambia. The community health nursing component is one of the major components of the nursing curriculum at all levels of training. Basically, every general nurse is taught to operate as a community health nurse. However, to be registered as a public health nurse by the General Nursing Council of Zambia, one must undergo the following levels of training. The individual undergoes 3 years of training as a registered nurse followed by 1 year of training as a midwife. In the past they would then undergo 2 years of training at the University of Zambia to obtain a diploma in public health nursing. This was phased out when the bachelor of science in nursing degree was initiated. At present, the individual pursues the bachelor of science in nursing degree and majors in community health nursing in the final year. The main role of the community health nurse includes competence and skill in the care of individuals, families, and communities in the following ways: 1. Critically explore and analyze current developments in community health as they relate to different populations at different levels of care. 2. Apply health promotion models and theories to community health nursing practice. 3. Design, implement, and manage community-based projects, programs, and services. 4. Integrate community-based agents into the health care system. 5. Use epidemiology concepts in the management of communicable and noncommunicable diseases. Courtesy Prudencia Mweemba, University of Zambia, School of Medicine, Department of Post Basic Nursing, Lusaka, Zambia, 2006. Several nursing initiatives from the United States have been developed to help address some of these global health problems. According to Sheila Davis, ANP-BC, FAAN, Director of Global Nursing, Partners in Health, the Dana Farber Cancer Institute has supported the creation of a nursing oncology partnership with Inshuti Mu Buzima (IMB) in Rwanda. Four experienced oncology nurses have committed to working alongside local nurses and physicians at IMB for 3-month rotations, to help Rwandan nurses develop the specialized skills and experience needed to raise the quality of oncology care. Another is Regis College in Massachusetts, which has partnered with the Haitian Ministry of Health to tackle the nursing education shortage in Haiti by developing a comprehensive 3-year master’s program for 12 Haitian nursing faculty members. Another is out of the University of San Diego, in collaboration with the Holy Innocents Children’s Hospital in Uganda. Nurses and physicians have been actively involved in building the first children’s hospital in the country and training the staff in pediatric care. A new entry into this global nursing arena is the development of the Global Nurse Initiative, a nonprofit organization that links health professionals with opportunities to volunteer in underprivileged areas (Global Nurse Initiative, 2013). Major Global Health Organizations Many international organizations have an ongoing interest in global health. Despite the presence of these well-meaning 69organizations, it is estimated that the less developed countries still bear most of the cost for their own health care and that contributions from major international organizations actually provide for less than 5% of needed costs. Recent reports indicate that the majority of funds raised by international organizations are used for food relief, worker training, and disaster relief (Shah, 2012; World Food Program, 2014). Shah (2012) reports that aid is often wasted by requiring recipients to use overpriced goods and services from donor countries; most aid does not go to the country in greatest need as aid is often used in order for the richer country to get their foot in the door of the poorer country to access its resources; and graft is still a major problem in developing countries—promised monies are funneled into the pockets of the local politicians who were chosen to help the people. International health organizations are classified as multilateral organizations, bilateral organizations, or nongovernmental organizations (NGOs) or private voluntary organizations (PVOs) (including philanthropic organizations). Multilateral organizations are those that receive funding from multiple government and nongovernment sources. The major organizations are part of the United Nations (UN), and they include the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the Pan American Health Organization (PAHO), and the World Bank. A bilateral organization is a single government agency that provides aid to less developed countries, such as the U.S. Agency for International Development (USAID). NGOs or PVOs, including the philanthropic organizations, are represented by such agencies as Oxfam, Project Hope, the International Red Cross, various professional and trade organizations, Catholic Relief Services (CRS), church-sponsored health care missionaries, and many other private groups. Specifically, the World Health Organization (WHO) is a separate, autonomous organization that, by special agreement, works with the United Nations through its Economic and Social Council. The idea for this worldwide health organization developed from the First International Sanitary Conference in 1902, a precursor to the WHO. The WHO was created in 1946 as an outgrowth of the League of Nations and the UN charter that provided for the formation of a special health agency to address the wide scope and nature of the world’s health problems. The WHO, headed by a director general and five assistant generals, has three major divisions: (1) the World Health Assembly approves the budget and makes decisions about health policies, (2) the executive board serves as the liaison between the assembly and the secretariat, and (3) the secretariat carries out the day-to-day activities of the WHO. The principal work of the WHO is to direct and coordinate international health activities and to provide technical medical assistance to countries in need. 70More than 1000 health-related projects are ongoing within the WHO at any one time. Requests for assistance may be made directly to the WHO by a country for a project, or the project may be part of a larger collaborative endeavor involving many countries. Examples of current collaborative, multinational projects include comprehensive family planning programs in Indonesia, Malaysia, and Thailand; applied research on communicable disease and immunization in several East African nations; and projects that investigate the viability of administering AIDS vaccines to pregnant women in South Africa and Namibia. For further information about the WHO, visit http://www.who and find the tab such as publications, countries, programmes, or health topics that meets your need. The WHO has supported the development of multiple health training programs for professionals in developing nations. An example of one is the Tanzania Nurse Initiative, which has been successful in strengthening nursing education in Tanzania by educating 415 nurses in HIV/AIDS prevention, care, and treatment; providing technical assistance and support on curriculum development and revision; and providing support to Tanzanian nursing schools (Global Health Workforce Alliance, 2014). Another multilateral agency is the United Nations Children’s Fund (UNICEF) (http://www.unicef.org). Formed shortly after World War II (WWII) to assist children in the war-ravaged countries of Europe, it is a subsidiary agency to the UN Economic and Social Council. After WWII, many social agencies realized that the world’s children needed medical and other kinds of support. With financial assistance from the newly formed UN General Assembly, post-WWII programs were developed to control yaws, leprosy, and TB in children. Since then, UNICEF has worked closely with the WHO as an advocate for the health needs of women and children under the age of 5. In particular, there have been multinational programs aimed at the provision of safe drinking water, sanitation, education, and maternal and child health. The Pan American Health Organization (PAHO) is one of the oldest continuously functioning multilateral agencies, founded in 1902, and predates the WHO. At present, PAHO serves as a regional field office for the WHO in Latin America, with a focused effort to improve the health and living standards of the Latin American countries. PAHO distributes epidemiologic information, provides technical assistance over a wide range of health and environmental issues, supports health care fellowships, and promotes health and environmentally related research, along with professional education. Focusing primarily on reaching people through their communities, PAHO works with a variety of governmental and nongovernmental entities to address the health issues of the people of the Americas. At present, a primary concern of PAHO is the prevention and control of AIDS and other sexually transmitted diseases amongst the most vulnerable: mothers and children, workers, the poor, older adults, refugees, and displaced persons. With the earthquakes in Haiti and Chile, and the drought and starvation in Guatemala, PAHO’s attentions are being directed toward crisis intervention (http://www.paho.org). Other focused efforts include the provision of public information, the control and eradication of tropical diseases, and the development of health system infrastructure in the poorer Latin American countries. PAHO collaborates with individual countries and actively promotes multinational efforts as well. Recently, PAHO has examined the effects of health care reform on nurses and midwifery in the Latin American countries and found that the reform changed the work environments, the scope of practice, and the relationship of nurses with other health care workers and providers. The role of PAHO in the development of healthy communities is discussed in Chapter 20. The World Bank (http://www.worldbank.org) is another multilateral agency that is related to the United Nations. Although the major aim of the World Bank is to lend money to the less developed countries so that they might use it to improve the health status of their people, it has collaborated with the field offices of the WHO for various health-related projects such as the control and eradication of the tropical disease onchocerciasis in West Africa, as well as programs aimed at providing safe drinking water and affordable housing, developing sanitation systems, and encouraging family planning and childhood immunizations. The World Bank also sponsors programs to protect the environment, as reflected by the $30 million project in Brazil to protect the Amazon ecosystem and reduce the effects on the ozone layer; to support people in less developed countries to pursue careers in health care; and to improve internal infrastructure, including communication systems, roads, and electricity, all of which ultimately affect health care delivery. Bilateral agencies operate within a single country and focus on providing direct aid to less developed countries. The U.S. Agency for International Development (USAID) (http://www.usaid.gov) is the largest of these and supports long-term and equitable economic growth and advances U.S. foreign policy objectives by supporting economic growth, agriculture, and trade; global health; and democracy, conflict prevention, and humanitarian assistance. It provides assistance in five regions of the world: sub-Saharan Africa, Asia, Latin America and the Caribbean, Europe and Eurasia, and the Middle East. All bilateral organizations are influenced by political and historical agendas that determine which countries receive aid. Incentives for engaging in formal arrangements may include economic enhancements for the benefit of both countries, national defense of one or both countries, or the enhancement and protection of private investments made by individuals in these nations. Something similar is present in other developed nations around the globe. For example, the Japanese government currently has an active collaborative arrangement with Indonesia to study ways to control the spread of yellow fever and malaria. France gives most of its aid to its former colonies. Nongovernmental organizations (NGOs) or private voluntary organizations (PVOs), as well as philanthropic organizations, provide almost 20% of all external aid to less developed countries. NGOs and PVOs are represented by many different kinds of religious and secular groups. Representatives of these independent citizen organizations are increasingly active in policymaking at the United Nations. These organizations are often the most effective voices for the concerns of ordinary 71people in the international arena. NGOs include the most outspoken advocates of human rights, the environment, social programs, women’s rights, and more (Kaiser Family Foundation, 2010). An example of an NGO is the Holy Innocents Children’s Hospital in Mbarara, Uganda (http://www.holyinnocentsuganda.com) (the result of a nurse-led initiative and a U.S.-based NGO that acquired the funds, built the hospital, trained the staff, and then turned it over to the Ugandans to operate and expand) is a 50-bed dedicated children’s hospital that since its opening in 2009 has cared for more than 100,000 children. Its mortality rate is one quarter that of the local government hospital because the goal of the hospital was to save lives and to have available the necessary supplies to achieve this goal. The administrative and professional staff training has helped this hospital be self-sustaining with minimal continued assistance from the U.S.-based NGO and its donors. The International Red Cross (http://www.icrc.org) is one of the best-known NGOs. Although the Red Cross is most often associated with disaster relief and emergency aid, it lays the groundwork for health intervention as a result of a country’s emergency. It is a volunteer organization that consists of approximately 160 individual Red Cross societies around the world, and it prides itself on its neutrality and impartiality with respect to politics and history. Therefore, it seeks permission from the country in which the disaster occurs before services are rendered. Another NGO that provides health services and aid to countries experiencing warfare or disaster is Médecins sans Frontières (MSF) (http://www.msf.org), also home of Doctors without Borders. It is an international, independent, medical humanitarian organization that delivers emergency aid to people affected by armed conflicts, epidemics, health care exclusion, and natural or man-made disasters. Unlike the Red Cross, MSF does not seek government approval to enter a country and provide aid and it often speaks out against observed human rights abuses in the country it serves. MSF was the recipient of the Nobel Peace Prize in 1999 and the Conrad Hilton Prize in 1998. In Uganda, Doctors without Borders is involved with the local medical school in Mbarara to help develop an intensive malaria intervention approach to help improve the survival rate of children affected by cerebral malaria (personal communication with Dr. Bitariho Deogratias, Professor of Orthopedics at Mbarara Science and Technology University School of Medicine, January 2013). The professional and trade organizations are PVOs that are found mostly in the more developed and industrialized countries. One of the most famous of the professional and technical organizations is the Institut Pasteur (http://www.pasteur.fr/ip/easysite/pasteur/en/institut-pasteur), which began in the 1880s. Its laboratories have facilitated the development of sera and vaccines for countries in need, disseminated current health information, and trained and provided fellowships for medical training and study in France. They have facilities in Africa, South and Central America, and Southeast Asia. Religious organizations, reflecting several denominations and religious interests, support many health care programs, including hospitals in rural and urban areas, refugee centers, orphanages, and leprosy treatment centers. For example, the Maryknoll Missionaries, sponsored by the Roman Catholic Church, carry out health service projects around the world. The missionaries comprise a large group of religious as well as lay people trained and educated in a variety of educational and health care professions. The Catholic Relief Services (CRS) (http://crs.org) is the official international humanitarian agency of the Catholic community in the United States. CRS alleviates suffering and provides assistance to people in need who are affected by war, starvation, famine, drought, and natural disasters, in more than 100 countries, without regard to race, religion, or nationality. Many Protestant and evangelical groups throughout the world function both as separate entities and as part of the Church World Service, which works jointly with secular organizations to improve health care, community development, and other needed projects. Other private and voluntary groups that assist with the worldwide health effort include CARE (http://www.care.org), Oxfam (www.oxfam.org.uk), and Third World First. Several of these organizations receive additional funding from developed countries including the United States, the United Kingdom, Sweden, Canada, and countries in Western Europe. Philanthropic organizations receive funding from private endowment funds. A few of the more active philanthropic organizations that are involved in world health care include the W. K. Kellogg Foundation, the Milbank Memorial Fund, the Pathfinder Fund, the Hewlett Foundation, the Ford Foundation, the Rockefeller Foundation, the Carnegie Foundation, and the Gates Foundation. The purpose and programmatic goals of each organization differ widely with respect to funding, and their purposes often change as their governing boards change. Some of the worldwide health care activities that have been sponsored in the past include projects in public and preventive health; vital statistics; medical, nursing, and dental education; family planning programs; economic planning and development; and the formation of laboratories to investigate communicable diseases. Many private and commercial organizations such as Nestlé and the Johnson & Johnson Company provide financial and technical backing for investment, employment, and access to market economies and to health care. Although these organizations have been present throughout the world for more than 30 years, they have come under criticism for the promotion and marketing of infant formulas, pharmaceuticals, and medical supplies, especially to lesser-developed countries. The intense marketing that is done in these countries is known as commodification, turning health care into a business with clients as consumers and health care professionals from altruistic healers to business technicians. Breast cancer awareness is the best known of these practices in the United States (http://www.theguardian.com/commentisfree/2012/oct/03/pinkification-breast-cancer-awareness-commodified). There is global controversy as to the legitimacy of commodification. For example, in the sentinel article by Segal, Demos, and Kronenfeld (2003) the health commodification of pharmaceuticals in southern India was a concern because the companies gave little consideration to the cultural and social 72structure of the country, thus interfering with the long-standing traditional Indian medical system. In southern India, good health and prosperity are related to certain social parameters bestowed to families and communities as a result of their conformity to the socio-moral order that was established by their ancestors, gods, and patron spirits. The taking of pharmaceutical agents thus disrupts the social and cultural order of things that have been traditionally addressed by cultural practices. Information about volunteering for many NGOs and PVOs can be obtained from the Internet web sites included in the text. Nurses have developed global initiatives, participate in global health projects, and lead global health organizations such as Doctors without Borders. Becoming a global citizen is the responsibility of all (http://www.globalnurseinitiative.org/). Global Health and Global Development Global health is not just a global public health agenda; it does not begin and end with the individual; it must consider all factors within a country that affect health, such as environment, education, national and local policies, health care and access to health care, economics (importing and exporting of goods, industry, technology), war, and public safety. This paradigm shift is called global health diplomacy, which refers to multilevel and multifactor negotiation processes involving environment, health, emerging diseases, and human safety. It is now recognized that to solve global health problems, one must build capacity for global health diplomacy by training public health professionals and diplomats, respectively, to prevent the imbalances that emerge between foreign policy and public health experts and the imbalances that exist in negotiating power and capacity between developed and developing nations (Hunter et al, 2013). The cutting edge of global health diplomacy raises certain cautions regarding health’s role in trade and foreign policies. Unfortunately, securing health’s fullest participation in foreign policy does not ensure health for all, but it supports the principle that foreign policy achievements by any country in promoting and protecting health will be of value to all (Hunter et al, 2013). Nurses cannot think in isolation about health for the global population; they must think more broadly to achieve their goals through a multidisciplinary, multilevel approach involving such dimensions as economic, industrial, and technological development. An example of this global health diplomacy approach, developed by the author and her colleagues, is the Uganda Project. What began as a simple request to help a community in Uganda save the lives of children dying unnecessarily from preventable diseases has turned into a sustainable community development project. Serving as consultants to an NGO, led by the school of nursing at the University of San Diego, and working collaboratively with the departments of environmental science and business, students and faculty have provided volunteer service and consultation to the people of Mbarara, Uganda on the building, implementation, and sustainability of a children’s hospital in their community. Such consultation involved addressing the training of health care professionals on pediatric care and lay health educators to help improve the health of the community; assessing and intervening on water quality issues affecting public health; and assessing and making recommendations for business ventures that could help support the fiscal sustainability of the hospital and improve the economics of the community. It is hoped that future projects will include faculty and students from the school of peace studies to help the community learn how to deal with conflict and social justice issues and the school of education to help support the teacher training that might better serve the education of the children (Bolender and Hunter, 2010). Access to services and the removal of financial barriers alone do not account for the public’s use of health services. In fact, the introduction of health care technology from developed countries to less developed countries has led to less-than-satisfactory results. For example, equipment donated to the Holy Innocents Children’s Hospital (HICH) in 2009-2012 has not been as usable as the donors had hoped because of the significant difference in power voltage necessary to run the machines; power outages in Uganda with secondary power surges, which have burnt out the equipment’s power components; and power outages requiring the use of a gas generator, which may or may not produce enough power to effectively run the machines (personal communication with John Baptist Mujuni, HICH administrator, January 2012). The World Bank reported that during the 1980s in an eastern Mediterranean country, two thirds of the high-output x-ray machines were not in use because of a lack of qualified and trained individuals to carry out routine maintenance and repairs. Even in Uganda, there are minimal qualified technicians to repair broken x-ray units, rebreathing units for the neonatal intensive care unit (NICU) area, and EKG machines for monitoring the critically ill children (personal communication with John Baptist Mujuni, HICH administrator, January 2012). Countries devastated by war have lost their total infrastructure for food, trade, social justice, health, water, and public security as evident today in Afghanistan, the West Bank, Gaza, Darfur, Syria, and other war-torn countries. When implementing services for less developed nations, it is essential to conduct needs assessments to learn what a community has, what a community wants, and what it can sustain. Quite simply, well-intended projects can fail because first, the project served the purpose of the donors and not the needs of the people; second, because no assessment was done to ascertain what resources the country had and what services the country could sustain. When projects are developed that pay attention to the intent of global health diplomacy, then there is improvement in the overall health status of a population, which secondarily can contribute to the economic growth of a country in several ways (WHO, 2013c): • Reduction in production loss caused by workers who are absent from work because of illness • Increase in the use of natural resources that, because of the presence of disease entities, might have been inaccessible • Increase in the number of children who can attend school and eventually participate in their country’s economic growth • Increase in monetary resources, formerly spent on treating disease and illness, now available for the economic development of the country 73 Because the economics of international development are complex, it is often difficult to convince governments to direct their resources away from perceived needs such as military and technology and, instead, place resources in health and educational programs. Ideally, the role of the more-developed countries is to assist less developed countries to identify internal needs and to support cost-efficient measures and share their technology and industrial expertise. It is important that nurses who work in international communities acknowledge the importance of global health diplomacy and its various parameters: culture, politics, economics, technology, public health, social justice, foreign policy, and public safety. Provision of health services alone will not ease a country’s health care plight (Figure 4-6). image FIG 4-6 “NICU” in a local Ugandan community hospital: one oxygen concentrator and one suction machine. (Courtesy A. Hunter.) Health Care Systems The countries of the world present many different kinds of health care systems. Most consist of the population to be served, health care providers, third-party payers, health care facilities, and those who control access and usability of the system (Shakarishvili et al, 2010). Understanding some of these principles is highlighted when one compares the health care systems in the Netherlands, Mexico, Uganda, Ecuador, the United Kingdom, and China. For more information on the lists of countries and the per capita expenditures on health care, please see the report at http://dpeaflcio.org/the-u-s-health-care-system-an-international-perspective/. The Netherlands In the Netherlands, under a health policy reform movement in 2006, residents are required to purchase health insurance, which is provided by private health insurers (for-profit or nonprofit) that compete for business. Everyone must be insured and the insurers are required to accept every resident in their coverage area, regardless of preexisting conditions. The government provides larger subsidies to insurers for participants who are sicker, are elderly, or have preexisting conditions. Tax credits are given to low-income clients to help them purchase insurance. People under age 18 are insured at no cost. There is a separate universal national social insurance program for long-term care, known as the AWBZ, or Exceptional Medical Expenses Act. Insurers offer a choice of policies at a range of costs. In some of the plans, the insurer negotiates and contracts with the health provider, whereas more costly plans allow clients to choose their health provider and be reimbursed by the insurer. The insured also pay a flat-rate premium to their insurer for a policy. Everyone with the same policy pays the same premium, and lower-income residents receive a health care allowance from the government to help make payments (Daley and Gubb, 2013). Mexico Mexico has a fractionalized system with a variety of public programs. There is no universal coverage, but a social security–administered system does cover those who are employed. The private insurance market is used mostly by wealthy residents. The Seguro Popular program, created in 2003, has been set up to help cover more of the uninsured population. Poor families can participate in Seguro Popular for free, and people who do not participate in the insurance program can still access services through the Ministry of Health, although sometimes with some difficulty. The different public set-ups and private insurers all use different systems of medical facilities and providers, with a wide range of quality reported in those services. The social security system provides broad coverage for medical services, including primary care, acute care, ambulatory and hospital care, pregnancy and childbirth, as well as prescription medications. The Seguro Popular system provides access to an established set of essential medical services and the needed drugs for those conditions, as well as 17 high-cost interventions such as breast cancer treatment. The services are provided through government, usually state-run, facilities. Out-of-pocket payments by clients represent over half of financing for the Mexican health care system, whereas the public schemes are financed through general taxes and payment from the employer and employee, determined by salary. The Seguro Popular is also funded by taxes, contributions from the state and federal government, and payments by the families, as a percentage of income. Participants in Seguro Popular pay nothing at the time of delivery of the service (Puig et al, 2009). Uganda Uganda’s health care system is a national service, meaning that health care is supposed to be free and accessible to all. There are five clinic and hospital facilities that patients can access (if they are staffed, if the staff workers are not extorting money from the people, and if they have supplies). These clinics and hospitals work on a referral basis; if a level I or II facility cannot handle a case, it refers it to a unit the next level up. Often units do not have the essential drugs, meaning the patients have to buy them from pharmacies or other drug sellers. Level I clinics do health counseling; level II can take care of common diseases such as malaria and antenatal care; level III clinics are where 74outpatients are seen and treated, a maternity ward exists, and minimal (screening) laboratory services are provided; level IV is a mini-hospital with the kind of services found at level III clinics, but with wards for men, women, and children who can be admitted for short stays; and level V is a tertiary hospital for patients who are trauma victims, have major health problems, or are in need of mental health, dentistry, and surgery services. Although this sounds like an excellent system, my years of experience in Uganda can attest to both its strengths and weaknesses, with the greatest weakness being the lack of health professionals and the lack of supplies—too many children die because they have no oxygen, no intravenous (IV) fluids, and no antibiotics. Other aspects of the health system in Uganda are the faith-based hospitals; private medical practices/clinics set up by individual doctors or nurses as an income generator for themselves; and the traditional healers who practice herbal therapy, magic, bloodletting, and other nontherapeutic activities that often cause more harm than good (Kamwesiga, 2011; Kelly, 2009). Ecuador The health system in Ecuador has both a public sector and a private sector, with the public sector providing health care services to the whole working and uninsured populations. Private insurance is for the middle and high-income group, which includes about 3% of the population. In addition, there are about 10,000 private physicians’ offices, generally equipped with basic infrastructure and technology, located in major cities, and the population tends to make direct payments out of pocket at the time they receive care. There are special government programs to provide nutrition for the poor and maternity services to ensure healthy pregnancies and deliveries (Lucio et al, 2011). Recent reports by expatriate visitors to Ecuador indicate that the greatest perk for foreign residents is the high-quality, low-cost health care. There is personal attention from medical practitioners not seen in the United States since the 1960s; and in the bigger cities, one will find hospitals with state-of-the-art equipment, as well as specialists in all fields and physicians with private clinics. The United Kingdom It is also useful to examine the United Kingdom, with a tax-supported health system that is owned and operated by the government. Services are available to all citizens without cost or for a small fee. Administration of health services is conducted through a system of health authorities (Trusts). Each Trust plans and provides services for 250,000 to 1 million people. The services offered by each Trust are comprehensive, in that health care is available to all who want it and covers all aspects of general medicine, disability and rehabilitation, and surgery. Although physicians are the primary providers in this system, nurses and allied health professionals are also recognized and used. Services are made available through hospitals, private physicians and allied health professional clinics, and health outreach programs such as hospice, and environmental health services. Physicians are paid by the number of clients they serve and not by individual visits (Boyle, 2011). Although the British system has come under criticism in past years, individual citizens still maintain a high level of support for government funding and control of their health services. Clients, especially the elderly and new mothers, receive assistance from the district nurses (public health nurses). One of the hallmarks of the British system is a reduction in infant mortality, from 14.3 deaths per 1000 births in 1975 to 5.4 in 2002. Overall life expectancy in Great Britain also improved during the same period (77.2 years in 2000). This has been done while holding down gross spending on health care. A 2009 report by Sutherland found that the United Kingdom has seen a significant fall in mortality rates from the major killers: cancer, coronary heart disease, and stroke. Client ratings of quality care are high all across the United Kingdom; however, there is concern about rising health expenditure over the past 10 years (Sutherland, 2009). China China has made tremendous strides since 1949 in providing access to health care for its citizens. At present, China is a large developing country with many human resources (Yun et al, 2010). Nursing comprises a large segment of the health care workforce, yet there are too few nurses to meet the needs of the population. China, like the United States, is engaged in health care reform. China also has more physicians than nurses, which is different than in most other areas of the world. Nurse density in China is higher in urban than in rural areas, and this poses a problem in a large country in which much of the territory is rural in nature. Like many other countries, China has made public health advances by controlling contagious diseases such as cholera, typhoid, and scarlet fever, and by reducing infant mortality (Yun et al, 2010). These accomplishments in public health were credited to a political system that was and is largely socialistic and features a health care system that is described in socialistic terms as collective. The Chinese collective system emphasized the common good for all people, not individuals or special groups. This system was financed through cooperative insurance plans. The collective health care system was owned and controlled by the state and used “barefoot” doctors. Barefoot doctors were medical practitioners trained at the community level and who could provide a minimal level of health care throughout the country. Barefoot doctors combined Western medicine with traditional techniques such as acupuncture and herbal remedies. The government focused on improving the quality of water supplies and disease prevention, and implemented massive public health campaigns against sanitation problems, such as flies, mosquitoes, and the snails that spread schistosomiasis. Box 4-2 describes a Healthy Cities initiative that took place in Chengdu, China. Today, health care in China is managed by the Ministry of Public Health, which sets national health policy. The current Chinese government continues to make health care a priority and has set goals to provide medical care to all of its citizens. The Chinese government published its health care reform plan in 2009. In developing this plan the government took into account recommendations from the WHO and the World Bank. Among the aims of the plan are to develop a system of health 75insurance to help people pay for catastrophic illness, to increase and improve the education for nurses in order to intervene in the growing nursing shortage, and to develop urban health centers. At present, a small percentage of Chinese nurses work in public health, and some authors attribute this to the low pay in these settings. Hospitals and clinics are typically located in urban areas, which means that people in rural areas must travel a great distance for care, and even then, the care may be substandard and the wait time to receive care may be long. It is estimated that approximately 200 million people in China lack health insurance. When the State Council published its health care reform plan in April of 2009, a 3-year goal of “covering 90% of the Chinese population by 2011 and achieving universal health care by 2020” was established. The nursing education system in China has developed rapidly. All college-based nursing education was terminated during the period of the Cultural Revolution and began again only in the mid-1980s. At present the nursing education system includes associate degree, baccalaureate, master’s degree, and doctoral programs. Interestingly, the image of nursing has improved, based on the effectiveness of nurses during recent public health crises and events that claimed international attention. Specifically, nurses played important and effective roles in caring for people during the disasters caused by the SARS virus in 2003 and the Sichuan earthquake in 2008. More recently, nurses were well recognized in China for their considerable work during the 2008 Olympic Games in Beijing (Yun et al, 2010). Unfortunately, pay and working conditions are contributing to the desire of many Chinese nurses to leave the country. Major Global Health Problems and the Burden of Disease Despite the gains that have been made in improving the health of so many around the globe, the increasing population, decreasing food and water sources, and increasing poverty related to a global economic crisis are all contributing to a critical demise in health. The amount of debt incurred by less developed countries has increased steadily over the last 20 years, and money that was once used for health care has been used to pay off growing debt. Communicable diseases that are often preventable are still common throughout the world and are more common in less developed countries. Also, both developed and less developed countries are seeking ways to cope with the aging of their populations—a population that presents governments with the burden of providing care for those who become ill with more expensive noncommunicable and chronic forms of diseases and disabilities. Illnesses such as AIDS continue to raise concerns, especially in child-bearing women, adolescents, and young adults. Long-standing diseases such as TB, dysentery, and mosquito-borne diseases, especially malaria, still persist and have become drug resistant, adding to the growing burden of overextended health care delivery systems. Mortality statistics do not adequately describe the outlook of health in the world. The WHO (2014d) has developed an indicator called the global burden of disease (GBD). The GBD combines losses from premature death and losses of healthy life that result from disability. Premature death is defined as the difference between the actual age at death and life expectancy at that age in a low-mortality population. People who have debilitating injuries or diseases must be cared for in some way, most often by family members, and thus they no longer can contribute to the family’s or a community’s economic growth. The GBD represents units of disability-adjusted life-years (DALYs) (WHO, 2014e) (Box 4-4). Thirty-five percent of the health factors contributing to the DALY numbers in 2011 were related to communicable diseases, maternal and perinatal conditions, and nutritional deficits; 54% of DALYs were in noncommunicable conditions such as respiratory, cardiac, musculoskeletal, and other conditions; and the rest were related to injuries. Tables 4-1 and 4-2 reflect the conditions with the greatest impact on the 2011 DALYs (WHO, 2014e). Box 4-4 Calculating Disability-Adjusted Life-Years DALYs are composed of years lived with disability (YLDs) and years of life lost due to premature mortality (YLLs). YLDs, the morbidity component of the DALYs, are calculated as follows: YLD = image Number of cases x duration till remission or death x disability weight. Within the DALY calculation are the social weighting factors: 1. Duration of time lost because of a death at each age: Measurement is based on the potential limit for life, which has been set at 82.5 years for women and 80 years for men. 2. Disability weights: The degree of incapacity associated with various health conditions. Values range from 0 (perfect health) to 1 (death). Four prescribed points between 0 and 1 represent a set of accepted disability classes. 3. Age-weighting function, Cxe−βx, where C = 0.16243 (a constant), β = 0.04 (a constant), e = 2.71 (a constant), and x = age; this function indicates the relative importance of a healthy life at different ages. 4. Discounting function, e−r(x − a), where r = 0.03 (the discount rate), e = 2.71 (a constant), a = age at onset of disease, and x = age; this function indicates the value of health gains today compared with the value of health gains in the future. 5. Health is added across individuals: 2 people each losing 10 DALYs are treated as showing the same loss as 1 person losing 20 years. “In summary, one DALY can be thought of as one lost year of ‘healthy’ life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences” (see http://www/who.int/healthinfo/global_burden_disease/) http://www.cbra.be/publications/Devleesschauwer2014b.pdf TABLE 4-1 Top 20 DALY Conditions 2011 Rank GHE Code Cause DALYs (000s) % DALYs DALYs per 100,000 Population 1 39 Lower respiratory infections 164804 6.0 2375 2 113 Ischaemic heart disease 159659 5.8 2301 3 114 Stroke 135369 4.9 1951 4 11 Diarrhoeal diseases 118789 4.3 1712 5 50 Preterm birth complications 110688 4.0 1595 6 10 HIV/AIDS 95226 3.5 1372 7 118 Chronic obstructive pulmonary disease 89605 3.3 1291 8 153 Road injury 78792 2.9 1136 9 51 Birth asphyxia and birth trauma 78199 2.8 1127 10 83 Unipolar depressive disorders 75002 2.7 1081 11 140 Congenital anomalies 57697 2.1 832 12 80 Diabetes mellitus 56402 2.1 813 13 22 Malaria 55414 2.0 799 14 138 Back and neck pain 52692 1.9 759 15 58 Iron-deficiency anaemia 46244 1.7 667 16 3 Tuberculosis 42240 1.5 609 17 155 Falls 40782 1.5 588 18 161 Self-harm 39787 1.4 573 19 68 Trachea, bronchus, lung cancers 37252 1.4 537 20 123 Cirrhosis of the liver 34925 1.3 503 From ChildInfo: Monitoring the situation of children and women. Available at http://www.childinfo.org/maternal_mortality.html. Accessed March 20, 2014. TABLE 4-2 Top 10 DALYs in Broad Categories 2011 Rank Broad Cause DALYs (000s) % DALYs DALYs per 100,000 Population 1 Infectious diseases (incl. respiratory infections) 624141 22.7 8996 2 Cardiovascular diseases 378875 13.8 5461 3 Injuries 296836 10.8 4278 4 Neonatal conditions 231581 8.4 3338 5 Cancers 223539 8.1 3222 6 Mental and behavioral disorders 198370 7.2 2859 7 Respiratory diseases 134246 4.9 1935 8 Neurological and sense organ conditions 128613 4.7 1854 9 Musculoskeletal diseases 108401 4.0 1562 10 Endocrine, blood, immune disorders, diabetes mellitus 88211 3.2 1271 http://www.who.int/healthinfo/global_burden_disease/estimates_regional/en/index1.html Table 4-1 indicates that in 2011, 88% of the disability-adjusted life-years were the result of the top 10 conditions. Psychiatric disorders, although traditionally not regarded as a major epidemiologic problem, are shown by consideration of disability-adjusted life-years to have a huge impact on population ranking in the top 10 on the global burden of disease index. From just this table, 2.4 billion DALYs were lost worldwide, which equates to 70 million deaths of newborn children or to 150 million deaths of people who reach age 50. Approximately 2.5 million neonatal deaths occurred and more than 20 million 76children under age 5 died during the same year in less developed countries. If these children could face the same risks as those in developed nations, the deaths would decrease by 90%. This example demonstrates the importance of having accessible and affordable disease prevention programs for children around the world (WHO, 2014e). Infections and parasitic diseases remain a threat to the health of the majority of the world and are diseases seen in the United States in newly arriving immigrants. Studies demonstrate the continuing need for intervention for infectious and other kinds of communicable diseases. Conditions that contribute to one fourth of the GBD throughout the world include diarrheal disease, respiratory tract infections, worm infestations, malaria, and childhood diseases such as measles and polio. Sub-Saharan Africa demonstrated a GBD of 43% DALYs lost, largely because of preventable diseases among children (WHO, 2014e). According to the U.S. Global Health Policy fact sheet published by the Kaiser Family Foundation (2010), globally there were 33 million people living with HIV in 2007, up from 29.5 million in 2001, the result of continuing new infections, people living longer with HIV, and general population growth. HIV is a leading cause of death worldwide and the number one cause of death in Africa. An estimated 8 in 10 people infected with HIV do not know it. HIV has led to a resurgence of TB, particularly in Africa, and TB is a leading cause of death for people with HIV worldwide. Women represent half of all people living with HIV worldwide, and more than half (60%) in sub-Saharan Africa. Globally, there were 2.5 million children living with HIV in 2009, 370,000 new infections among children, and 260,000 AIDS deaths. There are approximately 16.6 million AIDS orphans today (children who have lost one or both parents to HIV), most of whom live in sub-Saharan Africa (89%). 77Uganda’s emphasis on ameliorating HIV/AIDS is a model for all African nations; however, there are still too many Ugandan children under 5 years old who are AIDS orphans. Unfortunately, despite the efforts of advocates, donors, and affected countries, there needs to be greater attention given to the long overdue effort to expand access to antiretroviral therapy, which is still available to less than 10% of those who urgently require it. Determining the total amount of loss, even using the GBD, is difficult because it does not address the many consequences of disease and injury such as post–trauma and infectious physical disabilities. Nor can it measure the short- or long-term effects of familial and marital dysfunction, family violence, or war. The following further elaborates on selected communicable diseases that still contribute substantially to the worldwide disease burden (TB, AIDS, and malaria) and other health problems such as maternal and women’s health, diarrheal disease in children, nutrition, natural and man-made disasters. Communicable Diseases Prevention of communicable diseases is through immunization and improving environmental conditions. One example of the long-term benefits of immunizing children against communicable diseases is the successful campaign against smallpox that the WHO conducted during the 1960s and 1970s. Smallpox has been virtually eliminated throughout the world, with only occasional and incidental reporting from laboratory accidents and inoculation complications. The systematic and planned smallpox program formed the basis for a series of worldwide efforts that are now being implemented to control and eradicate other infectious and communicable diseases. In 1974 the WHO formed the Expanded Program on Immunization, which sought to reduce morbidity and mortality from diphtheria, pertussis, tetanus, TB, measles, and poliomyelitis throughout the world (WHO, 2010). In the 2010 State of the World Report on immunizations and vaccines, the WHO noted that for the first time in documented history the number of children dying every year had fallen below 10 million. This appears to be the result of improved access to clean water and sanitation, increased immunization coverage, and the integrated delivery of essential health interventions. Unfortunately, almost 20% of the children born each year do not get the complete routine immunizations scheduled for their first year of life. This is most prevalent in developing countries and for those children born in the very rural communities. In developing countries, more vaccines are available and more lives are being saved; however, death from pertussis in developing countries is 40 per 1000 infants, and 10 per 1000 in older children. It still occurs in industrialized countries but at less than 1 per 1000 cases. Although free vaccination clinics are brought to the people, they are often not used because of lack of knowledge, fear propagated by the traditional healers, and suspicion of anything offered by the government. Reaching these vulnerable children—typically in poorly served remote rural areas, deprived urban settings, fragile states, and strife-torn regions—is essential in order to meet the Millennium Development Goals (MDGs; United Nations, 2013b). The WHO has estimated that if all the vaccines now available against childhood diseases were widely adopted, and if countries could raise vaccine coverage to a global average of 90%, by 2015 an additional 2 million deaths a year could be prevented among children under age 5. This level of vaccination would reduce child deaths by two thirds and achieve one of the MDG goals. It would also greatly reduce the burden of illness and disability from vaccine-preventable diseases and contribute to improving child health and welfare, as well as reducing hospitalization costs (WHO, Immunizations, 2010b). As discussed in Chapter 10, environmental sanitation is critical to the well-being of people around the globe. Many of the major health risks relate to interactions between people and their environment. For example, in developing nations, community drinking water sources can be contaminated by agricultural runoffs containing toxic pesticides and fertilizers, but they can also be contaminated by naturally occurring elements in the earth such as arsenic and fluoride. This author and her colleagues have found gross heavy metal (primarily arsenic) contamination of the water sources in Uganda including the government filtered water, bottled water from clean water bottling companies in Uganda, bore holes (wells), river, swamps, and springs (Bolender et al, 2012, 2013; Jameel et al, 2012). Efforts are underway to assess the extent of this problem across Uganda and to assess the effects on the population. We have already discovered unexplained neurological symptoms in the adults and persistent anemia in the children; which could have its causative origin in the arsenic-contaminated water consumed by the people. Long-term absorption of arsenic in humans has been associated with skin cancer, cancer of the bladder and lungs, developmental effects, neurotoxicity, diabetes, and cardiovascular disease (Global Poverty Project, 2013; WHO, Fact Sheet on Arsenic, 2012c). In developing nations, it is not uncommon for hospitals and HIV testing centers to dump waste products into the local rivers that often supply the local household water. Worldwide, environmental factors play a role in more than 80% of adverse outcomes reported by the WHO, including infectious diseases, injuries, mental retardation, and cancer, to name a few. Globalization and industrialization in the developing world have increased daily exposure to pollution and a wide array of chemicals in air, water, and food. At the same time, fecal pollution of drinking water sources caused by a lack of basic sanitation still exists. The effects of environmental risk factors are magnified by conditions often prevalent in poorer, undeveloped countries such as poor nutrition, poverty, lack of education about risks, and conflicts. Children are particularly susceptible to environmental risks because their systems are still developing. It is estimated that about one quarter of global disease is caused by avoidable environmental exposures; for young children in the developing world, causes of environmentally related deaths are acute respiratory infections, related to poor air quality; and diarrhea, related to poor drinking water quality. Annually, about 3 million children under the age of 5 die of environment-related diseases. There are projects that train and give technical assistance, data collection and analysis, laboratory analyses, research, surveillance, and emergency responses to 78international communities (American Society of Hematology, 2013; WHO, Fact Sheet on Child Deaths, 2013b). As of 2013, 783 million people still do not have access to clean water, and their water sources are often far away, unclean, and unaffordable; 2.5 billion people or 40% of the world’s population lack an adequate toilet or latrine. Getting hold of clean water is not good enough if the water is being made dirty because there are no toilets, and toilets are not good enough if there is no hygiene promotion to persuade whole communities to change the habits of generations and use the latrines. Estimates by the Joint Monitoring Program of UNICEF and the WHO predict that at the current rate of progress, approximately 2 billion people will still lack access to a clean environment by 2015. In sub-Saharan Africa 50% of people lack this basic human right, and their need may not be met until 2072 if the current rate continues (UNICEF, Water, Sanitation and Hygiene, 2010). Tuberculosis In 2012, according to the WHO (Tuberculosis Fact Sheet, 2012d) about 8.6 million people fell ill with tuberculosis and 1.3 million died of the disease. Ninety-five percent of TB deaths occur in low to middle income countries, and TB is one of the top three causes of death for women ages 15-44. Children are not immune to this bacterium, as the WHO report indicates that more than 530,000 children diagnosed with the disease and 74,000 HIV-negative children died of TB. It is a leading killer of people with HIV, and up to 80% of TB clients are HIV positive in countries with a high prevalence of HIV. People with HIV are much more likely to develop TB; as are those infected with malaria, especially children, because of the physiological damage to the liver, spleen, and hematological systems. A child or adult with any one of the three diseases mentioned is more prone to the other two, and this triad is the new scourge of impoverished nations. The WHO estimates that more than one third of infectious disease deaths are due to this deadly triad of AIDS, TB, and malaria (WHO, Tuberculosis Fact Sheet, 2012d). It is expected that at least one third of the world’s population, or 1.7 billion people, harbor the TB pathogen Mycobacterium tuberculosis. The Stop TB Partnership, engaging nearly 300 governments and agencies, has brought consensus on approaches to global control of this disease, galvanized support, and launched new support mechanisms, such as the Global TB Drug Facility, an initiative to increase access to high-quality TB drugs. The Working Group on Tuberculosis recommends seven priorities to meet the MDG targets for this disease for 2015. All this effort has resulted in some good news. It has been shown that the number of people falling ill with tuberculosis each year is declining, although very slowly. The world appears to be on track to achieve the Millennium Development Goal to reverse the spread of TB by 2015, especially given that the TB death rate dropped 45% between 1990 and 2010. Two factors are a threat to TB control and eradication. The first is the AIDS virus. The appearance of HIV has added to the difficulty of treatment programs in both developed and less developed countries. More important, HIV-positive individuals with infectious TB have an increased likelihood of transmitting TB to their families and to the community, further increasing the prevalence of this condition. The second is the growing multidrug resistance of the TB bacillus to isoniazid and rifampin, the two drugs used to treat it. Resistance to these drugs is already evident around the world, including in the Mexico-Texas border communities. The WHO and other organizations maintain that a high priority should be given to TB control and eradication programs around the world. They advocate a short-term chemotherapy regimen for smear-positive clients as being one of the most cost-effective health interventions available (Forman et al, 2012; WHO, Tuberculosis Fact Sheet, 2012d). The bacille Calmette-Guérin (BCG) vaccine, which has been available since the 1920s, was promoted as an effective vaccine to induce active immunity against TB, especially among children living in TB-endemic or high-risk TB areas that are impoverished and crowded. The BCG vaccine has a documented protective effect against meningitis and disseminated TB in children. It does not prevent primary infection and, more importantly, does not prevent reactivation of latent pulmonary infection, the principal source of bacillary spread in the community. The impact of BCG vaccination on transmission of TB is therefore limited (WHO, 2012d). The standard chemotherapeutic agents used in many countries for TB are isoniazid, thioacetazone, and streptomycin, and they are effective at converting sputum-positive cases to noninfectivity. The drugs and the combinations that are used vary from country to country. To be effective, however, treatment must be carried out on a consistent basis, and many less developed countries have difficulty persuading clients to purchase the medications and to adhere to any treatment regimen. In 1990 the WHO Global Tuberculosis Program (GTB) promoted the revision of national TB programs to focus on short-course chemotherapy (SCC), with directly observed treatment (DOT). DOT programs have been successful in the United States and in several less developed countries, including Malawi, Mozambique, Nicaragua, and Tanzania, producing a cure rate of approximately 80%. The SCC program involves aggressive administration of chemotherapeutic drugs combined with short-term hospitalization. The key to the program lies in a well-managed system with a regular supply of anti-TB drugs to the treatment centers, follow-up care, and rigorous reporting and analysis of client information (IOM, 2011). Lasting control of AIDS, TB, and/or malaria will depend on strengthening the health, economic, political, education, and other infrastructure necessary to sustain life and promote the well-being of the people. It will require sustained investment in physical infrastructure, drug distribution systems, management at all levels, and, most importantly, human resources such as the training and appropriate use of community health workers to deliver some essential services and education. Unfortunately, the failure of developed countries to fulfill their pledges of more development aid, and the failure of developing countries themselves to invest in health, are overarching barriers to health systems development. HIV/AIDS, TB, and malaria are only three of the challenges facing poor people. Only stronger, integrated health systems can provide a platform to sustain a successful fight against these diseases while advancing the other 79health priorities of developing countries, including child and maternal health and chronic disease. It is important, when conducting a health assessment interview, always to ask whether the client has recently traveled out of the United States or to one of the border areas along the United States–Mexico perimeter. People who travel abroad may bring back diseases that are difficult to diagnose. In addition, people often cross the border into Mexico to fill a prescription for medicine because it is often less expensive than in the United States. Unfortunately, many times the medications brought back have been relabeled and are out of date. Acquired Immunodeficiency Syndrome As discussed in Chapter 14, AIDS remains a major cause of morbidity and mortality throughout the world. More than 70 million people have been infected with HIV since the beginning of the epidemic; approximately 35 million people have died of AIDS. At the end of 2011, 34.0 million people globally were living with HIV with an estimated 0.8% of the adult population aged 15-49 years infected. The burden of the epidemic continues to vary considerably between countries and regions; however, sub-Saharan Africa remains most severely affected, with nearly 1 in every 20 adults (4.9%) living with HIV and accounting for 69% of the global population infected with this virus (IOM, 2012; WHO, HIV/AIDS, 2014f). For more information, go to http://www.who.int/gho/hiv/hiv_013.jpg?ua=1 (WHO, Global Health Observatory—HIV/AIDS, 2014f). The Kaiser Family Foundation report (2013a) stated that approximately 35.3 million people were living with HIV in 2012, up from 29.4 million in 2001. This rise appears to be the result of continuing new infections (averaging 6300 per day), people living longer with HIV, and general population growth. When comparing the population growth with the HIV incidence rates, overall new HIV infections have declined by 33% since 2001. Of interest is that 1.6 million people died of AIDS in 2012, which was a 30% decrease since 2005. Such results appear to be the result of antiretroviral treatment (ART) scale-up. The majority of new infections are being transmitted heterosexually, placing women and children at increased risk for acquiring the infection. Gender inequalities, lack of access to services, and sexual violence against women and children increase their vulnerability to HIV. Women represent about half (52%) of all people living with HIV worldwide and younger women are biologically more susceptible to HIV. Unfortunately, young people often believe the disease can be cured with drugs and thus they can be less cautious; in addition, cultural practices exist whereby older men marry virgins to cure them of AIDS or to prevent them from getting AIDS. By 2012, there were 3.3 million children globally living with HIV, with 260,000 new infections identified and 210,000 children who lost their lives to AIDS. Sadly, there are approximately 17.3 million children with AIDS who have lost one or both parents to HIV; most of these children live in sub-Saharan Africa (88%) and will either die from the disease or be treated as social outcasts by the community at large (Kaiser Family Foundation, 2013a). Worldwide prevention programs are important because failing to control this virulent disease will result in damaging and costly consequences for all countries in the future. Ideally, the goal is primary prevention of HIV. When prevention efforts fail at this level, the next goal is secondary prevention, or early diagnosis and treatment. Aggressive interventions in many African nations have begun to make a difference in the life potential for patients diagnosed with HIV. Combination ART has contributed to the reduced morbidity and mortality rate since 2001 and in sub-Saharan Africa alone, the number of people receiving ART increased significantly from 50,000 in 2002 to 7.5 million in 2012. In 2012, ART covered 61% of individuals who were eligible for treatment, representing 65% of the 2011 U.N.General Assembly Special Session target of treating 15 million by 2015. New WHO guidelines recommend starting treatment of HIV earlier in the course of illness. Given these new recommendations, 25.9 million people are now eligible for treatment (Kaiser Family Foundation, 2013a). See the levels of prevention box below to learn about prevention of HIV. image Levels of Prevention Global Health Care Primary Prevention Teach people how to avoid or change risky behaviors that might lead to contracting human immunodeficiency virus (HIV). Secondary Prevention Initiate screening programs for HIV. Tertiary Prevention Manage symptoms of HIV, provide psychosocial support, and teach clients and significant others about care and other forms of symptom management. Malaria Malaria affects more than 50% of the world’s population and hits tropical Africa the hardest. However, there have been major global efforts to control and eliminate malaria that have saved an estimated 3.3 million lives since 2000, reducing malaria mortality rates by 45% globally and by 49% in Africa, according to the “World Malaria Report 2013” published by the WHO (see http://www.who.int/malaria/publications/world_malaria_report_2013/en/). The large majority of the 3.3 million lives saved between 2000 and 2012 were in the 10 countries with the highest malaria burden, and among children under 5 years of age, which is the group most affected by the disease. Over the same period, malaria mortality rates among children in Africa were reduced by an estimated 54%. An expansion of prevention and control measures has contributed to a consistent decline in malaria deaths and illness. Unfortunately, the new WHO report notes a slowdown in the expansion of interventions to control mosquitoes for the second successive year, particularly in providing access to insecticide-treated bed nets, because of lack of funds to procure bed nets. My experience in Uganda still finds that 80malaria and its sequelae are the number one cause of death in children less than 8 years of age. Malaria is caused by the Anopheles mosquito and is the only mosquito-borne disease that can be prevented and cured by pharmacological management (WHO, Malaria Report, 2013e). It is caused by parasitic transmission from the infected female mosquito to its host. There are four parasite species that cause malaria, the most serious being Plasmodium falciparum, which causes microvascular sequestration and obstruction in the brain, kidney, and liver leading to cerebral malaria, anemia, kidney failure, hypoglycemia, disseminated intravascular coagulation (DIC), fluid-electrolyte imbalance, and death (CDC, 2013a). Symptoms vary and range from mild to severe physiological responses (mild fever and chills to temperatures of 106° F with prolonged chills, seizures, and dehydration). A range of effective antimalarial interventions exists for the prevention, treatment, and control of malaria. These include the use of insecticide-treated bed nets (ITNs); indoor residual spraying; intermittent presumptive treatment during pregnancy; early diagnosis and prompt treatment with effective antimalarials; management of the environment to control mosquitoes; health education; and epidemic forecasting, prevention, and response (CDC, 2013a; WHO, 2013e). Methods of vector control vary widely, from using the larvae-eating fish tilapia to the use of insecticidal sprays and oils. Needless to say, the latter poses a potential threat to the environment in tropical areas where a delicate ecosystem is already threatened by other potential hazards such as lumbering and mining. Countries that do not have strict environmental laws continue to use dichlorodiphenyltrichloroethane (DDT) sprays to control mosquito populations despite the advent of DDT-resistant mosquitoes. The non-DDT insecticide sprays, such as malathion, generally cost more, presenting an extra financial burden to less developed countries. Methods for control and eradication that are being considered by malaria-ridden countries are environmental management, reduction and control of the source, and elimination of the adult mosquito. There are significant global efforts being made to “blanket” endemic communities with insecticide-treated mosquito nets. A multitude of NGO projects are distributing ITNs to contribute to this initiative: Project Mosquito Net in Kenya (www.projectmosquitonet.org), Nothing But Nets (www.nothingbutnets.net/), Global Giving for Africa (www.globalgiving.org/projects/mosquito-nets-for-africa-families), Angola Mosquito Net Project (https://angolamosquitonetproject.wordpress.com/) and Holy Innocents Children’s Hospital Uganda (www.holyinnocentsuganda.org) are examples of organizations actively engaged in preventing malaria and saving lives. However, coverage levels are inadequate in endemic countries, especially in poor communities. Without adequate and predictable funding, the progress against malaria is also threatened by emerging parasite resistance to artemisinin, the core component of artemisinin-based combination therapies (ACTs), and mosquito resistance to insecticides. Artemisinin resistance has been detected in four countries in Southeast Asia, and insecticide resistance has been found in at least 64 countries. Although chemotherapeutic agents can be used for both protection and treatment of the disease, they are expensive and often cause side effects. However, evidence suggests that the Plasmodium sporozoites are becoming resistant to both treatment and preventive chemotherapeutic agents, especially chloroquine and its derivatives. Alternative therapies and/or combinations of medications such as sulfadoxine/pyrimethamine (Fansidar), amodiaquine, artemisinin, artemether, and atovaquone/proguanil (Malarone) are somewhat effective in treating malaria. Recent reports indicate that drug manufacturers in these endemic countries are diluting the drugs so that clients, especially children, are not receiving therapeutic levels of the medications. Many children suffer the effects of partially treated malaria, and once hospitalized, IV quinine is the drug of choice. Unfortunately, quinine has significant neurotoxic and cardiovascular side effects that need monitoring (CDC, 2013a). Efforts are underway to develop an antimalarial vaccine and one candidate vaccine, known as RTS,S/AS01, has been shown to almost halve the number of malaria cases in young children (aged 5 to 17 months at first vaccination) and to reduce by about one fourth the malaria cases in infants (aged 6 to 12 weeks at first vaccination) (Malaria Vaccine Initiative, 2013). As discussed in Chapter 13, persons who live or travel to Anopheles-infested areas should protect themselves with mosquito netting, clothing that protects vulnerable parts of the body, repellents for both their bodies and their clothes, and antimalarial medications such as Malarone or doxycycline. Diarrheal Disease The normal intestinal tract regulates the absorption and secretion of electrolytes and water to meet the body’s physiological needs. More than 98% of the 10 L of fluid per day entering the adult intestines is reabsorbed (Ahs et al, 2010; Alexander and Blackburn, 2013). The remaining stool water, related primarily to the indigestible fiber content, determines the consistency of normal feces from dry, hard pellets to mushy, bulky stools, varying from person to person, day to day, and stool to stool. This variation complicates the definition of diarrhea. For adults diarrhea is present when three or more liquid stools are passed in 24 hours. The frequent passage of formed stool is not diarrhea. Although young nursing infants tend to have five or more bowel movements per day, stools that are liquid without any formation and/or are more than what is normal for the child constitute diarrhea (Ahs et al, 2010; Farthing et al, 2012). Definitions are complicated by the observable presence of blood, mucus, or parasites and the age of the affected person. Diarrhea, one of the leading causes of illness and death in children less than 5 years of age throughout the world, is most prominent in the less developed countries despite recent initiatives by the WHO to correct this problem. Each year there are 760,000 diarrhea deaths in children under five; there are 1.7 billion cases of diarrheal disease every year related to unsafe water, sanitation, and hygiene; and it is the leading cause of malnutrition in children under five (WHO, Diarrhea Fact Sheet, 2013f). Causes of diarrhea are just as varied and diverse as its definitions and perceptions. Some of the causes include (1) viruses such as the rotavirus and Norwalk-like agents, (2) 81bacteria, including Campylobacter jejuni, Clostridium difficile, Escherichia coli, Salmonella, and Shigella, (3) environmental toxins, (4) parasites such as Giardia lamblia and Cryptosporidium, and (5) worms. Nutritional deficiencies can also cause diarrhea and are most often a result of infectious agents. Of these, the rotavirus has emerged as a major world concern, hospitalizing 55,000 American children and killing 1 million children in the world each year (Farthing et al, 2012; WHO, Diarrhea Fact Sheet, 2013f). Three major diarrhea syndromes exist: • Acute watery diarrhea, which results in varying degrees of dehydration and fluid losses that quickly exceed total plasma and interstitial fluid volumes and is incompatible with life unless fluid therapy can keep up with losses. Such dramatic dehydration is usually due to rotavirus, enterotoxigenic E. coli, or Vibrio cholerae (the cause of cholera), and it is most dangerous in the very young. • Persistent diarrhea, which lasts 14 days or longer, and is manifested by malabsorption, nutrient losses, and wasting; it is typically associated with malnutrition, either preceding or resulting from the illness itself. Even though persistent diarrhea accounts for a small percentage of the total number of diarrhea episodes, it is associated with a disproportionately increased risk of death. • Bloody diarrhea, which is a sign of the intestinal damage caused by inflammation. Bloody diarrhea, defined as diarrhea with visible or microscopic blood in the stool, is associated with intestinal damage and nutritional deterioration, often with secondary sepsis. Mild dehydration and fever may be present. Bloody diarrhea should not be confused with dysentery, because dysentery is a syndrome consisting of the frequent passage of characteristic, small-volume, bloody mucoid stools, abdominal cramps, and tenesmus (a severe pain that accompanies straining to pass stool). Agents that cause bloody diarrhea or dysentery can also provoke a form of diarrhea that clinically is not bloody diarrhea, although mucosal damage and inflammation are present microscopically. The release of host-derived cytokines alters host metabolism and leads to the breakdown of body stores of protein, carbohydrate, and fat and the loss of nitrogen and other nutrients. Those losses must be replenished during the expected prolonged convalescence. For these reasons, bloody diarrhea calls for management strategies that are markedly different than those for watery or persistent diarrhea. New bouts of infection that occur before complete restoration of nutrient stores can initiate a downward spiral of nutritional status terminating in fatal protein-energy malnutrition (Farthing et al, 2012). Diarrheal diseases are rampant among the impoverished. Poverty is associated with poor housing, crowding, dirt floors, lack of access to sufficient clean water or to sanitary disposal of fecal waste, cohabitation with domestic animals and zoonotic transmission of pathogens, and a lack of refrigerated storage for food. Unfortunately, even when the cause of the diarrhea is eliminated, poverty can restrict the ability to provide age-appropriate, nutritionally balanced diets or to modify diets so as to mitigate and repair nutrient losses. The lack of adequate, available and affordable medical care increases the problem. Children suffer from an apparently never-ending sequence of infections and rarely receive appropriate preventive care, and too often their parents seek health care only when the children have become severely ill. Dehydration is an immediate result of diarrhea and leads to a loss of fluid and electrolytes. The loss of up to 10% of the body’s electrolytes can lead to shock, acidosis, stupor, and failure of the body’s major organs (e.g., kidneys, heart). Persistent diarrhea often leads to loss of body protein, an increased time-limited inability to digest and absorb dairy products, and increased susceptibility to infection. Every country should have as a major aim the prevention and control of diarrheal disease, especially in infants and children. Many countries have developed diarrhea control programs that improve childhood nutrition. These programs instruct in breastfeeding and weaning practices and promote oral rehydration therapy and the use of supplementary feeding programs (Farthing et al, 2012). However, all these programs must be considered in conjunction with improving the social and economic conditions that contribute to safe environmental, sanitary, and general living conditions of populations around the world. The following How To box provides useful resources for keeping well informed about public health issues including water quality. How to Stay Current about Global Health One way to stay current with the world’s health problems and advances is by reading the newspaper daily. Examples of newspapers that cover international health on an ongoing basis include the Wall Street Journal, USA Today, the Washington Post, and the New York Times. The following websites are examples of sources that pertain to international or global health: • U.S. Department of Health and Human Services: http://www.globalhealth.gov/ • Global Health Council: http://www.globalhealth.org/ • Centers for Disease Control and Prevention: http://www.cdc.gov/globalhealth/ • World Health Organization: http://www.who.int/en/ • Pan American Health Organization: http://new.paho.org/ • World Bank: http://www.worldbank.org/ • Institute of Medicine: http://www.iom.edu/ • Millennium Development Goals: http://www.undp.org/mdg/ Maternal and Women’s Health Maternal health is central to the health of women, as well as the well-being of their children and families, and the economic productivity of their countries. A woman’s ability to survive pregnancy and childbirth is closely related to how effectively societies invest in and realize the potential of women not only as mothers, but as critical contributors to sustaining families and transforming nations. When investments in women—as mothers, as individuals, as family members, and as citizens—lag, the economic cost of maternal death and illness is enormous. Ostrowski (2010) stated that when women have better education and health, then mothers have greater household decision-making power and their children are better educated, becoming productive adults able to help build long-term 82economic growth. The World Bank found that during economic crises, poor families who sent women to work were better able to make ends meet. Progress and investment in maternal health have lagged far behind estimates of what is needed to achieve MDG 5, Improve Maternal Health. Progress in the last 20 years on key maternal health indicators varies by outcome and region, but it has been uneven, inequitable, and inadequate overall. The two regions of the world with the worst maternal health status—South Asia and sub-Saharan Africa—show minimal signs of improvement largely because of poverty, disempowerment of women, and overall poor health status of women in developing countries. Women’s reproductive health, especially their ability to control their fertility and avoid HIV infection, is also closely associated with their health as mothers. Although maternal death and disability represent a high burden of disease in the developing world, interventions to improve maternal health are available and cost-effective (Kaiser Family Foundation, 2013c; Kott, 2011; WHO, Family Planning Fact Sheet, 2013g). In Uganda, Reproductive Health Uganda (RHU), formerly the Family Planning Association of Uganda (FPAU), provides services in 29 of the country’s districts, targeting young people and marginalized groups to improve reproductive health. They offer family planning; HIV/AIDS testing and counseling; diagnosis and treatment of sexually transmitted infections (STIs); advocacy against female genital mutilation (FGM); and post-abortion care to high-risk constituencies such as internally displaced persons (IDPs), people at high risk of HIV/AIDS, young women in conflict-affected areas, sex workers, hawkers, saloonists, bicycle taxi drivers, maids—any group subject to violence and disempowerment (www.rhu.or.ug). Despite FPAU’s intent to improve the reproductive health of Ugandan women, there are barriers to the success of this initiative: continued cultural practices related to submissiveness of women and dependency on men for well-being of self and the children; bride wealth practices that give ownership to the man and permit beatings and other abuses of his wife; kinship patterns in which widowed women belong to the oldest brother; the fact that child care and all work related to the home and the children are performed by the women and girls; the fact that a woman’s worth is still dependent on her ability to reproduce, even knowing that the more pregnancies a woman incurs, the less healthy the newborn and mother; and the practice of polygamy, allowing for transmission of STIs and HIV/AIDS. The WHO and UNICEF have continued their worldwide initiatives to reform the health care received by women and children in less developed countries (WHO, Maternal Health Fact Sheet, 2013h). However, studies on women’s health indicate that more than one third (35%) of all maternal deaths around the world are due to severe bleeding, primarily postpartum hemorrhage; sepsis (8%); unsafe abortion (9%); hypertension (18%); and conditions that complicate pregnancy such as malaria, anemia, and HIV (20%). In developing nations there is a significant incidence of lack of prenatal care during pregnancy and high fertility rates, often due to a lack of access to contraception and other family planning and reproductive health services, as well as cultural belief systems that increase the lifetime risk of maternal death. Every year, more than half a million women die in pregnancy and childbirth around the world. This figure has altered little in the last 30 years. In sub-Saharan Africa, a number of countries have halved their levels of maternal mortality since 1990 but not in the more impoverished nations such as the Congo, Uganda, Ghana, and others. However, between 1990 and 2010, the global maternal mortality ratio declined by only 3.1% per year. This is far from the annual decline of 5.5% required to achieve MDG 5 (WHO, Maternal Mortality Fact Sheet, 2012e). Equally distressing is the fact that worldwide, the ratio of maternal deaths to live births (the maternal mortality ratio) has remained essentially static during this period. Africa continues to have the highest maternal-child morbidity and mortality rate, with 51% of all maternal deaths occurring in sub-Saharan Africa. The maternal mortality ratio in developing countries is 240 per 100,000 births versus 16 per 100,000 in developed countries. The risk of maternal mortality is highest for adolescent girls under 15 years old. HIV currently accounts for 6.2% of maternal deaths in Africa and has reversed the progress made in maternal health in some countries. image Lifetime Risk of Maternal Deaths in Sub-Saharan Africa versus Industrialized Nations. (From ChildInfo: Monitoring the situation of children and women. Available at http://www.childinfo.org/maternal_mortality.html. Accessed March 20, 2014) In sub-Saharan Africa, infectious diseases, childhood illnesses, and maternal causes of death account for as much as 70% of the burden of disease. By comparison, these conditions account for only one third of the burden in South Asia and Oceania, and less than 20% in all other regions. In addition, whereas the average age of death throughout Latin America, Asia, and North Africa increased by more than 25 years between 1970 and 2010, it rose by less than 10 years in most of sub-Saharan Africa (WHO, Global Burden of Disease Report, 2012b). The WHO found that some of the sociocultural factors that prevent women and girls from benefiting from quality health services and attaining the best possible level of health include the following (WHO, Women’s Health Fact Sheet, 2013h): • Unequal power relationships between men and women • Social norms that decrease education and paid employment opportunities • An exclusive focus on women’s reproductive roles • Potential or actual experience of physical, sexual and emotional violence Within Africa, the greatest disease burden remains from maternal health, child health, HIV, TB, and malaria; outside Africa the greatest disease burden is the rising incidence of noncommunicable diseases and rising life expectancy (Summers, 2013). Throughout the world, women between 15 and 44 years of age account for approximately one third of the world’s disease burden, and women between 45 and 59 for one fifth of the burden. This burden comprises diseases and conditions that are either exclusively or predominantly found in women, including maternal mortality and morbidity, cervical cancer, anemia, STIs, osteoarthritis, and breast cancer, with HIV/AIDS leading the statistics (Mathers, 2009). Although most of these conditions can be dealt with by cost-effective prevention and screening programs, many less 83developed countries have ignored women’s health issues other than those directly related to pregnancy and childbirth for two major reasons: (1) women are not seen as valued members of society, and (2) most of the afflicted women are poor, malnourished, and cannot pay for health care services. Sub-Saharan Africa accounts for the majority of the world’s births. Although all countries profess to offer prenatal services and safe birthing services, most are unavailable, inaccessible, and unaffordable by women (WHO, Maternal Health Fact Sheet, 2013h). An African woman’s risk of dying from pregnancy-related causes is 1 in 20, followed by Bangladesh, Pakistan, and India. These three countries account for nearly half of the world’s maternal deaths, but only 29% of the world’s births; they have more maternal deaths each week than Europe has in a year. Still, an accurate reporting of maternal deaths is difficult to obtain because many of the women who die are poor and live in remote areas, and their deaths are considered by many to be unimportant (Mathers, 2009) (See table above). Risk factors for maternal mortality include poor nutritional status, disease conditions, high parity, and age less than 20 years and greater than 35 years. To date, little attention has been paid to the problem of maternal mortality, even though the reported incidences are high throughout the world. The WHO and the UN are addressing this problem by calling for government initiatives and actions to address maternal morbidity and mortality from obstetrical deaths as well as those that arise from indirect causes. MDG 5 aims to reduce the maternal mortality ratio by three quarters, improve the proportion of births attended by skilled health personnel, promote universal access to reproductive health, improve contraceptive rates, decrease adolescent birth rates, provide antenatal care coverage, and address the unmet need for family planning by 2015 (WHO, 2012c). In some countries it is difficult to counsel women on family planning and spacing their children so as to promote maternal and fetal health when a woman’s value depends on her ability to reproduce and more than 50% of children die before they reach adolescence. The result of poor maternal health accounts for the increase in premature births and the increased risk for high morbidity rates in children less than 5 years because of their own compromised nutritional and immune state. Low birth weight is a major risk factor for premature births, which account for more than one quarter (29%) of newborn deaths, followed by asphyxia (22%), sepsis (15%), pneumonia (10%), congenital abnormalities (7%), diarrhea (2%), and tetanus (2%). Undernutrition and lack of access to clean water and sanitation significantly increase children’s vulnerability to death. Newborn deaths account for most child deaths (41%), followed by diarrhea (14%), pneumonia (14%), malaria (8%), injuries (3%), HIV/AIDS (2%), and other infectious or noncommunicable diseases (18%, including measles [1%]) (Kaiser Family Foundation, Global Health Policy, 2013b). In 2012 approximately 6.6 million children died before the age of 5 which is nearly one half the number that died in 1990 but still much too high a number of deaths (World Bank, 2013b). Even though programs in many countries have been initiated, safe motherhood initiatives are still needed throughout the world. These programs and initiatives need to include providing accessible family planning services and prenatal and postnatal health care services, ensuring access to safe abortion procedures, and improving the nutritional status of all women. 84 Nutrition and World Health Many children around the world are underweight and have multiple micronutrient deficiencies such as for iron, zinc, and vitamin A. Poor nutrition by itself or that associated with infectious disease accounts for a large portion of the world’s disease burden (Mathers, 2009; WHO, 2013d). Improved nutrition is related to stronger immune systems, decreased illness, better maternal and child health, longer life spans, and improved learning outcomes for children. Healthy protein balances are able to support major physiological stress with improved healing and ability to utilize protein-binding drugs; better nutrition is a prime entry point to ending poverty and a milestone to achieving better quality of life. Environmental and economic conditions related to poverty contribute to underconsumption of nutrients, especially those nutrients needed for protein building such as iodine, vitamin A, and iron. Worldwide, women and children suffer disproportionately from nutrition deficits, especially the micronutrients just mentioned (Mathers, 2009). Children in Haiti die daily from hunger; more than 60% of the population is undernourished and children under the age of 5 suffer an even higher percentage. more than 800 million people (or one out of every five people in developing nations) are undernourished; and every few seconds, about every time one takes a breath, a child in the developing world dies of hunger and related diseases (Global Nutrition Alliance, 2010). Poor nutrition also leads to stunting, or low height and weight for a given age. Stunting often results from eating foods that do not provide adequate energy or protein. Because protein foods are usually more expensive than nonprotein food sources, many households reduce, or unconsciously eliminate, protein-rich foods to save money (Hunter, unpublished research, 2012). I have cared for and watched many children with marasmus (total caloric deprivation) and Kwashiorkor (protein deficiency starvation) die who could have been saved if affordable protein and nutritious food were available. Usually this condition begins because an infant has been weaned away from breastfeeding after a year to make room for the next baby, and the food used in its place is mainly sugar and water or a starchy gruel. Kwashiorkor symptoms are apathy, muscular wasting, edema, and pigmentation loss in the skin and hair. Marasmus is a wasting away of the body tissues and symptoms are like kwashiorkor with fretfulness and an appearance of “skin and bones.” Iron deficiencies are also common in less developed countries and severely affect women and children. When iron is low, fewer red blood cells are produced, and this reduces the capacity of the blood to transport oxygen. As a result, symptoms ranging from fatigue and inability to concentrate to impaired physical and cognitive development of children can occur. Iron deficiency anemia may also cause problems during pregnancy, particularly in developing countries where it can increase the risk of premature delivery, as well as the risk of maternal and fetal complications and death. Inadequate iron from food is the most common reason for iron deficiency anemia, especially among infants and children. Parasites, infections, stomach and digestive diseases, and blood loss during menstruation may also worsen anemia. A deficiency of iron in the diet can reduce appetite, physical productivity, the ability to learn, and growth. The American Society of Hematology (2013) reported that while the global prevalence of anemia decreased between 1990 and 2010 (from 40.2% to 32.9%), the disease has demonstrated an increase in global YLDs from 65.5 million to 68.4 million. The DALY burdens associated with major depression (63.2 million YLDs), chronic respiratory diseases (49.3 million YLDs), and general injuries (47.2 million YLDs) are less than the DALY burden of anemia. This is due to the increased incidence of anemia in children <5 years. This age group accounted for more cases of anemia than any other age group and had the highest severity of disease in low- and middle-income regions. Unfortunately the data also demonstrated a widening gender gap in anemia burden over time with female prevalence rates remaining higher in most regions and age groups. Other common dietary deficiencies include zinc, iodine, vitamin A, folic acid, and calcium. Zinc is important because it is an essential part of many enzymes and plays an important role in protein synthesis and cell division. The health consequences of zinc deficiency include poor immune system function, growth retardation, and delayed sexual maturity in children. Zinc deficiency is caused by low intake and/or low absorption of bioavailable zinc. Diets low in meat and fish increase the risk of zinc deficiency, because zinc is poorly bioavailable in cereals. Vitamin A is another essential nutrient in the human diet, contributing to the functioning of the retina, the growth of bone, and the immune response. Apart from preventable, irreversible blindness, vitamin A deficiency also causes reduced immune function, leading to an increased risk of severe infectious disease and anemia. It also increases the risk of death during pregnancy for both the mother and fetus and after birth for the newborn. An estimated 250 million preschool children in developing countries are affected by vitamin A deficiency, although severe deficiency that causes blindness is declining (Kaiser Family Foundation, 2013c; WHO, Global Prevalence of Vitamin A Deficiency, 2013i). The impact of malnutrition and dietary deficiencies is significant. Any malnourished condition in a population can increase susceptibility to illness. For example, the principal causes of death among malnourished persons are measles, diarrheal and respiratory disease, TB, pertussis, and malaria. The loss of life from these diseases can be measured as 231 DALYs worldwide, with one fourth of the 231 being directly attributable to malnourishment and dietary deficiencies. Individual governments and organizations such as the International Red Cross, WHO, and many international religious and private foundations have been active in promoting better nutrition. Worldwide initiatives directed at overcoming nutritional deficits include the following (Global Nutrition Alliance, 2010): control of infectious diseases, nutritional education, control of intestinal parasites, micronutrient fortification of food, food supplementation, and food price subsidies. Médecins sans Frontières (Doctors without Borders) was the first to use the life-saving supplement, invented in 2003 by a French scientist, called Plumpy'nut. Plumpy'nut requires no 85water preparation or refrigeration and has a 2-year shelf life, making it easy to deploy in difficult conditions to treat severe acute malnutrition. It is distributed under medical supervision, to humanitarian organizations for food aid distribution. The ingredients include peanut paste; vegetable oil; powered milk; powdered sugar; vitamins A, B-complex, C, D, E, and K; and minerals including calcium, phosphorus, potassium, magnesium, zinc, copper, iron, iodine, sodium, and selenium. These are combined in a foil pouch and each 92-g pack provides 500 kilocalories (kcal) or 2.1 megajoules (MJ). Natural and Man-Made Disasters As discussed in Chapter 23, earthquakes, floods, drought, and other natural hazards continue to cause tens of thousands of deaths, hundreds of thousands of injuries, and billions of dollars in economic losses each year around the world. Disasters represent a major source of risk for the poor and wipe out development gains and accumulated wealth in developing countries. In 2012, only 357 natural triggered disasters were registered; a decrease from 394 observed in the years past. However, natural disasters still killed a significant number, even though there was a decline in deaths. Contrary to other indicators, economic damages from natural disasters did show an increase to above average levels (143 billion 2012 US$), with estimates placing the figure at US$ 157 billion. Over the last decade, China, the United States, the Philippines, India, and Indonesia together constitute the top five countries that are most frequently hit by natural disasters. In 2012, China had its fourth highest number of natural disasters over the last decade with 13 floods and landslides, 8 storms, 7 earthquakes, and 1 period of extreme temperature. The single deadliest disaster in 2012 was Typhoon Bopha, which killed 1901 people in the Philippines (Center for Research on the Epidemiology of Disaster, 2013). Natural disasters such as earthquakes, tsunamis, and floods can often come at the least expected time. Others, such as hurricanes and cyclones, are increasing in severity and destruction. Droughts are increasing as the threat of global warming rises. Typically, the poor are the worst hit, for they have the least resources to cope and rebuild. Hurricane Katrina resulted in a 90,000 square mile disaster zone, equivalent to the area of Great Britain, and more than 1800 died. The Indonesian tsunami of 2005 killed at least 230,000 people, and the livelihoods of millions were destroyed in more than 10 countries affected by the tsunami. The earthquake in Haiti in 2010 destroyed a country and crushed the hopes of thousands of Haitians. Human activity is contributing to massive extinctions, from various animal species, to forests, and the ecosystems that support marine life. The costs associated with deteriorating or vanishing ecosystems are high. The World Resources Institute reports that there is a link between biodiversity and climate change, and rapid global warming can affect an ecosystem's chance to adapt naturally (World Resources Institute, 2012). The four worst types of natural disasters are as follows: • Earthquakes and tsunamis: Examples are January 12, 2010—more than 230,000 people were killed when a 7.0-magnitude earthquake struck Haiti; May 12, 2008—about 70,000 people were killed and 18,000 people were reported missing after a 7.9-magnitude earthquake struck Sichuan, China; October 8, 2005—at least 80,000 people were killed and 3 million left homeless after a quake struck the mountainous Kashmir district in Pakistan. • Volcanic eruptions: Examples are July 15, 1991 when Mount Pinatubo on Luzon Island in the Philippines erupted, blanketing 750 square kilometers with volcanic ash and more than 800 died; November 13-14, 1985 when at least 25,000 were killed near Armero, Colombia, when the Nevado del Ruiz volcano erupted, triggering mudslides. • Hurricanes, cyclones, and floods: Examples are July-August 2010, when monsoon rains hit northwest Pakistan and more than one fifth of the country was under water, more than 1700 people were killed, and 17.2 million people were victims; May 3, 2008, when Cyclone Nargis, with winds that exceeded 190 km/hour and waves six meters high, struck Myanmar, leaving as many as 100,000 dead, according to U.S. estimates; October 26-November 4, 1998, when Hurricane Mitch killed 11,000 in Honduras and Nicaragua and left 2.5 million homeless. • Pandemics and famines: 1900-present, malaria has been the leading cause of death in the developing world, causing severe illness in 500 million people each year and killing more than 1 million annually; 1984-1985, the Ethiopian famine that killed at least 1 million in Ethiopia; and 1980-present, the toll from AIDS worldwide is estimated at 25 million, with 40 million others infected with HIV (http://www.cbc.ca/news/world/the-world-s-worst-natural-disasters-1.743208). When poor countries face natural disasters, such as hurricanes, floods, earthquakes, and fires, the cost of rebuilding becomes even more of an issue when they are already burdened with debt. Often, poor countries suffer with many lost lives and/or livelihoods. Aid and disaster relief often do come in from international relief organizations, rich countries, and international institutions, but poor countries often pay millions of dollars a week back in the form of debt repayment. The aftermath of a natural disaster may be as devastating as the disaster itself. Inadequate shelter, unclean water, and lack of security are some of the most commonly reported problems, even a year after the event. The physical force of a disaster not only causes immediate injury and death, but each type of disaster can result in its own combination of physical injuries. In earthquakes, buildings and the objects inside them can fall, injuring those who live or work there. Floods can result in drowning, and wildfires can cause burns and illness from smoke inhalation. In addition to the direct injury and death caused by the disaster's force, there can be other serious adverse effects on the well-being of those living in the area. The large numbers of people who are suddenly ill or injured can exceed the capacity of the local health care system to care for them. In addition to the burden of increased numbers of clients, the system itself can become a victim of the disaster. Hospitals may be damaged, roads blocked, and personnel unable to perform their duties. The loss of these resources occurs at a time when they are most 86critically needed. The disaster can also hamper the ability to provide routine, nonemergency health services. Many people may be unable to obtain care and medications for their ongoing health problems. The disruption of these routine services can result in an increase in illness and death in segments of the population that might not have been directly affected by the disaster. The most serious consequences of natural disasters are related to mass population displacements, unsanitary conditions, lack of clean water, lack of nutritious foods, lack of safe housing, and the increased risk of diseases prevalent in crowded and unsanitary living conditions: typhoid fever, cholera, dysentery, TB, and infectious respiratory conditions (Petrucci, 2012). Man-made disasters may include bioterrorism, chemical agents, pandemics and epidemics, radiation, and terrorism. The five worst man-made disasters in recent history are as follows: • Bhopal Gas Tragedy, India in 1984 where more than 500,000 people were exposed to methyl isocyanine gas and other chemicals. Thousands of people died within the first hours of the leak, but over time estimates of 5000 to 16,000 deaths from the leak have been made. • Deepwater Horizon Oil Spill, Gulf of Mexico in 2010 that killed 11; leaked anywhere from 40,000 to 162,000 barrels of oil a day; took 47,829 people 89 days to finally cap the well; and 3500 workers and volunteers on the clean-up site are suffering liver and kidney damage from their exposure to the 1.8 million gallons of toxic oil. • Chernobyl Meltdown, Ukraine in 1986. Thirty-one volunteers died trying to shut the reactor down and nearly 4000 deaths so far have been thought to be attributable to the radiation poisoning people living near Chernobyl underwent. To this day, no one is sure what the final death toll from the Chernobyl meltdown will be. • Fukushima Meltdown, Japan in 2011 with more than 100,000 people evacuated and displaced from the surrounding areas; 600 people dying during the evacuation; 300 cleanup workers receiving excessive exposure to radioactive waste; and the resulting unknown long-term health effects that could include people as far away from the meltdown as North America. • Global Warming that impacts rising sea levels, desertification, animal extinction, and damage from intense superstorms such as Hurricane Katrina, Hurricane Sandy, and Typhoon Haiyan in the Philippines has already created some of the first groups of climate-change refugees, and some estimate that number will rise to 150 million by 2050 (http://www.policymic.com/articles/23620/5-worst-man-made-disasters-in-history). Other man-made disasters are the bioterrorism attack and the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death of people, animals, or plants, which may lead to pandemics and epidemics (anthrax, cholera, Ebola virus, Lassa fever, plague, and smallpox, to name a few). A pandemic is an epidemic of infectious diseases that spread through human populations across a large region such as a continent or the globe (e.g., HIV/AIDS, smallpox, TB, H1N1, SARS); whereas an epidemic is when new cases of a certain disease in a given human population exceed what is expected (cancer, heart disease, seasonal flu). These agents are typically found in nature, but it is possible that they could be changed to increase their ability to cause disease, to make them resistant to current medicines, or to increase their ability to be spread into the environment in order to threaten a government or intimidate or coerce a civilian population (CDC, Bioterrorism, 2013b; Infectious disease: Global Challenges. Bioterrorism, 2013). Bioterrorism is a significant public health threat that could produce widespread, devastating, and tragic consequences, and it would impose particularly heavy demands on international public health and health care systems. Nurses and other health personnel need to be aware and vigilant to the health consequences of terrorism and the potential use of biological agents to instill fear and to spread disease. A nation's capacity to respond to the threat of bioterrorism depends in part on the ability of health care professionals and public health officials to rapidly and effectively detect, diagnose, respond, and communicate during a bioterrorism event. The national health care community—including public health agencies, emergency medical services, hospitals, and health care providers—would bear the brunt of the consequences of a biological attack. Attacks with biological agents are likely to be covert, rather than overt (CDC, 2013b). Terrorists may prefer to use biological agents because they are difficult to detect; they do not cause illness for several hours to several days. A chemical emergency occurs when a hazardous chemical has been released and the release has the potential to harm people's health. Chemical releases can be unintentional, as in the case of an industrial accident, or intentional, as in the case of a terrorist attack. Sarin and ricin are the two most recent notorious chemicals used; however, mustard gas, cyanide, and tear gas have existed for decades. Agent Orange was used by the American troops in Vietnam, and mustard gas was commonly used during World War I and even during the Gulf War (http://www.policymic.com/articles/62023/10-chemical-weapons-attacks-washington-doesn-t-want-you-to-talk-about; http://science.howstuffworks.com/mustard-gas4.htm). Radiation poisoning occurs when an excess amount of radiation is released to harm people's health. These may be unintentional and intentional events. Intentional terrorist events are those designed to contaminate food and water with radioactive material; spread radioactive material into the environment by using conventional explosives (e.g., dynamite), called a dirty bomb, or by using wind currents or natural traffic patterns; bomb or destroy a nuclear reactor; cause a truck or train carrying nuclear material to spill its load; or explode a nuclear weapon. The word genocide was developed by a jurist named Raphael Lemkin in 1944. By combining the Greek word genos (race) with the Latin word cide (killing), genocide was defined by the United Nations in 1948 to mean any of the following acts committed with intent to destroy, in whole or in part, a national, ethnic, racial, or religious group, including (1) killing members of the group, (2) causing serious bodily or mental harm to members of the group, (3) deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part, (4) imposing measures intended to prevent births 87within the group, and (5) forcibly transferring children of the group to another group (Genocide Watch, International Alliance to End Genocide, 2013; http://www.genocidewatch.org/). The most notable genocides were the Al-Anfal genocide of the Kurds in Iraq, with more than 280,000 killed and many thousands unaccounted for; the Rwandan genocide, where the Hutus slaughtered hundreds of thousands (possibly 1 million) of their Tutsi relatives; the Irish potato famine, where more than a million Irish died because of lack of intervention by the British to feed the starving populace; the Native American genocide, with the loss of more than 1 million indigenous people to intentional infections with smallpox, war, and starvation; the Bosnian genocide and the annihilation of the Bosnian Muslims and Serbs to ethnically cleanse the country; and the most notable, the Holocaust, in which more than 6 million Jews and other ethnically disenfranchised populations were lost (http://listverse.com/2013/05/03/10-atrocious-genocides-in-human-history/). Genocide continues today in Syria, Darfur, and the Central African Republic. Following genocide, there are biopsychological changes such as physical stress reactions (cardiovascular, neurological) and mental stress responses, especially post-traumatic stress disorders and depression. Many people flee and become refugees or internationally displaced people. These refugees flee to neighboring countries, placing social, political, and economic burdens on these countries. I have been to the refugee camps in Uganda for refugees from Rwanda, the Congo, Kenya, and even northern Uganda, whose people have been victims of the Liberation Rebel Army (LRA) as political turmoil continues to plague the civilians in East Africa. The victims of genocide often face discrimination in refugee camps or in their new country of permanent residence if they do not return home. Individuals who return to their home countries are often plagued with uncertainty regarding lost property and other belongings. The biological and psychosocial effects of genocide are not exclusive to the child and adult victims, but affect the perpetrators as well. Marginalization and dehumanization place a mental toll on the victims that often results in negative cognitive, behavioral, affective, relational, and spiritual effects. Many perpetrators are forced into committing these acts, and achieving desensitization is necessary for a nonviolent person to kill or to commit violent acts. This is evident in the boy soldiers of the LRA (some as young as 6 years old) who are forced to kill or be killed and become desensitized through the use of alcohol, drugs, and repeated exposure to death (Vollhardt and Bilewicz, 2013). After genocidal conflicts have ceased, restoration of a country's infrastructure, as well as reconciliation, must begin. The ramifications of genocide are widespread, and community leaders must find the most effective ways of initiating the healing process. The United Nations has tried to develop strategies to prevent genocide from occurring and is encouraging initiatives that include appropriate comprehensive cultural competence in the delivery of services; supporting and organizing treatment and care that is fair and just to all members of specific societies, regardless of age, gender, race, cultural beliefs, religion, sexual orientation, affiliation, and civil status; encouraging international organizations to make mental and behavioral health a priority in conflict assistance throughout the various stages of genocide; and encouraging its member organizations to emphasize the importance of social work in regard to genocide in their respective countries (Vollhardt and Bilewicz, 2013). Surveillance Systems Surveillance systems, discussed in Chapter 24, are used to track potential risks for intentional harm to the people of the world. There are systems in place to assess the risks for man-made and natural disasters to prevent the atrocities to mankind discussed previously. These systems may be on-the-ground specialists who acquire information about the political stability of nations, or they may be satellite systems that track weather, volcanic, and earthquake activities. How would a government find out that a deliberate outbreak had taken place? For the international system, the WHO monitors disease outbreaks through the Global Outbreak Alert and Response Network (Center for Research on the Epidemiology of Disaster, 2012; WHO, 2014g). This network, formally launched in April 2000, electronically links the expertise and skills of 72 existing networks from around the world, several of which were uniquely designed to diagnose unusual agents and handle dangerous pathogens. Its purpose is to keep the international community constantly alert to the threat of outbreaks and ready to respond. It has four primary tasks: 1. Systematic disease intelligence and detection: The first responsibility of the WHO network is to systematically gather global disease intelligence, drawing from a wide range of resources, both formal and informal. Ministries of Health, WHO country offices, government and military centers, and academic institutions all file regular formal reports with the Global Outbreak Alert and Response Network. An informal network scours world communications for rumors of unusual health events. 2. Outbreak verification: Preliminary intelligence reports from all sources, both formal and informal, are reviewed and converted into meaningful intelligence by the WHO Outbreak Alert and Response Team, which makes the final determination on whether a reported event warrants cause for international concern. 3. Immediate alert: A large network of electronically connected WHO member nations, disease experts, health institutions, agencies, and laboratories is kept continually informed of rumored and confirmed outbreaks. The network also maintains and regularly updates an Outbreak Verification List, which provides a detailed status report on all currently verified outbreaks. 4. Rapid response: When the Outbreak Alert and Response Team determines that an international response is needed to contain an outbreak, it enlists the help of its partners in the global network. Specific assistance available includes targeted investigations, confirmation of diagnoses, handling of dangerous biohazards (biosafety level IV pathogens), client care management, containment, and logistical support in terms of staff and supplies. 88 In summary, if health care professionals and emergency responders are to be prepared to manage natural or manmade disasters, it is critical that there be cooperative efforts at the international, national, state, and local levels (Box 4-5). Such disaster response is not the domain of any one specialty; nurses, doctors, mental health experts, first responders, EMTs, volunteers, engineers, and many more need to be part of the team that helps people overcome the physical, emotional, social, and economic devastation. Nurses need to have political, historical, social, medical, nursing, and public health knowledge in order to be more effective in finding the resources their clients need to recover successfully. image Linking Content to Practice The role and involvement of nurses in global health relies heavily on nursing standards of practice and core competencies of both nurses and other public health professionals. The role also varies from country to country. It is not surprising to learn that nursing plays a more active role in health care delivery in the more technologically advanced countries. The more developed countries have a defined role for nurses, whereas the role is less well defined, if it is defined at all, in less developed countries. However, nurses need to remember that addressing the health of the people of the world is not restricted to meeting the physical health needs but, in order to be successful, must incorporate the concept of global health diplomacy. Physical, environmental, mental, political, fiscal, economic, safety, and educational “health” are intertwined in achieving the goals we all have for helping the people of the world obtain optimal well-being. Assessment of each of these areas is cited in standards of practice for nursing and public health professionals and is essential in the global nursing role. See the Quad Council on Nursing's competencies (Swider et al, 2014), which incorporate those of the Council on Linkages core competencies for public health professionals. Each set of competencies recommends analytic/assessment skills that are crucial to working in a global health arena. They also talk about the importance of cultural competence skills and communication skills that are relevant to the people with whom you are working. During the last decade, some less developed countries have implemented primary health care programs directed at prevention and management of important public health problems. With the increasing migration between and within countries because of war and famine, a greater need for nursing expertise to alleviate suffering of refugees and displaced persons has emerged. Starvation, disease, death, war, and migration underscore the need for support from the wealthier nations of the world. More than 30 million refugees and internally displaced persons in less developed countries currently depend on international relief assistance for survival. Death rates in these populations during the acute phase of displacement have been up to 60 times the expected rates. Displaced populations in Ethiopia and southern Sudan have suffered the highest death rates. In Afghanistan and in war-torn Iraq, infectious diseases accounted for one half of all admissions to the hospital—mostly malaria and typhoid fever. The greatest death rate has been in children 1 to 14 years old. The major causes of death have been measles, diarrheal diseases, acute respiratory tract infections, and malaria. In addition, poor sanitation in many hospitals and clinics and shortages of drugs and qualified health care workers produce huge gaps for needed health care services. Continued violence accounts for a population afraid to leave home to seek medical help. 89 Nurses from more developed countries are recruited to combat the major mortality in refugee camps: malnutrition, measles, diarrhea, pneumonia, and malaria. Nurses, collaborating with other experts, are following the principles of primary health care and are promoting adequate food intake, safe drinking water, shelter, environmental sanitation, and immunizations. These life-saving practices have been implemented in the following countries: Thailand (Myanmar refugees), Rwanda, Zaire, Angola, Afghanistan, the Sudan, Uganda, and the former Yugoslavia. Nurses are making a difference; however, nurses involved in this work must be culturally astute and responsive, be well educated about the world and well versed in the tasks required to achieve positive outcomes, able to critically reason, able to make decisions, able to identify who are appropriate team members, and be able to collaborate with the team. They ought not be afraid of taking risks, they should be action-oriented, and they need to be flexible and altruistic. Global health work is a labor of love, it is a giving of self to make a difference in the lives of others less fortunate, and it is the most rewarding work in which many nurses have ever been engaged. Council on Linkages Between Academic and Public Health Practice: Core Competencies for Public Health Professionals. Washington, DC, 2010. Public Health Foundation/Health Resources and Services Administration. Quad Council of Public Health Nursing Organizations. Competencies for Public Health Nursing Practice, Washington, DC, 2003, ASTDN, revised 2009. Box 4-5 What Can Nursing Do in the Event of a Disaster? The International Council of Nursing (ICN, 2009) policy paper on disaster preparedness outlines actions, including risk assessment and multidisciplinary management strategies, as critical to the delivery of effective responses to the short-, medium-, and long-term health needs of a disaster-stricken population. These actions include the following: Help People to Cope with Aftermath of Terrorism • Assist people to deal with feelings of fear, vulnerability, and grief. • Use groups that have survived terrorist attacks as useful resources for victims. Allay Public Concerns and Fear of Bioterrorism • Disseminate accurate information on the risks involved, preventive measures, use of antibiotics and/or vaccines, and reporting suspicious letters or packages to the police or other authorities. • Address hoax messages, false alarms, and threats; any perceived threat to the public health must be investigated. Identify the Feelings That You and Others May be Experiencing • In the aftermath of terror, even health care professionals can feel bias, hatred, vengeance, and violence toward ethnic or religious groups that are associated with terrorism. These feelings can compromise their ability to provide care for these groups. Yet as the ICN Code of Ethics for Nurses affirms, nurses are ethically bound to provide care to all people. Explain that feelings of fear, helplessness, and loss are normal reactions to a disruptive situation. • Help people remember methods they may have used in the past to overcome fear and helplessness. • Encourage people to talk to others about their fears. • Encourage others to ask for help and provide resources and referrals. • Remember that those in the helping professions (e.g., nurses, physicians, social workers) may find it difficult to seek help. • Convene small groups in workplaces with counselors/mental health experts. Assist Victims to Think Positively and to Move Toward the Future • Remind others that things will get better. • Be realistic about the time it takes to feel better. • Help people to recognize that the aim of terrorist attacks is to create fear and uncertainty. • Encourage people to continue with the things they enjoy in their lives and to live their normal lives. Prepare Nursing Personnel to be Effective in a Crisis/Emergency Situation • Incorporate disaster preparedness awareness in educational programs at all levels of the nursing curriculum. • Provide continuing education to ensure a sound knowledge base, skill development, and ethical framework for practice. • Network with other professional disciplines and governmental and nongovernmental agencies at local, regional, national, and international levels. From ICN. Nursing Matters: Terrorism and bioterrorism: nursing preparedness. Available at http//www.icn.ch/publications/disaster-planning–and relief. Accessed December 27, 2010; International Council of Nurses (ICN): Code of Ethics for Nurses, Geneva, 2000, ICN. Practice Application You are sent to a country ravaged by war, in which many people are refugees. You are asked to work side by side with other nurses, both foreign and native to the country. A. What would you do first to develop this group of nurses into a functioning team? B. Which health and environmental problems would you attempt to handle early in your work? C. Identify second-stage interventions and prevention once the initial crisis stage is relieved. Answers can be found on the Evolve site. Key Points • Global health is a collective goal of nations and is promoted by the world's major health organizations. • Global health cannot be achieved without using the constructs of global health diplomacy: addressing and finding solutions to physical, environmental, fiscal, economic, political, safety, educational, and trade issues. • As the political and economic barriers between countries fall, the movement of people back and forth across international boundaries increases. This movement increases the spread of various diseases throughout the world. • Nurses play an active role in the identification of potential health risks at U.S. borders, with immigrant populations throughout the United States, and as participants in global health care delivery. • Understanding a population approach is essential for understanding the health of specific populations. • Universal access to health care for the world's populations relies on strong primary care. • The major organizations involved in world health are (1) multilateral, (2) bilateral and nongovernmental or private voluntary, and (3) philanthropic. • The health status of a country is related to its economic and technical growth. More technologically and economically advanced countries are referred to as developed, whereas those that are striving for greater economic and technological growth are termed less developed. Many less developed countries shift financial resources from health and education to other internal needs, such as defense or economic development, and this shift does not help the poor. • The global burden of disease (GBD) is a way to describe the world's health. The GBD combines losses from premature death and losses that result from disability. The GBD represents units of disability-adjusted life-years (DALYs). • Critical global health problems still exist and include communicable diseases such as tuberculosis, measles, mumps, rubella, and polio; maternal and child health; diarrheal diseases; nutritional deficits; malaria; and AIDS. • Natural and man-made disasters have become global health concerns. Clinical Decision-Making Activities 1. In your class, divide into small groups and discuss how you might find out if there are immigrant communities in your area (you may need to contact your local health department, area social workers, or community social organizations and churches). 2. Discuss how you can gain access to one of these immigrant groups. 3. On gaining access, how would you go about determining what specific kinds of services the people need? What are their beliefs about health and health care? What customs regarding health were followed in their country of origin? How does the American health care system differ from the health care system in their country? 4. As a nurse, what kinds of interventions can you implement with immigrant populations? What special skills or knowledge do you need to provide care to immigrant populations? 5. Write to one of the major international health organizations or visit their Internet web page and obtain their mission and goal statements. What is the focus of their health-related activities? Does the organization that you identified have a specific role defined for nurses? How can a nurse who is interested become involved in their programs and activities? 90 6. Pick a country or area of the world outside the United States that interests you. Go to the library or use the Internet to obtain information about the following: a. Status of health care in that country b. Major health concerns c. Global burden of disease (GBD) d. Whether this country is developed or lesser developed e. Which, if any, global health care organizations are involved with the delivery of health care in that country 7. Choose one or more of the following countries, and find out from your local or state health department the health risks that are involved in visiting that country: Indonesia, Zaire, Paraguay, Bangladesh, Kuwait, Kenya, Mexico, China, and Haiti. 8. 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World Health Organization. Metrics: Disability-Adjusted Life Year (DALY). Health statistics and health information systems. http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/; 2014. World Health Organization. HIV/AIDS. Global health observatory. http://www.who.int/gho/hiv/en/; 2014 [Accessed February 20, 2014]. World Health Organization. Global outbreak alert & response network. http://www.who.int/csr/outbreaknetwork/en/; 2014 [Accessed March 28, 2014]. World Resources Institute. World resource report 2010-2011. http://www.wri.org/publication/world-resources-report-2010-2011; 2012. Yun H, Jie S, Anli J. Nursing shortage in China: state, causes, and strat. Chapter 5 There is strong evidence to suggest that poverty can be directly related to poorer health outcomes. Poorer health outcomes lead to reduced educational outcomes for children, poor nutrition, low productivity in the adult workforce, and unstable economic growth in a population, community, or nation. However, improving health status and economic health is dependent on the “degree of equality” in policies that improve living standards for all members of a population including the poor. To move toward improving a population's health, there must be an “investment in public health” by all levels of government (Robert Wood Johnson Foundation, 2013). Estimates indicate that public spending on health care makes a difference, but a sustained and sufficient level of investment in prevention at the federal, state, and local levels is needed to improve the overall health status of populations (Trust for America's Health, 2013a,b and 2014). Several facts are known from the literature (Kaiser Family Foundation, 2013; Robert Wood Johnson Foundation, 2013; DeNavas-Walt et al, 2013; U.S. Department of Health and Human Services [USDHHS], 2012): • In 2012, approximately 48 million (15.4%) of the estimated 311.1 million people in the United States were without health insurance (DeNavas-Walt et al, 2013). Over the past decade, the number of uninsured individuals has increased, largely due to the struggling economy and weak job market (Kaiser Family Foundation, 2012a). As the Affordable Care Act is implemented, new and affordable options will become available, hopefully reducing the number of uninsured individuals and families (Kaiser Family Foundation, 2012a). • The rate of uninsured was higher among people with lower incomes and lower among those with higher incomes. For households with less than $25,000 annual income, 24.9% did not have health insurance coverage in 2012 (DeNavas-Walt et al, 2013). • Adults are more likely to be uninsured than children (Kaiser Family Foundation, 2013). • Young adults (ages 19-25 years) account for a disproportionately large share of the uninsured, largely due to their low incomes (Kaiser Family Foundation, 2013; USDHHS, 2012). • The uninsured rate for all children was 8.9% in 2012. For children living in poverty the uninsured rate was 12.9%, which was higher than the rate of children not in poverty (7.7%) (DeNavas-Walt et al, 2013). • Minorities are more likely to be uninsured than whites. About 32% of Hispanics and 21% of black Americans were uninsured in 2011, compared with 13% of non-Hispanic whites (Kaiser Family Foundation, 2012a; USDHHS, 2012). 96 • More than 8 in 10 (80%) of the uninsured are in working families (Kaiser Family Foundation, 2012a). • About 62% are from families with one or more full-time workers. • About 16% are from families with part-time workers. • Individuals without health insurance are less likely to receive preventive care, such as blood pressure, cholesterol, and cancer screenings, than those with insurance coverage (Kaiser Family Foundation, 2012a). • Those without health insurance are more likely to be hospitalized for preventable problems, and when hospitalized receive fewer diagnostic and therapeutic services; they also have higher mortality rates than those with insurance (Kaiser Family Foundation, 2012a). • Adults without insurance are nearly twice as likely to report being in fair or poor health than those with private insurance (Kaiser Family Foundation, 2012a). • Studies indicate that gaining health insurance restores access to health care considerably and reduces the adverse effects of having been uninsured (Kaiser Family Foundation, 2012a). • The poor are more likely to receive health care through publicly funded agencies. • An emphasis on individual health care will not guarantee improvement of a population or a community's health (see Chapter 3 for more discussion). Approximately 97% of all health care dollars are spent for individual care whereas only 3% are spent on population-level health care. The 3% includes monies spent by the government on public health as well as the preventive health care dollars spent by private sources. These numbers indicate that there has not been a large investment in the public's health or population health in the United States (National Center for Health Statistics [NCHS], 2012). The United States spends more on health care than any other nation. The cost of health care has been rising more than the rate of inflation since the mid-1960s, yet the U.S. population does not enjoy better health as compared with nations that spend far less than the United States. The current health care system has been reaching the point where it is not affordable (Turnock, 2011; Trust for America's Health, 2013b). An estimated $10 per person invested in community-based prevention programs can lead to improved health status of the population and reduced health care costs (Robert Wood Johnson Foundation, 2012). This return on investment represents medical cost savings only and does not include the significant gains that could be achieved in worker productivity, reduced absenteeism at work and school, and enhanced quality of life. Nurses are challenged to implement changes in practice and participate in research, evidence-based practice, and policy activities designed to provide the best return on investment of health care dollars (i.e., to design models of care, at a reasonable price, that improve access or quality of care). Meeting this challenge requires a basic understanding of the economics of the U.S. health care system. Nurses should be aware of the effects of nursing practice on the delivery of cost-effective care. In 2010, a new health reform law, the Patient Protection and Affordable Care Act (PL 111-148) was passed by Congress and signed into law on March 23, 2010. There is now a greater emphasis in the Affordable Care Act (ACA) on improving participation and the outcomes of prevention, and population health. Public Health and Economics Economics is the science concerned with the use of resources, including the production, distribution, and consumption of goods and services. Health economics is concerned with how scarce resources affect the health care industry (McPake et al, 2013; Phelps, 2012). Public health economics, then, focuses on the production, distribution, and consumption of goods and services as related to public health and where limited public resources might best be spent to save lives or best increase the quality of life (Centers for Disease Control and Prevention [CDC], 2015). Economics provides the means to evaluate society's attainment of its wants and needs in relation to limited resources. In addition to the day-to-day decision making about the use of resources, there is a focus on evaluating economics in health care (McPake et al, 2013; Phelps, 2012). While in the past there has been limited focus on evaluating public health economics, it is becoming more obvious what evaluating public health and preventive care can do in terms of cost savings and, more importantly, quality of life (Trust for America's Health, 2013b). This type of evaluation will help to present challenges to public policymakers (legislators). Public health financing often causes conflict because of the views and priorities of individuals and groups in society, which may differ from those of the public health care industry. If money is spent on public health care, then money for other public needs, such as education, transportation, recreation, and defense, may be limited. When trying to argue that more money should be spent for population-level health care or prevention, data are becoming available that show the investment is a good one. Public health finance is a growing field of science and practice that involves the acquiring, managing, and using of monies to improve the health of populations through disease prevention and health promotion strategies. This field of study also focuses on evaluating the use of the money and the impact on the public health system (Honoré, 2012). Although the public health system had been considered for many years as involving only government public health agencies such as health departments, today the public health system is known to be much broader and includes schools, industry, media, environmental protection agencies, voluntary organizations, civic groups, local police and fire departments, religious organizations, industry/business, and private sector health care systems, including the insurance industry. All can play a key role in improving population health (Institute of Medicine, 2003; Trust for America's Health, 2013a). The goal of public health finance is “to support population focused preventive health services” (Honoré, 2012). Four principles are suggested that explain how public health financing may occur (Sturchio and Goel, 2012): • The source and use of monies are controlled solely by the government. 97 • The government controls the money, but the private sector controls how the money is used. • The private sector controls the money, but the government controls how the money is used. • The private sector controls the money and how it is used. When the government provides the funding and controls the use, the monies come from taxes, user fees (e.g., license fees and purchase of alcohol/cigarettes), and charges to consumers of the services. Services offered at the federal government level include the following: • Policymaking • Public health protection • Collecting and sharing information about U.S. health care and delivery systems • Building capacity for population health • Direct care services Select examples of services offered at the state and local levels include the following: • Environmental health monitoring • Population health planning • Disaster management • Preventing communicable and infectious diseases • Direct care services (see Chapter 46 for more examples) When the government provides the money but the private sector decides how it is used, the money comes from business and individual tax savings related to private spending for illness prevention care. When a business provides disease prevention and health promotion services to its employees and sometimes families, such as immunizations, health screenings, and counseling, the business taxes owed to the government are reduced. This is considered a means by which the government provides money through tax savings to businesses to use for population health care. When the private sector provides the money but the government decides how it is used, either voluntarily or involuntarily, the money is used for preventive care services for specific populations. A voluntary example is the private contributions made to reaching Healthy People 2020 goals. An involuntary example is the Occupational Safety and Health Administration requiring industry to provide the financing to adhere to certain safety standards for use of machinery, air quality, ventilation, and eyewear protection to reduce disease and injury. This, for example, has the effect of reducing occupation-related injuries in the population as a whole. When the private sector is responsible for both the money and its use of resources, the benefits incurred are many. For example, an industry may offer influenza vaccine clinics for workers and families that may lead to “herd immunity” in the community (see Chapter 12 on epidemiology). A business or community may institute a “no-smoking” policy that reduces the risk of smoking-related illnesses to workers, family, and the consumers of the businesses' services. A voluntary philanthropic organization may give a local community money to provide services for assisting low-income communities to improve their environment (Fortunato and Sessions, 2011). These are but a few examples of how public health services and the ensuring of a healthy population are not only government related. The partnerships between government and the private sector are necessary to improve the overall health status of populations. This partnership is emphasized in the ACA. Principles of Economics Knowledge about health economics is particularly important to nurses because they are the ones who are often in a position to allocate resources to solve a problem or to design, plan, coordinate, and evaluate community-based health services and programs. Two branches of economics are important to understand for their application in health care: microeconomics and macroeconomics. Microeconomic theory deals with the behaviors of individuals and organizations and the effects of those behaviors on prices, costs, and the allocating and distributing of resources. Economic behaviors are based on (1) individual or organization choices and the consumer's level of satisfaction with a particular good (product) or service, or use of a service, and (2) the amount of money available to an individual or organization to spend on a particular good or service (its budget limits). Microeconomics applied to health care looks at the behaviors of individuals and organizations that result from tradeoffs in the use of a service and budget limits. A good example of reducing services because of cost by an organization is the reduction in school health nursing services by health departments. The microeconomic example of the industry providing preventive services to its employees represents a behavior by the industry that provides for the use of a service and helps the industry's budget by reducing health care insurance premium costs. The terms of the Patient Protection and Affordable Health Care Act (2010) allow employers to provide incentive rewards to employees for participation in wellness programs. Providing the service may also increase worker productivity and promote a healthier workforce, thus enhancing economic growth (Hall, 2010). Because of the unique characteristics of health care, some economists believe that health care is special. There are debates about whether health care markets can ensure that health care is delivered efficiently to consumers. Cost-benefit and cost-effectiveness analyses are techniques used to judge the effect of interventions and policies on a particular outcome, such as health status (Feldstein, 2012). Supply and Demand Two basic principles of microeconomic theory are supply and demand, both of which are affected by price. A simple illustration of the relationship between supply and demand is provided in Figure 5-1. The upward-sloping supply curve represents the seller's side of the market, and the downward-sloping demand curve reflects the buyer's desire for a given product. image FIG 5-1 Supply-and-demand curve. As shown in Figure 5-1, suppliers are willing to offer increasing amounts of a good or service in the market for an increasing price (Colander, 2012). The demand curve represents the amount of a good or service the consumer is willing to purchase at a certain price. This curve illustrates that when few quantities of a 98good or service are available in the marketplace, the price tends to be higher than when larger quantities are available. The point on the curve where the supply and demand curves cross is the equilibrium, or the point where producer and consumer desires meet (See Box 5-1). Supply and demand curves can shift up or down as a result of the following factors (McPake et al, 2013): • Competition for a good or service • An increase in the costs of materials used to make a product • Technological advances • A change in consumer preferences • Shortages of goods or services Box 5-1 Principles of the Laws of Supply and Demand The Law of Supply • At higher prices, producers are willing to offer more products for sale than at lower prices. • The supply increases as prices increase and decreases as prices decrease. • Those already in business will try to increase production as a way of increasing profits. The Law of Demand • People will buy more of a product at a lower price than at a higher price, if nothing changes. • At a lower price, more people can afford to buy more goods and more of an item more frequently than they can at a higher price. • At lower prices, people tend to buy some goods as a substitute for more expensive goods. Data from Curriculum Link, 2010. Provides a review of the laws of supply and demand. Using the example of industry-offered health care, it was not likely that a small industry of fewer than 50 employees would be able to offer incentive-based on-site illness prevention services. The demand might be great to keep employees healthy and on the job. The supply has been limited by the cost and numbers of services available in the community. Therefore, the cost was likely to be higher for the small business than for the large industry that offers its own services. The ACA proposes to offer preventive services free to the consumer, requiring insurance companies to cover these services (USDHHS, ACA, 2014a). Efficiency and Effectiveness Two other terms are related to microeconomics: efficiency and effectiveness. Efficiency refers to producing maximal output, such as a good or service, using a given set of resources (or inputs), such as labor, time, and available money. Efficiency suggests that the inputs are combined and used in such a way that there is no better way to produce the service, or output, and that no other improvements can be made. The word efficiency often focuses on time, or speed in performing tasks, and the minimizing of waste, or unused input, during production. Although these notions are true, efficiency depends on tasks as well as processes of producing a good or service and the improvements made (Feldstein, 2012). Effectiveness, on the other hand, refers to the extent to which a health care service meets a stated goal or objective, or how well a program or service achieves what is intended. For example, the effectiveness of a mass immunization program is related to the level of “herd immunity” developed to reduce the problem that the program was addressing (see Chapter 12). Box 5-2 illustrates the differences between efficiency and effectiveness (Feldstein, 2012). Box 5-2 Efficiency versus Effectiveness To illustrate the differences between efficiency and effectiveness, consider the case of a nurse who is designing a community outreach program to educate high-risk, first-time mothers about the importance of childhood immunizations. The most efficient method to disseminate the information to a large number of mothers might be to have the child health team from the public health department hold an evening educational session, open to the public, at the health department. The most effective means of offering the program might be to link public health nurses with new mothers for one-on-one, in-home counseling, demonstration, and follow-up. The goals of the program could be stated as follows: • To change the behavior of the mothers regarding providing immunizations for their children • To increase community mothers' knowledge and awareness of infectious diseases • To reduce the incidence of preventable infections in the community • To decrease the number of hospital admissions Macroeconomics Microeconomics focuses on the individual or an organization, whereas macroeconomic theory focuses on the “big picture”—the total, or aggregate, of all individuals and organizations (e.g., behaviors such as growth, expansion, or decline of an aggregate). In macroeconomics, the aggregate is usually a country or nation. Factors such as levels of income, employment, general price levels, and rate of economic growth are important. This aggregate approach reflects, for example, the contribution of all organizations and groups within health care, or all industry within the United States, including health care, on the nation's economic outlook. 99 When the media refer to “the economy,” the phrase is typically used as a macroeconomic term to describe the wealth and financial performance of the nation as an aggregate. Health care contributes to the economy through goods and services produced and employment opportunities. The primary focuses of macroeconomics are the business cycle and economic growth. Business expands and contracts in cycles. These cycles are influenced by a number of factors, such as political changes (a new president is elected), policy changes (new legislation is implemented, such as the Patient Protection and Affordable Health Care Act of 2010), knowledge and technology advances (a new vaccine to treat H1N1/H5N1 is placed on the market), or simply the belief by a recognized business leader that the cycle is or should be shifting (e.g., when the head of the Federal Reserve Board changes interest rates). The human capital approach is a measure of macroeconomic theory (Goodwin et al, 2014). In this approach improving human qualities, such as health, are a focus for developing and spending money on goods and services because health is valued; it increases productivity, enhances the income-earning ability of people, and improves the economy. Therefore, there is a positive rate of return on the “investment in human capital.” The individual, population, community, and nation all benefit. If the population is healthy, premature morbidity and mortality are reduced, chronic disease and disability are reduced, and economic losses to the nation are reduced. As an example, more people can work and be productive because they are healthy. The employing company makes more money because people are more productive. More taxes are paid into the local, state, and national economy, and more money is spent by individuals because they are productive, earning money, and taking advantage of the goods and services offered in their community. Measures of Economic Growth Economic growth reflects an increase in the output of a nation. Two common measures of economic growth are the gross national product (GNP) and the gross domestic product (GDP). GNP is the total market value of all goods and services produced in an economy during a period of time (e.g., quarterly or annually). GDP is the total market value of the output of labor and property located in the United States (Strawser, 2014). GDP reflects only the national U.S. output, whereas GNP reflects national output plus income earned by U.S. businesses or citizens, whether within the United States or internationally. This discussion focuses on GDP, because U.S. health care spending reports are based on GDP (NCHS, 2010). Nurses face microeconomic and macroeconomic issues every day. For example, they are influenced by microeconomics when referring clients for services, informing clients and others of the cost of services, assessing community need for a particular service, evaluating client access to services, and determining health provider and agency response to client needs. Nurses who work with aggregates of individuals and communities are faced with macroeconomic issues, such as health policies that make the development of new programs possible; local, state, and federal budgets that support certain programs; and the total effect that services will have on improving the health of the community and reducing the poverty level of the population. In short, knowledge about health economics can enhance a nurse's ability to understand and argue a position for meeting population health needs. Economic Analysis Tools The primary methods used to assess the economics of an intervention are cost-benefit analysis (CBA), cost-effectiveness analysis (CEA), and cost-utility analysis (CUA). CBA is considered the best of these methods. In simple form, CBA involves the listing of all costs and benefits that are expected to occur from an intervention during a prescribed time. Costs and benefits are adjusted for time and inflation. If the total benefits are greater than the total costs, the intervention has a net positive value (NPV). Future or continued funding is given to the intervention with the highest NPV. This technique provides a way to estimate overall program and social benefits in terms of net costs. A good example of using CBA would be the cost of an influenza vaccine mass immunization program in a community. If most people in the community are vaccinated and the rate of influenza is low or decreased from past years or in relation to the national average, the benefits are many. Citizens can work, play, go to school, participate in other community activities, and, again, be productive. The community is healthy. These are but a few of the benefits of this program. CBA requires that all costs and benefits be known and quantifiable in dollars; herein lies the major problem with its use. Although it is fairly easy to estimate the direct dollar costs of a health care program, it is often very difficult to quantify the nondollar benefits and indirect costs. For example, benefits and costs could come in the form of increased income and expenses, which are fairly easy to measure. More difficult to measure are benefits such as improved community welfare resulting from a particular program, and the costs to the community that would result if the program did not exist. The value of potential lives lost because of lack of access to health care services is one example. The potential for a great number of lives lost from H1N1 resulted in the development of programs and monies invested with pharmaceutical companies in an attempt to reduce the risk of lives lost should the United States experience an epidemic from this disease risk. Although benefits could only be assumed from the cost investment, it was determined that the investment was essential (CDC, 2009). CEA expresses the net direct and indirect costs and cost savings in terms of a defined health outcome. The total net costs are calculated and divided by the number of health outcomes. Although the data required for CEA are the same as for CBA, CEA does not require that a dollar value be put on the outcome (e.g., on an outcome such as quality of life). CEA is best used when comparing two or more strategies or interventions that have the same health outcome in the population. Both CEA and CBA are useful to nurses as they conduct community needs analyses and develop, propose, implement, and evaluate programs to meet community health needs. In both cases, the cost of a particular program or intervention is examined relative to the money spent and outcomes achieved. Using the same example of the mass immunization program, a comparison of 100the overall outcomes of the client visit to the clinic for vaccination in one community versus the mass immunization program at the community center in another community could be done. Outcomes could be the percentage of the population vaccinated by each method and the rate of influenza in each community. In this process, if the higher cost program results in lower rates of illness then that program would be considered the most effective. An objective commonly used when CEA is performed in health care is improvement in quality of adjusted life-years (QALYs) for clients. QALYs are the sum of years of life multiplied by the quality of life in each of those years. The QALY assigns a value, ranging between 0 (death) and 1 (perfect health), to reflect quality of life during a given period of years (Lindemark et al, 2014). In conducting a CEA, the cost of a program or an intervention is compared with real or expected improvements in clients' quality of life. The How To Box lists the steps involved in conducting a CEA. The QALY is often used in malpractice suits to award money to clients who have been injured by health care. How to Do a Cost-Effectiveness Analysis (CEA) In a cost-effectiveness analysis (CEA), the outcome of the service option is measured in a natural, nonmonetary unit such as years of life gained, therapeutic successes such as reducing the numbers of influenza cases in a community, or lives saved. Results are expressed as the net cost required to produce one or each of the outcomes. The cost to outcome is expressed as a ratio of cost per unit of outcome, where the numerator is a monetary value corresponding to the net expenditure of resources and the denominator is the net improvement in health expressed in nonmonetary terms. The steps for performing a simplified CEA are as follows: 1. Establish a program or service goals and objectives. 2. Consider all possible alternatives to achieve the goal or objectives, which could mean comparing two different programs that are attempting to achieve the same outcome. 3. Measure net effects to reflect a change in health status or health outcome. 4. Analyze costs for each alternative or program for reducing the cases of influenza in a community, such as a mass immunization clinic for a total community population or having individuals choose to go to their private provider for the vaccine. 5. Combine CEA results with other types of information such as past results of a similar program in a different year and the change in influenza cases in the community for the year of the comparison of programs, not included in the CEA, to make the most appropriate therapeutic or policy decision. Depending on the program or intervention goals, the most effective means of providing a service is not necessarily the least costly, particularly in the short run. This is particularly true in public health, where the cost-effectiveness of a preventive service may not be known until sometime in the future. For example, the total cost savings of a community no-smoking program might be difficult to project 10 years into the future. After 10 years, the number of lung cancer cases or deaths that have occurred can be compared with those in the 10 years before the program, and the cost-effectiveness of the no-smoking program can be shown. Trust for America's Health (2013a,b), along with a number of other agencies, is publishing reports that are beginning to show positive results and cost savings from prevention programs. Factors Affecting Resource Allocation in Health Care The distribution of health care is affected largely by the way in which health care is financed in the United States. Third-party coverage, whether public or private, greatly affects the distribution of health care. Also, socioeconomic status affects health care consumption, because it has determined the ability to purchase insurance or to pay directly out-of-pocket. A description of the effects of barriers to health care access and the effects of health care rationing on the distribution of health care follow. Although the barriers are still issues, it remains to be determined how the health care reform of 2010 will change the barriers to access and distribution. One solution proposed is the Health Insurance Marketplace (Patient Protection and Affordable Care Act, 2010). The Uninsured In 1996, 68% of the total U.S. population had private health insurance. An additional 15% received insurance through public programs, and 17%, or 37 million, were uninsured. In 2008 the number of uninsured persons had increased to 47 million. By 2012 the number had grown to 48 million citizens (DeNavas-Walt et al, 2013). The typical uninsured person is a member of the workforce or a dependent of this worker. Uninsured workers are likely to be in low-paying jobs, part-time or temporary jobs, or jobs at small businesses (Kaiser Family Foundation, 2012a). These uninsured workers have not been able to afford to purchase health insurance, or their employers may not have offered health insurance as a benefit. Others who are typically uninsured are young adults (especially young men), minorities, persons less than 65 years of age in good or fair health, and the poor or near poor. These individuals may have been unable to afford insurance, may lack access to job-based coverage, or, because of their age or good health status, may not perceive the need for insurance. Because of the eligibility requirements for Medicaid, the near poor are actually more likely to be uninsured than the poor. Socioeconomic status is inversely related to mortality and morbidity for almost every disease. Poor Americans with an income below the poverty level have a mortality rate nearly several times greater than that of middle-income Americans, even after accounting for age, sex, race, education, and risky health behaviors (e.g., smoking, drinking, overeating, and lack of exercise) (Robert Wood Johnson Foundation, 2009 and 2013). Historically, the link between poor health and socioeconomic status resulted from poor housing, malnutrition, inadequate sanitation, and hazardous occupations. Today, explanations include the cumulative effects of a number of characteristics that explain the concept of poverty. These characteristics include low educational levels, unemployment or low occupational status (blue-collar or unskilled laborer), low 101wages, being a child or an older person over the age of 65 years, or being a member of a minority group (NCHS, 2012). Access to Health Services Access to health services is a public health issue (USDHHS, 2010). Medicaid is intended to improve access to health care for the poor. Although persons with Medicaid have improved access compared with the uninsured, Medicaid recipients have been only about half as likely to obtain needed health services (e.g., medical-surgical care, dental care, prescription drugs, and eyeglasses) as the privately insured. Specifically, the poorest Americans have Medicaid insurance, yet they also have the worst health (Kaiser Family Foundation, 2013). The primary reasons for delay, difficulty, or failure to access care included inability to afford health care and a variety of insurance-related reasons, including the insurer not approving, covering, or paying for care; the client having preexisting conditions; and physicians refusing to accept the insurance plan. Other barriers include lack of transportation, physical barriers, communication problems, child care needs, lack of time or information, or refusal of services by providers. In addition, lack of after-hours care, long office waits, and long travel distance are cited as access barriers. Community characteristics also contribute to individuals' ability to access care. For example, the limited prevalence of managed care and the limited number of safety net providers, as well as the wealth and size of the community, affect accessibility. Because reimbursement for services provided to Medicaid recipients has been low, physicians are discouraged from serving this population. Thus, people on Medicaid frequently have not had a primary care provider and may have relied on the emergency department for primary care services. Although physicians can respond to monetary incentives in client selection, emergency departments are required by law to evaluate every client regardless of ability to pay. Emergency department copayments are modest and are frequently waived if the client is unable to pay. Thus, low out-of-pocket costs have provided incentives for Medicaid clients and the uninsured to use emergency departments for primary care services. With the ACA, some of the issues and barriers that have previously existed may disappear. This depends on whether Congress continues attempts to repeal all or part of PL 111-148 or change some of the mandates in the law. By 2014 Medicaid recipients may benefit from the law in its current structure as follows: (1) Medicaid will expand to include all non–Medicare-eligible persons under age 65 with incomes up to 133% of federal poverty level, (2) all Medicaid-eligible persons will be guaranteed a benchmark benefit package, and (3) states will be given the option to develop a basic health plan for uninsured individuals who do not qualify for the Medicaid program, at 133% to 200% of the poverty level. At present, all states provide Medicaid and CHIP (Children's Health Insurance Program) health care coverage for some individuals, families and children, pregnant women, the elderly with certain incomes, and people with disabilities. Some states cover all adults below certain income levels. Because coverage differs by state, one must seek information about the specific state of interest. Some states are expanding Medicaid coverage whereas others continue with prior coverage plans (USDHHS, ACA, 2014a). However, all persons must have some form of insurance coverage or they will be charged a fee. Poverty level income is adjusted annually for each state by the federal government to indicate how much money an individual or families may earn to qualify for subsidies such as food stamps, Medicaid, and CHIP. In 2014 the federal poverty level for an individual was $11,670; for a family of four the poverty level was $23,850. If, for example, an individual's income was 133% of the poverty level, then that individual earned no more than $15,521.10 (USDHHS, 2014b). Rationing Health Care Rationing health care in any form implies reduced access to care and potential decreases in acceptable quality of services offered. For example, a health provider's refusal to accept Medicare or Medicaid clients is a form of rationing. As with access to care, rationing health care is a public health issue. Where care is not provided, the public health system and nurses must ensure that essential clinical services are available. Managed care was thought to offer the possibility of more appropriate health care access and better-organized care to meet basic health care needs of the total population. A shift in the general approach to health care from a reactionary, acute-care orientation toward a proactive, primary prevention orientation has been necessary for some time to achieve not only a more cost-effective but also a more equitable health care system in the United States. The ACA, while providing coverage to more people, will not do away with rationing because the new law provides for a five-tiered plan (bronze, silver, gold, platinum, and catastrophic) and by creating state-based American Health Benefit Exchanges. Persons at differing levels of poverty will have reductions in out-of-pocket expenses based on income up to 400% of the poverty level and may receive tax credits and subsidies to assist with out-of-pocket expenses (USDHHS, ACA, 2014a). Healthy People 2020 Healthy People 2020 goals are examples of strategies to provide better health care access for all people. The Levels of Prevention Box shows the levels of economic prevention strategies. image Levels of Prevention Economic Prevention Strategies Primary Prevention Work with legislators and insurance companies to support Affordable Care Act coverage for health promotion to reduce the risk of disease. Secondary Prevention Encourage clients who are pregnant to participate in prenatal care and WIC (Women, Infants, and Children) to increase the number of healthy babies and reduce the costs related to preterm baby care. Tertiary Prevention Participate in home visits to mothers who are at risk for neglecting babies to reduce the costs related to abuse. 102 Primary Prevention Society's investment in the health care system has been based on the premise that more health services will result in better health, but non–health care factors also have an effect. Of the major factors that affect health—personal biology and behavior (or lifestyle), environmental factors and policies (including physical, social, health, cultural, and economic environments), social networks, living and working conditions, and the health care system—medical services are said to have the least effect. Behavior and lifestyle have been shown to have the greatest effect, with the environment and biology accounting for the greatest effect on the development of all illnesses (NCHS, 2012). Despite the significant impact of behavior and environment on health, estimates indicate that 97% of health care dollars are spent on secondary and tertiary care. Such a reactionary, secondary/tertiary care system results in high-cost, high-technology, and disease-specific care and is consistent with the U.S. system's traditional emphasis on “sickness care.” A more proactive investment in disease prevention and health promotion targeted at improving health behaviors, lifestyle, and the environment has the potential to improve the health status of populations, thereby improving quality of life while reducing health care costs. The USDHHS has argued that a higher value should be placed on primary prevention. The goal of this approach is to preserve and maximize human capital by providing health promotion and social practices that result in less disease. An emphasis on primary prevention may reduce dollars spent and increase quality of life. As data are made available about the effects of the emphasis of the ACA on primary prevention and primary care, then dollars spent and increased quality of life may be evaluated. The return on investment in primary prevention through gains in human capital has not been acknowledged in the past, unfortunately. As a consequence, large investments in primary prevention and public health care have not been made. Reasons given for this lack of emphasis on prevention in clinical practice and lack of financial investment in prevention include the following: • Provider uncertainty about which clients should receive services and at what intervals • Lack of information about preventive services • Negative attitudes about the importance of preventive care • Lack of time for delivery of preventive services • Delayed or absent feedback regarding success of preventive measures • Less reimbursement for these services than curative services • Lack of organization to deliver preventive services • Lack of use of services by the poor and elderly • More out-of-pocket expenses for the poor and those who lack health insurance A focus on prevention could mean reducing the need for and use of medical, dental, hospital, and health provider services. Under fee-for-service payment arrangements, this would mean that the health care system, the largest employer in the United States, would be reduced in size and would become less profitable. However, with the increasing costs of health care and consumer demand and the changes in financing mechanisms, there is a new trend toward financing more preventive care services as is reflected in the ACA coverage for these services. Today, third-party payers will be covering preventive services, recognizing that the growth of the health care system can no longer be supported. Under capitated health plans, health care providers stand to make money by keeping clients healthy and reducing health care use. Through combining client interests with financial interests of the health care industry, primary prevention and public health can be raised to the status and priority of acute care and chronic care. Despite difficulties, methods for determining prevention effectiveness, such as CEAs and CBAs, are becoming standard and used more widely. Two agendas for preventive services have been published that promote the preventive agenda: • The U.S. Preventive Services Task Force, Guide to Clinical Preventive Services (Agency for Healthcare Research and Quality [AHRQ], 2014) for clinicians in primary care that outlines the regular screening and risk factors to look for at various ages • The Community Preventive Services Task Force (2014), which emphasizes population-level interventions to promote primary prevention Regardless of the method, prevention-effectiveness analyses (PEAs) are outcome oriented. This area of research seeks to link interventions with health outcomes and economic outcomes, and to reveal the tradeoffs between the two. In theory, support for increasing national investment in primary prevention is sound and long-standing. Since the public health movement of the mid-nineteenth century, public health officials, epidemiologists, and nurses have been working to advance the agenda of primary prevention to the forefront of the health care industry. Today, these efforts continue across a number of disciplines and in both the public and the private sectors, and through the efforts for health care reform (Healthy People 2020 Box). image Healthy People 2020 Objectives Related to Access to Care • AHS-1: Increase the proportion of persons with health insurance. • AHS-2: (Developmental) Increase the proportion of insured persons with coverage for clinical preventive services. • AHS-6: Reduce the proportion of individuals that experience difficulties or delays in obtaining necessary medical care, dental care, or prescription medicines. AHS, Access to Health Services. The Context of the U.S. Health Care System The U.S. health care system is a diverse collection of industries that are involved directly or indirectly in providing health care services. The major players in the industry are the health professionals who provide health care services, pharmacy and 103equipment suppliers, insurers (public/government and private), managed care plans (health maintenance organizations, preferred provider organizations), and other groups, such as educational institutions, consulting and research firms, professional associations, and trade unions (see Chapter 3). Today, the health care industry is large, and its characteristics and operations differ between rural and urban geographic areas. In the twenty-first century, health policy and national politics reflect the importance of health care delivery in the general economy. Conflicts arise between competing special-interest groups that have different goals and objectives when it comes to the producing and consuming of health services. To some degree this is caused by federal and state policy changes about how health services are financed (public and private). Figure 5-2 illustrates the four basic components that make up the framework of health services delivery: service needs and intensity, facilities, technology, and labor. Intensity is the extent of use of technologies, supplies, and health care services by or for the client. Intensity includes and is a partial measure of the use of technology (NCHS, 2012). Medical technology refers to the set of techniques, drugs, equipment, and procedures used by health care professionals in delivering medical care to individuals. It also includes information technology and the system within which such care is delivered (NCHS, 2012). image FIG 5-2 Components of health services development. Health care systems have developed in four phases from the 1800s through 2000. These developmental stages correspond to different economic conditions. Developmentally, the four components of the health services delivery framework have changed over time, reflecting macrolevel, or societal, changes in morbidity and mortality, national health policy, and economics (Figure 5-3). image FIG 5-3 Developmental framework for health service needs and intensity, facilities, technology, and labor. First Phase The first developmental stage (1800 to 1900) was characterized by epidemics of infectious diseases, such as cholera, typhoid, smallpox, influenza, malaria, and yellow fever. Health concerns of the time related to social and public health issues, including contaminated food and water supplies, inadequate sewage disposal, and poor housing conditions (Shi and Singh, 2011). Family and friends provided most health care in the home. Hospitals were few in number and suffered from overcrowding, disease, and unsanitary conditions. Sick persons who were cared for in hospitals often died as a result of these conditions. Most people avoided being cared for in a hospital unless there was no alternative. In this first developmental phase, health care was 104paid for by individuals who could afford it, through bartering with physicians or through charity from individuals or organizations. The first county health departments were established in 1908. Technology to aid in disease control was very basic and practical but in keeping with the knowledge of the time. The physician's “black bag” contained the few medicines and tools available for treatment. The economics of health care was influenced by the types of health care providers and the number of practitioners, and the labor force then was composed mostly of physicians and nurses who attained their skills through apprenticeships, or on-the-job training. Nurses in the United States were predominantly female, and education was linked to religious orders that expected service, dedication, and charity (Kovner et al, 2011). The focus of nursing was primarily to support physicians and assist clients with activities of daily living. Second Phase The second developmental stage (1900 to 1945) of U.S. health care delivery was focused on the control of acute infectious diseases. Environmental conditions influencing health began to improve, with major advances in water purity, sanitary sewage disposal, milk and water quality, and urban housing quality. The health problems of this era were no longer mass epidemics but individual acute infections or traumatic episodes (Shi and Singh, 2011). Hospitals and health departments experienced rapid growth during the late 1800s and early 1900s as technological advances in science were made (Kovner et al, 2011). In addition to private and charitable financing of health care, city, county, and state governments were beginning to contribute by providing services for poor persons, state mental institutions, and other specialty hospitals, such as tuberculosis hospitals. Public health departments were emphasizing case finding and quarantine. Although health care was paid for primarily by individuals, the Social Security Act of 1935 signaled the federal government's increasing interest in addressing social welfare problems. Clinical medicine entered its golden age during this period. Major technological advances in surgery and childbirth and the identification of disease processes, such as the cause of pernicious anemia, increased the ability to diagnose and treat diseases. The first serological tests used as a tool for diagnosis and control of infectious diseases were developed in 1910 to detect syphilis and gonorrhea (Shi and Singh, 2011). The first virus isolation techniques were also developed to filter yellow fever virus, for example. The discovery and development of pharmacological agents, such as insulin in 1922 for control of diabetes, sulfa drugs in 1932 for treatment of infectious diseases, and antibiotics such as penicillin in the 1940s, eradicated certain infectious diseases, increased treatment options, and decreased morbidity and mortality (Shi and Singh, 2011). Advances in technology and knowledge shifted physician education away from apprenticeships to scientifically based college education, which occurred as a result of the Flexner Report in 1910. It was the beginning of medical education as it is today. Nurses were trained primarily in hospital schools of nursing, with an emphasis on following and executing physicians' orders. Nurses in training were unmarried and under the age of 30. They provided the bulk of care in hospitals (Kovner et al, 2011). Public health nurses, who tracked infectious diseases and implemented quarantine procedures, worked more collegially with physicians (Kovner et al, 2011). In this period the university-based nursing programs were established to accommodate the expanding practice base of nursing. Client education became a nursing function early in the development of the health care delivery system. Third Phase The third developmental stage (1945 to 1984) included a shift away from acute infectious health problems of previous stages toward chronic health problems such as heart disease, cancer, and stroke. These illnesses resulted from increasing wealth and lifestyle changes in the United States. To meet society's needs, the number and types of facilities expanded to include, for example, hospital clinics and long-term care facilities. The Joint Commission on Accreditation of Hospitals, established in 1951 and later renamed The Joint Commission on Accreditation of Healthcare Organizations (and now called The Joint Commission [TJC]), focused on the safety and protection of the public and the delivery of quality care. Changes in the overall health of American society also shifted the focus of technology, research, and development. Major technological advances included developments in the realms of chemotherapeutic agents; immunizations; anesthesia; electrolyte and cardiopulmonary physiology; diagnostic laboratories with complex modalities such as computerized tomography; organ and tissue transplants; radiation therapy; laser surgery; and specialty units for critical care, coronary care, and intensive care. The first “test tube baby” was born via in vitro fertilization, and other fertility advances soon emerged. Negative staining techniques for screening viruses via electronic microscope became available in the 1960s (Shi and Singh, 2011). Health care providers constituted more than 5% of the total U.S. workforce during this period. The three largest health care employers were hospitals, convalescent institutions, and physicians' offices. Between 1970 and 1984 alone, the number of persons employed in the health care industry grew by 90%. The number of personnel employed in the community also increased. The expansion of care delivery into other sites, such as community-based clinics, increased not only the number but also the types of health care employees. Technological advances brought about increased special training for physicians and nurses, and care was organized around these specialties. The ongoing shortage of nurses throughout the century was being seen in the 1970s and early 1980s. Nursing education expanded from hospital-based diploma and university-based baccalaureate education to include associate degree programs at the entry level. As the diploma schools of nursing began closing in the early- to mid-1980s, the number of baccalaureate and associate degree programs began to increase. Graduate nursing education expanded to include the nurse practitioner (NP) and clinical nurse specialist (CNS) to meet increasing demands for the education of 105nurses in a specialty such as public health. The first doctoral programs in nursing were instituted to build the scientific base for nursing and to increase the number of nurse faculty members. The role of the commercial health insurance industry increased, and a strong link between employment and the providing of health care benefits emerged. Furthermore, the federal government's role expanded through landmark policymaking that would affect health care delivery well into the twenty-first century. Specifically, the passage of Titles XVIII and XIX of the Social Security Act in 1965 created the Medicare and Medicaid programs, respectively. The health care system appeared to have access to unlimited resources for growing and expanding. Throughout the twentieth century, many public health advances were achieved. The life expectancy of U.S. citizens increased and has been related to public health activities. The most important achievements were in vaccinations, improved motor vehicle safety, safer workplaces, safer and healthier foods, healthier mothers and babies, family planning, fluoride in drinking water, and recognition of tobacco as a health hazard (Shi and Singh, 2011). Fourth Phase The fourth developmental stage (1984 to 2015) has been a period of limited resources, with an emphasis on containing costs, restricting growth in the health care industry, and reorganizing care delivery. For example, amendments were made to the Social Security Act in 1983 that created diagnostic-related groups and a prospective system of paying for health care provided to Medicare recipients. The 1997 Balanced Budget Act legislated additional federal changes in Medicare and Medicaid. Private-sector employer concerns about the rising costs of health care for employees and fear of profit losses spurred a major change in the delivery and financing of health care. Managed care systems were developed. This period included drastic change in the settings and organization of health care delivery. Transforming health care organizations became commonplace, and buzz words of the period were reorganization, reengineering, restructuring, and downsizing. Organization mergers occurred at an increased rate to consolidate care, to save money, and to coordinate care across the continuum (i.e., from “cradle to grave”). Merger discussions focused on horizontal integration, which indicated the union of similar agencies (e.g., a merger of hospitals), and vertical integration between different types of organizations (e.g., an acute care hospital, long-term care institution, and a home health facility). Initially these pressures brought about hospital closings and a shifting of care to other settings, such as ambulatory and community-based clinics and specialty diagnostic centers that offer technologies such as magnetic resonance imaging (MRI) and sonography. Rehabilitative, restorative, and palliative care, once delivered in the hospitals, was shifted to other settings, such as subacute care hospitals, specialty rehabilitation hospitals, long-term care institutions, and even individual homes. Although the basis of care delivery was no longer the traditional acute care hospital, the nature of the care delivered in hospitals changed remarkably, as evidenced by the following: • Patients admitted to hospitals were more acutely ill. • Length of stay for patients admitted to hospitals became shorter. • Care delivery became more intense as a result of the first two items. The widespread use of computers and the Internet enabled society to become increasingly sophisticated about health. The public's increasing knowledge about health care and awareness of health care advances influenced the demand for health care, such as diagnostic and therapeutic services for treatment. Furthermore, pharmaceutical companies and other technological suppliers actively marketed their products through television, printed advertisements, the Internet, and other sources, so clients rapidly became aware of the new technologies. Health professionals were increasingly dependent on technology to care for clients. Distance, as a barrier to the diagnosis and treatment of disease, was overcome through the use of telehealth. The insurance industry became the principal buyer of technology for the client. They often made decisions about when and if a certain technology would be used for a client problem. Nurses became dependent on technologies to monitor client progress, make decisions about care, and deliver care in innovative ways. The shift away from traditional hospital-based care to the community, together with the need to consider new models of care, brought about an increased emphasis on providing primary care, on developing care delivery teams, and on collaborating in practice and education. The substitution of one type of health personnel for another occurred to control care delivery costs. As examples, NPs were replacing physicians as primary care providers, and unlicensed personnel were replacing staff nurses in hospitals and long-term care facilities. These replacements caused much debate, with territorial, or “turf,” battles, for example, between physicians and nurses. The increase in specialization by health professionals led to changes in certification, qualifications, education, and standards of care in health professions. These factors, in turn, caused an increase in the number and kinds of providers to meet the demands of the health care system. The Bureau of Labor Statistics predicted that health care employment would be among the top eight professional and related industries with significant employment growth through 2020 (Lockard and Wolf, 2012). In the last part of the twentieth century, molecular tools were developed that provided a means of detecting and characterizing infectious disease pathogens and a new capacity to track the transmission of new threats, such as bioterrorism, and determine new ways to treat them. Challenges for the Twenty-First Century In the twenty-first century the emergence of new and the reemergence of old communicable and infectious diseases are occurring as well as larger foodborne disease outbreaks and acts of terrorism. Seven out of ten of all deaths in the United States are related to chronic disease (USDHHS, 2011). One in every two Americans has one or more chronic diseases. There 106is some concern that certain chronic diseases may be caused or intensified by infectious disease processes. Often there are complications that occur as a result of infectious disease, such as HIV/AIDS and tuberculosis, which can result in chronic lung disease and certain types of cancer, because of the compromised immune system. Health behaviors and economics related to poverty are also continuing to build the path to acute and chronic health problems (e.g., the global obesity epidemic) (World Health Organization [WHO], 2010). While some people choose to ignore behavioral factors related to obesity, such as physical activity and eating, those with insufficient income choose foods high in fat and sugar because those are the cheaper foods to obtain. The chronic disease burden is concentrated among the poor. Poor people are more vulnerable for several reasons, including increased exposure to risks and decreased access to health services. Chronic diseases can cause poverty in individuals and families and draw them into a downward spiral of worsening disease and poverty. Investment in chronic disease prevention programs is going to be essential for many low- and middle-income countries struggling to reduce poverty. For the United States, this issue is addressed in the ACA (2010). Health promotion and protection, disease surveillance, emergency preparedness, new laboratory and epidemiologic methods, continued antimicrobial and vaccine development, and environmental health research are continuing challenges for this century. The role of technology has also intensified during this century. Technology is now defined as the application of science to develop solutions to health problems or issues such as the prevention or delay of onset of diseases or the promotion and monitoring of good health. Examples of technology include medical and surgical procedures (angioplasty, joint replacements, organ transplants), diagnostic tests (laboratory tests, biopsies, imaging), drugs (biological agents, pharmaceuticals, vaccines), medical devices (implantable defibrillators, stents), prosthetics (artificial body parts), and new support systems (electronic health records, e-prescribing, and telemedicine). The labor force is changing to include radiology oncologists, geneticists, and surgical subspecialists, as well as allied and support professions such as medical sonographers, radiation technologists, and laboratory technicians. These have all been created to support the use of specific types of technology (HealthIT.gov). The infrastructure necessary to support more complex technologies is also considered to be a part of health care technology. Electronic health records and electronic prescribing are methods for coordinating the increasingly complex array of services provided, as well as allowing for electronic checks of quality to reduce medical errors (e.g., for drug interactions). Because technologies have become a part of standard medical practice, there are concerns about whether they are consistently being used properly and about the quality of the information provided by tests, imaging, and other technological outputs (NCHS, 2010). In addition to the labor force changes just described, physicians are increasingly moving away from solo practice to group practices, selling primary care practices to hospitals, or working as hospital or corporation employees. The emerging role of hospital intensivists is growing, with hospitals employing physicians to be in-house and available to patients and to their community physicians to cover nonurgent, urgent, and emergent care while the patient is hospitalized. More nurse practitioners and physician assistants can be found working side by side with the physician in the community and in the hospital as a member of the office, clinic team, or hospital staff. (See QSEN box below about teamwork and collaboration) image Focus on Quality and Safety Education for Nurses Teamwork and Collaboration Refers to the ability to function effectively with nursing and interprofessional teams and to foster communication, mutual respect, and shared decision making to provide quality client care. • Knowledge: Identify system barriers and facilitators of effective team functioning • Skill: Participate in designing systems that support effective teamwork • Attitudes: Values the influences of systems solutions in achieving effective functioning Teamwork and Collaboration Question As a strategy set forth by the Affordable Care Act, a fund was established to support prevention and wellness activities within states to reduce risks. Among the options for spending the funds was the establishment of programs and processes to reduce the rate of chronic disease. Monies have been distributed to states to promote prevention and wellness. Find out through your state government how the money is to be used. The Quad Council PHN competency: community dimensions of practice, indicates that beginning PHN's will collaborate with community partners to promote the health of their clients. Have PHNs at the state level or locally in your state been involved in collaborations to determine how chronic disease rates might be reduced in your area. If yes, how? If not, can you suggest how they might be? Also the PHN competency that addresses financial management and planning, suggests that PHNs may provide input into the fiscal planning and the narrative component of proposals submitted for external funding. Determine what the process will be for obtaining local funds for chronic disease and whether PHNs have had or will have input onto the proposals. Discussions are increasing regarding the integration of public health and primary care and developing the primary health care system (see Chapter 3). Public health nurses are more involved with population-centered care, assessment of community needs, and the development or implementation of programs that meet the needs of certain populations. There is a move to provide more care to clients in the home, such as the programs to provide care to new mothers and babies who are defined as at-risk. Public health nurses play key roles in developing and implementing plans for bioterrorism and natural disasters in the community (see Chapter 9). Nursing education is seeing a dramatic change in this century. There is a recommendation to move all advanced practice nursing to the level of the new doctoral program, begun in 2000, titled the Doctorate of Nursing Practice. This has the potential for closing specialist master's programs in nursing. 107This means the new BSN graduate, for example, can go into a doctoral program at graduation and become an advanced public health nurse or a nurse practitioner working in the community. The health care industry is one of the largest employers in the United States, and despite the economic downturn in 2008, has continued to grow. In addition, the largest number of employees in the industry are RNs (American Association of Colleges of Nursing, 2010; Lockard and Wolf, 2012). Along with other changes in health care delivery and health insurance plans, the ACA (2010) has proposed an emphasis on prevention and wellness by establishing the National Prevention, Health Promotion, and Public Health Council to coordinate health promotion and public health activities as well as the creation of a prevention and public health fund to expand and sustain these activities. These activities will assist in the development of a national strategy to improve health, reduce chronic disease rates, and address health disparities. Trends in Health Care Spending Much has been written in the popular and scientific literature about the costs of U.S. health care and how society makes decisions about using available and scarce resources. Given that economics in general and health care economics in particular are concerned with resource use and decision making, any discussion of the economics of health care must consider past and current health care spending. The trends shown here reflect public and private decisions about health care and health care delivery in the past. Past spending reflects past decision making; likewise, past decisions reflect the values and beliefs held by society and policymakers that undergird policymaking at any given point in time. According to the Centers for Medicare and Medicaid Services (CMS) (formerly the Health Care Financing Administration), national health expenditures reached $2.5 trillion in 2011. This is compared with the $600 billion in health care dollars that were spent in 1990 (Centers for Medicare and Medicaid Services [CMS], 2012a). The CMS predicts total U.S. health spending in 2019 will be $4.5 trillion. Health spending has outpaced increases in the gross domestic product, accounting for 17.3% of the GDP by 2009 rising to 17.8% in 2012 and projected to increase to 19.3% of the GDP in 2019. The percent GDP can be translated into dollars per 100 spent out of pocket. In 2009 $17.30 of every $100 was spent for health care. It also means that in 2009 approximately $8100 was spent on health care for every person in the U.S. population. In 2019 it is projected that out-of-pocket costs will be approximately $20 for every $100 spent. The effect of this economic growth represents a large increase in contrast to the approximately 13% GDP spent between 1992 and 2001. The GDP was at 17.8% in 2012 (CMS, 2012a). It is projected that with the implementation of the ACA costs will actually decline. Figure 5-4 shows a breakdown of the distribution in health care expenses for 2011, and Table 5-1 shows the growth in U.S. health care expenditures between 1960 and 2019 (NCHS, 2012). During fiscal year 2012-2013, the amount spent for public health activities ranged from $7.63 per person in 108Arizona to $144.99 per person in Hawaii (Trust from America's Health, 2014). image FIG 5-4 Distribution of U.S. health care expenditures, 2011. (From National Center for Health Statistics: Health, United States, 2012, with Special Feature on Emergency Care. Hyattsville, MD, 2013, U.S. Government Printing Office. Updated tables retrieved December 2014 from http://www.cdc.gov/nchs/hus/contents2012.htm#113) TABLE 5-1 Health Care Expenditures: 1960-2019* Calendar Year Total Health Expenditures (in billions of dollars) Total Health Expenditures per Capita per Person (in billions of dollars) Percentage of Gross Domestic Product 1960 26.7 143 5.1 1970 73.1 348 7.0 1980 245.8 1,067 8.8 1990 696.0 2,738 12.0 2000 1,309.9 4,560 13.3 2009 2,472.2 8,047 17.3 2010 2,563.6 8,402.3 17.9 2011* 2,695.0 8,660.5 17.9 2021* 4,482.7 14,102.6 19.6 *Projected expenditures. From Centers for Medicare and Medicaid Services, Office of the Actuary: National Health Care Expenditures and Projections: 1960–2021. U.S. Department of Health and Human Services, 2012a. Retrieved December 2014 from http://www.cms.gov/NationalHealthExpendData/ The largest portions of health care expenses were for hospital care and physician services, respectively, in 2011 (NCHS, 2012). Only a small fraction of total health care dollars was spent on home health, public health, and research and construction in 2011. The trends over time indicate that this has been an ongoing pattern of spending. Factors Influencing Health Care Costs Health economists, providers, payers, and politicians have explored a variety of explanations for the rapid rate of increase in health expenses as compared with population growth. That individuals have, over time, consumed more health care is not an adequate explanation. The following factors are frequently cited as having caused the increases in total and per capita health care spending since 1960: inflation, changes in population demographics, and technology and intensity of services (NCHS, 2012). Demographics Affecting Health Care A major demographic change underway in the United States is the aging of the population. Population changes are also affected by illnesses such as acquired immunodeficiency syndrome, and by chemical dependency epidemics. These changes have implications for providers' health services, and they affect the overall costs of health care. Because the majority of older adults and other special populations receive services through publicly funded programs, the growing health needs among these populations have great impact on costs, payments, and providers associated with Medicaid and Medicare programs. As the population ages and the baby boom generation ages and retires, federal expenses for Social Security have increased (Congressional Budget Office [CBO], 2010). At 78 million strong, the oldest of the baby boomers—born between 1946 and 1964—are already making unsustainable demands on federal entitlement programs such as Medicare and Medicaid (see Chapter 3 for further discussion). In its Long-Term Outlook for Medicare, Medicaid and Total Health Care Spending, the Congressional Budget Office (CBO) reports that spending for those programs was projected to account for 3% each of GDP in 2011 (CMS, 2012a). By 2035, in the absence of change, spending for Medicare alone (which is more likely to be impacted by aging baby boomers) will have more than doubled to 8%, and by 2080 it will have grown to 15% unless changes as recommended by the ACA (2010) are effective. The aging population is expected to affect health services more than any other demographic factor: • In 1950 more than 50% of the U.S. population was under 30 years of age. • In 1994, 50% of the population was 34 years of age or older. • In 1990 individuals 65 and older comprised 12% of the population. • In 2013 they comprised 14% of the population. • One in 7 citizens in 2013 was 65 and older compared to 1 in 5 in 1990. By 2050 they are estimated to comprise up to 20% of the population. In addition, the number of individuals 85 and older is expected to double between 1990 and 2050 because the population is living longer, healthier lives (U.S. Census Bureau, 2014). Although many older adults are independent and active, they are likely to experience multiple chronic and degenerative conditions that may become disabling. They are admitted to hospitals more often than the general population, and their average length of stay is more than 3 days longer than the overall average. They visit physicians more often and make up a larger percentage of nursing home residents than the general population (NCHS, 2012). Life expectancy, at an average of 78.7 years, and health status have been increasing in the United States. However, older adults continue to consume a large portion of financial resources. Health care providers are concerned about the growth in the older adult population because public funding sources, such as Medicare, have not been increasing their reimbursement rates sufficiently to cover inflation, and thus providers have been collecting a smaller amount for visits by older adult clients each year. The aging of the population also spurs concerns about funding their health care because of changes in the proportion of employed individuals to fully retired individuals. Persons in the workforce pay the majority of income taxes and all Social Security payroll taxes. The funding base for Medicare decreases as the population ages, as retirement rates increase, and as the numbers in the workforce decrease. As a result, some policymakers believe that Medicare and system reforms could ensure adequate financing and delivery of health care services to an aging population (PL 111-148, 2010). Health policy reform options being considered include increased age limits to become eligible for Medicare, means testing (i.e., determining a lack of financial resources) for Medicare eligibility, increased coverage for long-term care insurance, increased incentives for prevention, and less expensive and more efficient delivery arrangements and care settings (e.g., managed care arrangements). One example of a policy change to reduce the Medicare program burden was the prescription plan (Medicare D) that was passed by Congress in 2005 and became effective in January 2006. This plan, although complicated, required most Medicare recipients to provide a copayment for prescription medications. Although controversial, the plan is thought to provide a positive impact for the elderly who could not afford to pay for their prescriptions, while reducing the cost burden for those who had to pay full price for prescriptions. The ACA promises to close the “donut hole” by 2020 while providing a 50% discount when the Medicare recipients purchase medications covered on the brand name list, until 2020 (ACA and Medicare, 2014). The donut hole is the point at which a prescription D recipient has met the limit that the health insurance policy will pay for prescriptions in a given year and the requirement that the recipient will then be responsible for paying full price for all medicines until the end of the year covered by the health insurance. 109 Technology and Intensity The introduction of new technology enhances the delivery of care, but it also has the potential to increase the costs of care. As new and more complex technology is introduced into the system, the cost is typically high. However, clients often demand access to the technology, and providers want to use it. In an effort to keep health care costs down, however, payers have attempted to restrict the use of certain technologies. For example, the drug Viagra, developed for the treatment of impotence by Pfizer Pharmaceuticals, is a controversial technological advance that, as soon as it was available to the public, was in high demand and prescribed by providers. Initially, use was restricted by payers because of cost. The adoption of new technology demands investment in personnel, equipment, and facilities. Furthermore, new technology adds to administrative costs, especially if the federal government provides financial coverage for the service or is involved in regulating the technology. Table 5-2 outlines federal policy that has impacted technology and the cost of health care over time. TABLE 5-2 Federal Regulations Contributing to Health Care Technology/Cost Controls Year Federal Regulation 1906 Prescription drug regulation: Food, Drug, and Cosmetic Act, now the U.S. Food and Drug Administration (FDA) 1935 Social Security Act (PL 74-271): Provides grants-in-aid to states for maternal and child care, aid to crippled children, and aid to the blind and aged 1938 Food, Drug, and Cosmetic Act (PL 75-540): Establishes federal FDA protection for drug safety and protection for misbranded goods, drugs, cosmetics 1946 Hill-Burton Act (PL 79-725): Enacts Hospital Survey and Construction Act providing national direct support for community hospitals; establishes rudimentary standards for construction and planning; establishes community service obligation 1954 Hill-Burton Act amended (PL 83-482): Expands scope of program for nursing homes, rehabilitation facilities, chronic disease hospitals, and diagnostic or treatment centers 1963 Community Mental Health and Mental Retardation Center Construction Act (PL 88-164) 1965 Medicare Title 18; Medicaid Title 19 (PL 89-97): Amendments to Social Security Act provide Medicare and Medicaid to support health care services for certain groups 1966 Comprehensive Health Planning Act (PL 89-749): For health services, personnel, and facilities in federal/state/local partnerships 1971 President Nixon introduces concept of HMOs as the cornerstone of his administration's national health insurance proposal 1972 Social Security Act Amendments (PL 92-603): Extend coverage to include new treatment technologies for end-stage renal disease; provide for professional standards review organizations to review appropriateness of hospital care for Medicare/Medicaid recipients 1973 HMO Act (PL 93-222): Provides assistance and expansion for HMOs 1975 National Health Planning and Resources Development Act (PL 93-641): Designates local health system areas and establishes a national certificate-of-need (CON) program to limit major health care expansion at local and state levels 1978 Medicare End-Stage Renal Disease Amendment PL 95-292: Provides payment for home dialysis and kidney transplantation Health Services Research, Health Statistics, and Health Care Technology Act PL 95-623 establishes national council on health care technology to develop standards for use 1981 Omnibus Budget Reconciliation Act of 1981 (PL 97-351): Consolidates 26 health programs into 4 block grants (preventives, health services, primary care, and maternal and child health) 1982 Tax Equity and Fiscal Responsibilities Act (PL 97-248): Seeks to control costs by limiting hospital costs per discharge adjusted to hospital case mix 1983 Amended Social Security Act (PL 98-21): Establishes new Medicare hospital prospective payment system based on diagnosis-related groups (DRGs) 1986 1974 Health Planning and Resource Development Act (PL 93-641): was amended and moves certificate of need program to states 1989 Omnibus Reconciliation Act of 1989 (PL 101-239): Creates physician resource–based fee schedule to be implemented by 1992, with emphasis on high-tech specialties of surgery; creates Agency for Healthcare Policy and Research to research effectiveness of medical and nursing services, interventions, and technologies 1990 Ryan White CARE Act (PL 101-381): Authorizes formula-based and competitive supplemental grants to cities and states for HIV-related outpatient medical services Safe Medical Devices Act (PL 101-629): Gives FDA authority to regulate medical devices and diagnostic products 1993 Omnibus Budget Reconciliation Act (OBRA 93) (PL 103-66): Cuts Medicare funding and ends ROE payments to skilled nursing facilities; provides support for immunizations for Medicaid children 1996 Health Insurance Portability and Accountability Act: Protects health insurance coverage for laid-off or displaced workers 1997 Balanced Budget Act of 1997: Creates a new program for states to offer health insurance to children in low-income and uninsured families 1998 Balanced Budget Act of 1997 (PL 105-33): Authorizes third-party reimbursement for Medicare Part B services for NPs and CNSs 2003 Medicaid Nursing Incentive Act (HR 2295): Expands direct reimbursement to all NPs and CNSs and recognizes specialized services offered by advanced practice registered nurses such as primary care case management, pain management, and mental health services 2006 Medicare Part D: Provides a plan for prescription payments 2010 Patient Protection and Affordable Care Act passed and signed into law on March 23, 2010 2012 The Affordable Care Act provides for $18 million to expand health information technology to 37 health center networks Chronic Illness Chronic illness is a factor that is showing its impact on health care spending. Chronic disease accounted for 70% of deaths in the United States (USDHHS, 2011) and accounted for 75% of all health care spending in 2013 (USDHHS 2014c). Using Medical Expenditure Panel Survey (MEPS) data, chronic medical conditions are identified by those costing the most, the 110number of bed days, work-loss days, and activity impairments. The most chronic medical condition was stroke. Financing of Health Care Against the backdrop of today's chronic conditions, it must be appreciated that health care financing has evolved through the twentieth and into the twenty-first century from a system supported primarily by consumers to a system financed by third-party payers (public and private). From 1980 to 2011, the percentage of third-party public insurance payments increased slightly while the percentage of out-of-pocket payments had declined. Combined state and federal governments paid the most in 2011 (CDC, 2014c). Public Support The U.S. federal government became involved in health care financing for population groups early in its history. In 1798 the federal government created the Marine Hospital Service to provide medical care for sick and disabled sailors, and to protect the nation's borders against the importing of disease through seaports. The Marine Hospital Service is considered the first national health insurance plan in the United States (see Health Care Reform, Chapter 3). The National Health Board was established in 1879 and was later renamed the U.S. Public Health Service (PHS). Within the PHS, the federal government developed a public health liaison with state and local health departments for the purpose of controlling communicable diseases and improving sanitation. Additional health programs were also developed to meet obligations to federal workers and their families within the PHS, the Department of Defense, and the Veterans Administration (VA) (see Chapter 8). Medicare and Medicaid, two federal programs administered by the CMS, account for the majority of public health care spending. Table 5-3 compares these programs. The CMS is the federal regulatory agency within the U.S. Department of Health and Human Services (USDHHS) that is responsible for overseeing and monitoring Medicare and Medicaid spending. This agency routinely collects and reports actual health care use and spending and projects future spending trends. Through these programs, the federal government purchases health care services for population groups through independent health care systems, such as managed care organizations, private practice physicians, and hospitals. TABLE 5-3 Comparison of Medicare and Medicaid Program Features Feature Medicare Medicaid Where to obtain information Local Social Security Administration office State welfare office Recipients Client is 65 years or older, is disabled, or has permanent kidney failure Specified low-income and needy, children, aged, blind, and/or disabled; those eligible to receive federally assisted income Type of program Insurance Insurance Government affiliation Federal Joint federal/state Availability All states All states Financing of hospital insurance Medicare Trust Fund, mandatory payroll deduction, recipient deductibles, trust fund interest Federal and state governments Financing of medical insurance Recipient premium payments; general revenue, U.S. Treasury Federal and state governments Types of coverage Part A. Inpatient and outpatient hospital services, skilled nursing facilities (SNFs), limited nursing home care, home health services and hospice Part B. Prevention and screening services Part D. Prescription drugs from a formulary Inpatient and outpatient hospital services; nursing facility services: home health, physician services, rural health clinic services, community health center services; laboratory and x-rays; family planning; advanced practice nurse services, free-standing birth center services; medical care transportation; tobacco cessation counseling for pregnant women, vaccines for children; many optional services are available by state's choice From U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services: Medicare and You, and Medicaid Benefits, Baltimore, MD, 2015, USDHHS. Medicare The Medicare program, established in Title XVIII of the Social Security Act of 1965, provides hospital insurance and medical insurance to persons aged 65 and older, to permanently disabled persons, and to persons with end-stage renal disease—altogether approximately 46 million people in 2013 (CMS, 2014). Medicare has two parts: Part A (hospital insurance) covers hospital care, home care, hospice care, and skilled nursing care (limited); Part B (noninstitutional care insurance) covers “medically necessary” services such as health care provider services, outpatient care, home health, and other medical services such as diagnostic services, and physiotherapy. In 1999 a program called Medicare Advantage was added to the program (Part C). This is an option that can be chosen for additional coverage. This option includes both Part A and B services. The Part C plans are coordinated care plans that include health maintenance organizations (HMOs), private fee-for-service plans, and medical savings accounts (MSAs). Part C provides for all health care coverage costs after a high deductible (CMS, 2014). Medicare Part A is primarily financed by a federal payroll tax that is paid by employers and employees. The proceeds from this tax go to the Hospital Insurance Trust Fund, which is managed by the CMS. If a person did not have federal payroll 111deductions, Part A can be obtained by paying a monthly premium. Part A coverage is available to all persons who are eligible to receive Medicare, with older adults comprising the majority of these individuals. There is concern about the future of the Medicare Trust Fund, because projected expenses may be more than the trust fund resources. Payments to hospitals for covered services have been and continue to be higher than fund growth. Thus Medicare reimbursement policy has been changing in an attempt to control increasing hospital costs. Part A requires a deductible from recipients for the first 60 days of services with a reduced deductible for 61 to 90 days of service. The deductible has increased as daily hospital costs have increased. For skilled nursing facility (SNF) care, persons pay nothing for the first 20 days and a cost per day for days 21 through 100. After 100 days, persons must pay the total cost for care (CMS, 2013a). The person pays zero for hospice care and home health. The medical insurance package, Part B, is a supplemental (voluntary) program that is available to all Medicare-eligible persons for a monthly premium ($99.90 minimum in 2012) (CMS, 2012a). The vast majority of Medicare-covered persons elect this coverage. Part B provides coverage for services other than hospital (physician care, outpatient hospital care, outpatient physical therapy, mental health, and home health care) that are not covered by Part A, such as laboratory services, ambulance transportation, prostheses, equipment, and some supplies. After a deductible, up to 80% of reasonable charges are paid for medical and other services. For mental health services, 55% of the costs are paid. Part B resembles the major medical insurance coverage of private insurance carriers. Figure 5-5 shows the total expenses of the Medicare program from 1966 to 2012. image FIG 5-5 Medicare expenditures for selected years from 1966 to 2012. (From Centers for Medicare & Medicaid Services: National Health Expenditure Accounts: National Health Expenditure Data: Historical. 2012. Retrieved December 2014 from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html) Since the passing of the Medicare amendments to the Social Security Act in 1965, the cost of Medicare has increased dramatically. Hospital care continues to be the major factor contributing to Medicare costs. However, because of the shorter hospital stays, home health and nursing home costs have increased dramatically. As a result of rising health costs, Congress passed a law in 1983 that radically changed Medicare's method of payment for hospital services. In 1983 federal legislation (PL 98-21) mandated an end to cost-plus reimbursement by Medicare and instituted a 3-year transition to a prospective payment system (PPS) for inpatient hospital services (HCFA, 1998). The purpose of the new hospital payment scheme was to shift the cost incentives away from the providing of more care and toward more efficient services. The basis for prospective reimbursement is the 468 diagnosis-related groups (DRGs) (See Evidence-Based Practice Box). Also, the Balanced Budget Act of 1997 determined that payments to Medicare SNFs would be made on the basis of the PPS, effective July 1, 1998 (HCFA 1998). The PPS payment rates cover SNF services, including routine, ancillary, and capital-related costs (CMS, 2013b). In 2001 CMS developed a PPS for DRGs for home health with Health Insurance Prospective Payment System (HIPPS) codes. Evidence-Based Practice This retrospective study examined the incidence, costs, and factors associated with potentially avoidable hospitalizations (PAH) in dually eligible Medicare and Medicaid beneficiaries. This population was selected due to their complex clinical needs and high costs of care. Potentially avoidable hospitalizations were defined by an expert panel that identified conditions and associated Diagnostic Related Groups (DRGs) which can often be prevented or safely and effectively managed in a skilled nursing facility or home- and community-based services. Seventy-eight percent of the PAH were responsible from five conditions: pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease. The total costs of these hospitalizations were $3 billion for Medicare beneficiaries and $463 million for Medicaid beneficiaries. A sensitivity analysis found that between 77,000 and 260,000 hospitalizations and between $625 million and $1.9 billion in expenditures could be avoided each year in this population. Nurse Use Community health nursing initiatives, such as health education and case management, could significantly reduce the amount of hospital admissions in this population. Such interventions could greatly reduce the negative health effects and quality of life for this population, as well as reduce the high health care costs for this group. From Walsh EG, Wiener JM, Haber S, et al: Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and home- and community-based services waiver program. J Am Geriatr Soc 60:821–829, 2012. In 2009 the average amount spent for services for Medicare beneficiaries was approximately $8000 (Kaiser Family Foundation, 2012b). The average out-of-pocket spending is skewed to those beneficiaries who are older or have declining health. Approximately one in four Medicare beneficiaries spends 30% or more of their income on out-of-pocket health expenses (Kaiser Family Foundation, 2012b). This is because of the limits in Medicare coverage, including certain preventive care, and the limited number of physicians and agencies who accept 112Medicare and Medicaid payment. Older adults who do not have supplemental insurance must cover the difference between the Medicare payment and the additional costs for services. Medicaid The Medicaid program, Title XIX of the Social Security Act of 1965, provides financial assistance to states and counties to pay for medical services for poor older adults, the blind, the disabled, and families with dependent children. The Medicaid program is jointly sponsored and financed with matching funds from the federal and state governments. In 2013, 55 million people were enrolled in Medicaid (Kaiser Family Foundation, 2014). Medicaid expenditures from 1966 to 2012 are shown in Figure 5-6. Since the beginning of Medicaid, full payment has been provided for five types of services (NCHS, 2012): • Inpatient and outpatient hospital care • Laboratory and radiology services • Physician services • Skilled nursing care at home or in a nursing home for people more than 21 years of age • Early Periodic Screening, Diagnosis, and Treatment (EPSDT) programs for those less than 21 years of age image FIG 5-6 Medicaid expenditures for selected years from 1987 to 2012. (From Centers for Medicare & Medicaid Services: National Health Expenditure Accounts: National Health Expenditure Data: Historical. 2012. Retrieved December 2014 from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html) The 1972 Social Security amendments added family planning to the list of full-pay services. States can choose to add prescriptions, dental services, eyeglasses, intermediate care facilities, and coverage for the medically indigent as program options. By law, the medically indigent are required to pay a monthly premium. Any state participating in the Medicaid program is required to provide the six basic services to persons who are below state poverty income levels. Optional programs are provided at the discretion of each state. In 1989 changes in Medicaid required states to provide care for children less than 6 years of age and to pregnant women under 133% of the poverty level. For example, if the poverty level were $12,000, a pregnant woman could have a household income as high as $16,000 and still be eligible to receive care under Medicaid. These changes also provided for pediatric and family nurse practitioner reimbursement. In the 1990s states were allowed to petition the federal government for a waiver. If the waiver was approved, the states could use their Medicaid monies for programs other than the six basic services. The first waiver to be approved was given to Oregon for their health care reform plan. Other states have received waivers to develop Medicaid managed care programs for special populations. The 2010 health care reform plan provides for new approaches to offering Medicaid services and incentives for states to offer Medicaid services rather than through the waiver option as described previously (PL 111-148, 2010). The major expense categories for the Medicaid program have historically been skilled and intermediate nursing home care and inpatient hospital care. When combined, these two categories account today for 3% of all costs to the program (NCHS, 2012). Public Health Most public government agencies operate on an annual budget, and they plan for costs by estimating salaries, expenses, and costs of services for a year. Public health agencies, such as health departments and WIC (Women, Infants, and Children) programs, receive primary funding from taxes, with additional money for select goods and services through private third-party payers. Selected public health programs receive reimbursement for services as follows: through grants given by the federal 113government to states for prenatal and child health; through Medicare and Medicaid for home health, nursing homes, and WIC and EPSDT programs; and through collecting of fees on a sliding scale for select client services, such as immunizations.(Trust for America's Health, 2014). In 2011 only 3% of all health care–related federal funds was expended for federal health programs such as WIC, versus 97% for other types of health and illness care (such as hospital and physician services). In addition to this 3% allotment, public health funds also come through states and territorial health agencies. State and local governments contributed 16% to public and general assistance, maternal and child health, public health activities, and other related services in 2010 (NCHS, 2013). Other Public Support The federal government finances health services for retired military persons and dependents through TRICARE, the VA, and the Indian Health Service (IHS). These programs are very important in providing needed health care services to these populations (see Chapter 8). The Affordable Care Act: Public Health Support The ACA provides for prevention and public health funds with emphasis on chronic disease. Funds are provided to states to implement these provisions. See Table 5-4 for more detail. Also check the state of interest to see what that state is doing to implement this provision in ACA. TABLE 5-4 The Affordable Care Act's Prevention and Public Health Fund in Your State • Prevention and Public Health Fund • The fund is an unprecedented investment in promoting wellness, preventing disease, and protecting against public health emergencies • Much of this work is done in partnership with states and communities: • To help control the obesity epidemic • Fight health disparities • Detect and quickly respond to health threats • Reduce tobacco use • Train the nation's public health workforce • Modernize vaccine systems • Prevent the spread of HIV/AIDS • Increase public health programs' effectiveness and efficiency • Improve access to behavioral health services • Preventing Chronic Disease: A Smart Investment • Chronic diseases: The Prevention Fund helps states • Tackle the leading causes of death and root causes of costly, preventable chronic disease: • Detect and respond rapidly to health security threats • Prevent accidents and injuries Since the Affordable Care Act was passed in 2010, the U.S. Department of Health and Human Services has awarded $1.25 billion in Prevention Fund grants. Check your state to see what is being done to promote the public's health. Private Support Private health care payer sources include insurance, employers, managed care, and individuals. Although insurance and consumers have been prominent health care payment sources for some time, the role of employers, managed care, and consumers became increasingly prominent and powerful during the first decade of the twenty-first century, particularly as concerns grew about the use and changing nature of health insurance. Evolution of Health Insurance Insurance for health care was first offered for the private sector in 1847 by a commercial insurance company. The purpose of the insurance was to provide security and protection when health care services were needed by individuals. The idea behind insurance was that it provided security, guaranteeing (within certain limits) monies to pay for health care services to offset potential financial losses from unexpected illness or injury related to accidents, catastrophic communicable diseases (such as smallpox and scarlet fever), and recurring (but unexpected) chronic illnesses. A comprehensive study in the 1920s by the Committee on the Costs of Medical Care showed that a small portion of the population was paying most of the costs of medical care for the majority of the people. The Depression of the 1930s, rising medical costs, and the need to spread financial risk across communities spurred the development of the third-party payment system. The system began as a major industry in the 1930s with the Blue Cross system, which initially provided prepayment for hospital care. In 1939 Blue Shield created plans to provide physician payment. The Blue Cross plans began as tax-free, nonprofit organizations established under special enabling legislation in various states. In the 1940s and 1950s, hospital and medical-surgical coverage increased. Employee group coverage appeared, and profit-making commercial insurance underwriters began offering health insurance packages with competitive premiums. The commercial insurance companies could offer lower premium rates because of the methods used to set rates. Insurance and premium setting, in general, are based on the notion of risk pooling (i.e., insurance companies were willing to risk the unlikely event that all or even a large portion of individuals covered under a plan would need payment for health services at any given time). Blue Cross used a community rate, establishing a similar premium rate for all subscribers regardless of illness potential. In contrast, the commercial companies used 114an experience rate, in which the premium was based on an estimate of the illness risk or the number of claims to be made by the subscriber (Hicks, 2012). Premium competition, the offering of health insurance as a fringe benefit, and the use of health insurance as a negotiable collective bargaining item led to an increase in covered benefits, first-dollar coverage for medical care expenses, and increased employer-paid premiums. In turn, these factors pushed up insurance premium costs and health care costs and enabled insurance plans to cover high-cost segments of the population (the aged, poor, or disabled) because of the number of low-risk enrollees. The health needs of high-risk populations led to the passage of Medicare and Medicaid legislation. These and other national health programs targeted health care coverage for specific population groups. Because these programs directed additional money into the health care system to subsidize care, there were financial incentives to encourage the providing of services (i.e., the more services that were ordered, the greater the amount of money that would be received). Other incentives were related to the use of services by clients (i.e., the more available the payment was for services that might otherwise have gone unused, the more services that were requested). Greater increases in health insurance premiums have occurred as a result of pressure from employers, consumers, and policymakers. Driving forces behind this pressure are quality of care, client dissatisfaction, clients' rights, and the concern that these areas are being compromised in the managed care system. Furthermore, the initial cost savings from managed care may have occurred already, and costs will have to be increased to simply maintain coverage, not to mention providing new services and technologies. Although managed care changed the structure of financing and delivery of care, it was soon recognized that managed care was not the solution to the health care system's problems (Shi and Singh, 2011). Employers Since the beginning of Blue Cross and Blue Shield, health insurance has been tied to employment and the business sector. This tie was strengthened during World War II to compensate, attract, and retain employees. Since that time, employers have played the major role in determining health insurance benefits. However, with the economic downturn in 2008, employers began to reduce their health insurance benefits or return the cost of insurance. It is of interest that if a client has health insurance, the payment to the provider is less than the payment made by the client who does not have health insurance. In 2005 approximately 70% of the population under 65 years of age had private health insurance, most of which was obtained through the workplace (NCHS, 2005). In 2009 the percentage had decreased to about 60% (Kaiser Family Foundation, 2009). In 2005, 87% of employers paid 50% to 100% of the insurance premium (Kaiser Family Foundation, 2005). In 2009 employees paid a minimum of 26% to 36% of the health insurance premium with the employee's share of a family premium doubling in cost since 2000. For employees of small firms, the percentage of payment increased for all premiums (Kaiser Family Foundation, 2009). This substantial contribution to health care by the private business sector gave the employer considerable health care buying power in making policy about what services insurance would cover. Most older Americans were covered by Medicare; low-income children can now be covered by the Children's Health Insurance Program (CHIP) if enrolled by parents or guardians; and as previously described, some low-income adults were covered by Medicaid. Before the growth of insurance (i.e., before 1930 and the beginning of Blue Cross), the health care consumer had more influence over health care costs because payment was out of pocket. Consumers made decisions about how they would spend their money, making certain tradeoffs—for example, about the type of health care they were willing to buy and how much they would pay. Entering the system was restricted in large part to those who could afford to pay for care, or to those few who could find care financed through charitable and philanthropic organizations. With the beginning of the insurance (or third-party payer) system, health care costs were set by payers, and they determined the type of care or service that would be offered and its price. This began to change somewhat in the 1980s with the increased use of managed care. As the cost of health insurance has increased, some employers, in an effort to bypass the costs established by insurers, have found it less costly to self-insure. The employer does this by contracting directly with providers to obtain health care services for employees rather than going through health insurance companies. Some large businesses directly employ on-site providers for care delivery or offer on-site wellness programs. These programs within the private sector offer opportunities for nurses to provide wellness programs and health assessments to screen and monitor employees and their families. This move to self-insure resulted in savings to companies and reduced overall sick-care costs (Kovner et al, 2011). In a truly competitive market, the consumer buys goods and services at will, knowing the costs and expected value of services bought and choosing the provider of those services. In the health system where a third party pays for the services, this transaction has less meaning. The third party makes decisions about the level and type of care that will be purchased for clients and determines how payment will be made. The service provider and client have no influence on how services will be reimbursed. However, the consumer may select the payer/plan and indeed may influence the system through political channels. The average monthly cost for private health insurance has increased greatly through the years. Premiums reflect a shift of the health care cost burden from employers to employees as the percentage of employer contributions to health care declines. The decrease in employer contribution to health insurance premiums parallels the economic downturn of 2008, the move away from traditional insurance plans, and the move toward managed care plans or self-insurance plans by both small and large employers or toward dropping health insurance as a benefit. In 2008, 2 million people lost employer health insurance coverage (Kaiser Family Foundation, 2012a). From an economic point of view, the shift in responsibility for the cost of health insurance is not bad. In theory, this shift 115makes consumers more knowledgeable about (sensitive to) the price of health services. This means that they have more information for health care decision making and may consider price in making the decision to access types of health care services. Satisfaction with the quality of service rests with the person buying the insurance and receiving health care. As with employers, employees may choose health insurance voluntarily. Therefore three factors—the shifting of responsibility for health insurance premiums to employees, the changing demographics of the workforce in general, and the loss of employment due to the economic downturn—have resulted in a decline in employee enrollment in health insurance plans. Employees are choosing to use their resources to meet basic needs and are assuming the risks of having an illness for which they may have to pay. A minor health problem can lead to major medical debt for someone without health insurance (Kaiser Family Foundation, 2013). PL 111-148 includes a mandate for all citizens and legal residents to have qualifying health coverage. Employers will be required to offer coverage also, except for employers with fewer than 50 employees. These two requirements were to be in effect by 2014 unless repealed by Congress. Given that access to health insurance is tied to employment, there was growing concern in the late 1980s and early 1990s about the employment layoffs and downsizing occurring in private business. Those who lost their jobs lost their ability to pay for health insurance and to qualify to purchase insurance privately. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted to protect health insurance coverage for workers and families after a job change or loss (Health Care Financing Administration [HCFA], 1999; Nichols and Blumberg, 1998). Although this has increased the number of people who have access to health insurance and health care, there are claims that individual premiums are high, that insurance companies have lost their ability to pool risks, and that HIPAA is just one more federal control mechanism undermining competitive market influences. Individuals In 2011, individuals paid only approximately 14% of total health expenditures out of pocket (NCHS, 2014). However, these figures do not reflect the amount of money the consumer pays in taxes to finance government-supported programs such as Medicare and Medicaid, insurance premiums, and money paid for supplemental insurance to cover the gaps in a primary health insurance policy or Medicare. Managed Care Arrangements Managed care is the term used for a variety of health care arrangements that integrate the financing and the delivery of health care. Managed care offers an array of services to purchasers, such as employers, Medicaid, or Medicare, for a set fee. These are called risk-based plans. This fee, in turn, is used to pay providers through preset arrangements for services delivered to individuals who are covered (NCHS, 2012). The concept of managed care is based on the notion that the use of costly care could be reduced if consumers had access to care and services that would prevent illness through consumer education and health maintenance. Therefore, managed care uses disease prevention, health promotion, wellness, and consumer education (Kovner et al, 2011). In addition to risk-based plans, wherein the managed care organization accepts a set fee to cover all costs of care for the enrollee, there are cost-based plans. An example of such a managed care organization is the primary care case management (PCCM) organization often used by Medicaid programs. These PCCMs are composed of a variety of health care providers contracted with states to locate, coordinate, and monitor covered primary care and other services on a per client case management fee payment. Whereas HMOs assume risks for the costs of care, the PCCMs do not (NCHS, 2010). Although they seem relatively new to many clients of care, HMOs have actually been around since the 1940s. The Health Maintenance Organization Act was enacted in 1972, and since that time, the number of individuals receiving care through HMOs and other types of managed care organizations has increased considerably. Managed care is based, in part, on the principles of managed competition. Managed competition was introduced in health care in the late 1980s and early 1990s to address the increasing costs of health care and to introduce quality into the forefront of discussions. Managed competition simply means that clients make decisions and choose the health care services they want on the basis of the quality or reputation of the service. To make decisions, they use knowledge and information about health care problems, care, and providers, and they look at the costs of care. However, health care is a complex market and not one in which information about health care, health problems, and the costs of care are easy to get. With the passing of the ACA(2010), Accountable Care Organizations are being introduced as a new approach to managing care. Medical Savings Accounts Another insurance reform discussion at the political level concerns medical savings accounts (MSAs). These are also referred to as health savings accounts. MSAs are touted as a way of turning health care decision-making control over to the individuals receiving care. MSAs are tax-exempt accounts available to individuals who work for small companies, usually established through a bank or insurance company, that enable the individuals to save money for future medical needs and expenses (Internal Revenue Service [IRS], 2012). Money is contributed to an MSA by the employer, and the initial money put into an MSA does not come out of taxable income. Also, interest earned in MSAs is tax free, and unused MSA money can be held in the account from year to year until the money is used. MSAs, in theory, would allow individuals to make cost/quality tradeoffs and would require that individuals become knowledgeable about health care, become involved in health care decision making, and take responsibility for the decisions made. Providers, in turn, must be willing to provide and disclose information to individuals and give up control of health care decision making. The HIPAA and MSAs are examples of health insurance reform efforts, and these efforts will very likely remain in the forefront of political discussions for some time to come, especially with the health care reform discussions. 116 Health Care Payment Systems Several methods have been used by public and private sources to pay health care providers for health care services. These include retrospective and prospective reimbursement for paying health care organizations, and fee-for-service and capitation for paying health care practitioners (Kovner et al, 2011). Paying Health Care Organizations Retrospective reimbursement is the traditional reimbursement method, whereby fees for the delivery of health care services in an organization are set after services are delivered (Kovner et al, 2011). In this scenario, reimbursement is based on either organization costs or charges. The cost method reimburses organizations on the basis of cost per unit of service (e.g., home health visit, patient-day) for treatment and care. Costs include all or a percentage of added, allowable costs. Allowable costs are negotiated between the payer and provider and include items such as depreciation of building, equipment, and administrative costs (e.g., administrative salaries, utilities, and office supplies) (Kovner et al, 2011). For example, the unit of service in home health is the visit, and the agreed-on price is a set amount of money that the home health agency will be paid for a home visit in the region of the United States in which the home care agency is located. The charge method reimburses organizations on the basis of the price set by the organization for delivering a service (Kovner et al, 2011). In this case, the organization determines a charge for providing a particular service, provides the service to a client, and submits a bill to the payer; the payer in turn provides payment for the bill. With this method, the charge may be greater than the actual cost to the agency to deliver the service. When the charge method is used, the client often has to pay the difference between what is paid and what is charged. Prospective reimbursement, or payment, is a more recent method of paying an organization, whereby the third-party payer establishes the amount of money that will be paid for the delivery of a particular service before offering the services to the client (Kovner et al, 2011). Since the establishment of prospective payment in Medicare in 1983, private insurance has followed by requiring preapprovals before clients can receive certain services, such as hospital admission or mammograms more than once a year (Kovner et al, 2011). Under this payment scheme, the third-party payer reimburses an organization on the basis of the payer's prediction of the cost to deliver a particular service; these predictions vary by case mix (i.e., different types of clients, with different types, levels, and intensities of health problems), the client's diagnosis, and geographic location. This process is used in the DRG system of the hospital (Kovner et al, 2011). Similarly, ambulatory care services received by Medicare recipients are classified into ambulatory payment classes (APCs), which reflect the type of ambulatory clinical services received and resources required (CMS, 2012b). Prospective payment to skilled nursing facilities is also adjusted for case mix and geographic variations (CMS, 2012c). Positive and negative incentives are built into these reimbursement schemes. The retrospective method of payment encourages organizations to inflate prices in one area to offset agency losses in another. These losses can result from providing service to nonpaying clients or from providing care to clients covered under plans that do not cover the total costs of delivering a service (Kovner et al, 2011). The major disadvantage of this system is that little regard is given to the costs involved. This practice of charging a payer at a higher rate to cover losses in providing care is referred to as cost-shifting. Prospective cost reimbursement encourages agencies to stay within budget limits and adds an incentive for providing less service to contain or reduce costs. If an organization provides care to a particular patient or group of patients and keeps the costs of delivering the service lower than the amount of reimbursement, the provider keeps the difference; however, if the provider's costs exceed the reimbursement, the provider must assume the risk and pay the difference. The major disadvantage of this method is that organizations tend to overemphasize controlling costs and sometimes compromise quality of care. A growth in contracting, or competitive bidding, for health care services, intended to create incentives for providers to compete on price, has occurred as managed care has increased in health care markets. For example, contracting has been used by states to provide Medicaid services to eligible persons. Hospitals and other health care providers that do not have a contract with the state to provide services are not eligible to receive Medicaid payments for client care. Managed care organizations also use this approach to negotiate with health care organizations, such as hospitals, for coverage of services to be provided to covered enrollees, often called covered lives. Paying Health Care Practitioners The traditional method of paying health care practitioners is known as fee for service (Kovner et al, 2011) and is like the retrospective method just described. The practitioner determines the costs of providing a service, delivers the service to a client, and submits a bill for the delivered service to a third-party payer; the payer then pays the bill. This method is based on usual, customary, and reasonable (UCR) charges for specific services in a given geographic region, determined by periodic regional evaluations of physician charges across specialties (Kovner et al, 2011). Historically, Medicare, Medicaid, and private insurance companies have used this method of reimbursing physicians. A major effort to regulate and control the costs of physician fees was introduced in 1990 in the Omnibus Reconciliation Act. After a study by the Physician Payment Review Commission established by Congress, the resource-based relative value scale (RBRVS) was established. The RBRVS method reimburses physicians for specific services provided and the amount of resources required to deliver the service. Resources are defined broadly and include not only the costs of providing the service, but also the training that is required to provide a particular service and 117the time required to perform certain procedures, including client diagnosis and treatment. The RBRVS method of reimbursement, adopted by Medicare in 1991, acknowledges the breadth and depth of knowledge required by primary care physicians in the community to provide services aimed at prevention, health promotion, teaching, and counseling. Capitation is similar to prospective reimbursement for health care organizations. Specifically, third-party payers determine the amount that practitioners will be paid for a unit of care, such as a client visit, before the delivery of the service, thereby placing a limit on the amount of reimbursement received per patient (Kovner et al, 2011). In contrast to a fee-for-service arrangement, where the practitioner determines both the services that will be provided to clients and the charges for those services, practitioners being paid through capitation are given the rate they will be paid for a client's care, regardless of specific services provided. Therefore, for example, physicians and nurse practitioners are aware in advance of the payment they will receive to perform a routine, uncomplicated physical examination or a more complex, detailed physical examination, diagnosis, and treatment (Kovner et al, 2011). In capitated arrangements, physicians and other practitioners are paid a set amount to provide care to a given client or group of clients for a set period of time and amount of money. This arrangement, typically used by managed care organizations, is one whereby the practitioner contracts with the managed care organization to provide health care services to plan members for a preset and negotiated fee. The agreed-on fee is negotiated between the practitioner and the managed care organization before the delivery of services and is set at a discounted rate, and the practitioner and managed care organization come to a legal agreement, or contract, for the delivery and payment of services. The managed care organization pays the predetermined fee to the practitioner, often before the delivery of services, to provide care to plan members for a set period (Kovner et al, 2011). Reimbursement for Nursing Services Historically, practitioners eligible to receive reimbursement for health care services included physicians only. However, nurses who function in certain capacities, such as NPs, CNSs, and midwives, also provide primary care to clients and receive reimbursement for their services. Being recognized as primary care providers and eligible to receive reimbursement has not been an easy achievement. There are currently more than 250 nurse-managed clinics in the United States providing population-based preventive services, primary care, or specific wellness programs. Most are receiving financial support through Medicare, Medicaid, contracts, gifts, grants, and private donations. Hospital nursing care costs have traditionally been included as part of the overall patient room charge and reimbursed as such. Other agencies, such as home health care agencies, include nursing care costs with administrative costs, supplies, and equipment costs. Nursing organizations, such as the American Nurses Association (ANA), have long advocated that nursing care should become a separate budget item in all organizations so that cost studies can show the efficiency and effectiveness of the nursing profession. Spurred by efforts to control the costs of medical care, effective January 1, 1998, NPs and CNSs were granted third-party reimbursement for Medicare Part B services only, under Public Law 105-33 (ANA, 1999). This new law set reimbursement for NPs and CNSs at 85% of physician rates for the same service, an extension of previous legislation that allowed the same reimbursement rate to NPs and CNSs practicing in rural areas (Buppert, 1999). This law was passed after years of work in this area, including research documenting NP and CNS contributions to health care delivery and client outcomes and after active lobbying efforts by professional nursing organizations. Reimbursement for these nurses has not changed to any extent since the 1990s. In addition, data about the cost-to-benefit ratio, efficiency, and effectiveness of nursing care in general have been collected. Today, more than 250 nurse-managed clinics provide health care services to individuals in the United States who might not otherwise have access to health care, such as older adults, the homeless, and schoolchildren. All of these events have moved the discipline toward more autonomy in nursing practice and are serving as a means for evaluating and documenting nurses' contributions to health care delivery (Esperat et al, 2012). image Linking Content to Practice The balance of interest within society and health care will continue to shift toward a focus on quality, safety, and elimination of health disparities through public and private sector partnerships. Health care system concerns of the twenty-first century are expected to focus on examining the quality of health care relative to the costs of care delivered, reduction in disparities, access to care, and health care reform. These changes will result from continued efforts of both the public and private sectors to reform the U.S. health care system. The current era of health care delivery will be noted as a time of vast changes in all sectors of health care delivery. Nurses must plan for future changes in health care financing by becoming aware of the costs of nursing services, identifying aspects of care where cost savings can be safely achieved, and developing knowledge on how nursing practice affects and is affected by the principles of economics. Nursing must continue to focus on improving the overall health of the nation, defining its contribution to the health of the nation, deriving the value of nursing care, and ensuring its economic viability within the health care marketplace. Nurses must effect changes in the health care system by providing leadership in developing new models of care delivery that provide effective, high-quality care and by assuming a greater role in evaluating client care and nurse performance. It is through their leadership that nurses will contribute to improved decision making about allocating scarce health care resources, and promoting primary prevention as an answer to improve many of the current population level health outcomes. 118 Practice Application Connie, a nursing student, has identified a caseload of five families in a chronic disease program offered by the local public health department. She is interested in assessing the costs of care to her clients and to the agency. Connie approaches the public health nurse administrator and asks the following questions: A. How is the agency reimbursed for chronic disease management? Has the Affordable Care Act changed the way reimbursement occurs? B. Does the client have a responsibility for paying for services? C. Are nursing care costs known? D. Are services rationed to clients? On what basis? E. What effect will the chronic disease management program have on the community population? Answers can be found on the Evolve site. Key Points • From 1800 to 2000, the U.S. health care delivery system experienced four developmental stages, with different emphases on health care economics. With the twenty-first century, the health care delivery system has changed the focus of the fourth developmental stage. • Four basic components provide the framework for the development of delivery of health care services: service needs and intensity, facilities, technology, and labor (workforce). • Three major factors have been associated with the growth of the health care delivery system: price inflation, changes in population demographics, and technology and service intensity. • Chronic disease is becoming a major health factor affecting health care spending, with one in two Americans experiencing at least one chronic disease. • Health care financing has evolved through the twentieth century from a system financed primarily by the consumer to a system financed primarily by third-party payers. In the twenty-first century, the consumer is being asked to pay more. • To solve the problems of rising health care costs, the Affordable Care Act has been passed; this act also includes some form of rationing. • Excessive and inefficient use of goods and services in health care delivery has been viewed as the major cause of rising health care costs. • Economics is concerned with use of resources, including money, to fulfill society's needs and wants. • Health economics is concerned with the problems of producing services and programs and distributing them to clients. • The goal of public health economics is maximal benefits from services of public health providers, leading to health and wellness of the population. • The goal of public health is to provide the most good for the most people. • Nurses need to understand basic economic principles to avoid contributing to rising health care costs. • The GNP reflects the market value of goods and services produced by the United States. • The GDP reflects the market value of the output of labor and property located in the United States. • Microeconomic theory shows how supply and demand can be used in health care. • Macroeconomic theory helps one look at national and community issues that affect health care. • Social issues, economic issues, and communicable disease epidemics mark the problems of the twenty-first century. • Medicare and Medicaid are two government-funded programs that help meet the needs of high-risk populations in the United States. • A majority of the U.S. population has had health insurance. It is now mandated by law and has a penalty if citizens are not covered. • The uninsured segment represents millions of people, mostly the working poor, older adults, and children, and those who lost jobs in the economic downturn of 2008. • Poverty has a detrimental effect on health. • Health care rationing has always been a part of the U.S. health care system and will continue to be with health care reform. • Nurses are cost-effective providers and must be an integral part of health care delivery. • Healthy People 2020 is a document that has established U.S. health objectives. • Human life is valued in health economics, as is money. An emphasis on changing lifestyles and preventive care will reduce the unnecessary years of life lost to early and preventable death. Clinical Decision-Making Activities 1. Define the following terms in your own words: economics, health economics, public health economics, public health finance, gross national product, gross domestic product, consumer price index, and human capital. How do these terms relate to your work as a nurse? 2. Compare the advantages and disadvantages of applying economics to public health care issues. Be specific. 3. Compare and contrast efficiency and effectiveness of a public health program. What factors make these difficult to control? 119 4. Apply the concepts of supply and demand to an example from population health. Be precise in your answer. 5. Review Chapter 6. Debate in class the ethical implications of the goal of rationing. Focus your debate on the implications for nursing practice. What are some of the complexities of this question? 6. Invite a public health nurse administrator to meet with your class or clinical conference group. 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Is there evidence of an acute change in mental status from the patient’s baseline? YES, NO UNCERTAIN NOT APPLICABLE Inattention (The questions listed under this topic are repeated for each topic where applicable.) 2A. Did the patient have difficulty focusing attention (for example, being easily distractible or having difficulty keeping track of what was being said)? Not present at any time during interview Present at some time during interview, but in mild form Present at some time during interview, in marked form Uncertain 2B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come and go or increase and decrease in severity)? YES, NO UNCERTAIN NOT APPLICABLE 2C. (If present or abnormal) Please describe this behavior. Disorganized Thinking 3. Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable, switching from subject to subject? YES, NO UNCERTAIN NOT APPLICABLE Altered Level of Consciousness 4. Overall, how would you rate this patient’s level of consciousness? Alert (normal) Vigilant (hyper alert, overly sensitive to environmental stimuli, startled very easily) Lethargic (drowsy, easily aroused) Stupor (difficult to arouse) Coma (unarousable) Uncertain Disorientation 5. Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day? YES NO UNCERTAIN NOT APPLICABLE Memory Impairment 6. Did the patient demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions? YES NO UNCERTAIN NOT APPLICABLE Perceptual Disturbances 7. Did the patient have any evidence of perceptual disturbances, such as hallucinations, illusions, or misinterpretations (for example, thinking something was moving when it was not)? YES NO UNCERTAIN NOT APPLICABLE Psychomotor Agitation 8A. At any time during the interview, did the patient have an unusually increased level of motor activity, such as restlessness, picking at bedclothes, tapping fingers, or making frequent, sudden changes in position? YES NO UNCERTAIN NOT APPLICABLE Psychomotor Retardation 8B. At any time during the interview, did the patient have an unusually decreased level of motor activity, such as sluggishness, staring into space, staying in one position for a long time, or moving very slowly? YES NO UNCERTAIN NOT APPLICABLE Altered Sleep-Wake Cycle 9. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night? YES NO UNCERTAIN NOT APPLICABLE Scoring: For a diagnosis of delirium by CAM, the patient must display: 1. Presence of acute onset and fluctuating discourse AND 2. Inattention AND EITHER 3. Disorganized thinking OR 4. Altered level of consciousness Source: Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948. Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1: Acute Onset and Fluctuating Course This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient's baseline? Did the (abnormal) behavior fluctuate during the day; that is, did it tend to come and go, or increase and decrease in severity? Feature 2: Inattention This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention; for example, being easily distractible, or having difficulty keeping track of what was being said? Feature 3: Disorganized Thinking This feature is shown by a positive response to the following question: Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Feature 4: Altered Level of Consciousness This feature is shown by any answer other than "alert" to the following question: Overall, how would you rate this patient's level of consciousness? (alert [normal], vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable]) Source: Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948. The following case study is worth 50 points. Complete the case study and submit it to the drop box. You can either type your answers directly into the study or you can write them, take a picture and u Case Study Postoperative Delirium Patient Profile M.C. is a 74 year old male who has been in the intensive care unit (ICU) for 3 days after unexpected major abdominal surgery. He is becoming increasingly confused and agitated. Before surgery, he was alert and oriented. Subjective Data States he needs to “get out of here” Angry at family members for not “taking me home” Family members are very upset about M.C.’s confusion Objective Data Blood pressure 110/70, pulse 98, respirations 20, temperature 97.3 F Oxygen saturation 97% on nasal cannula oxygen at 2L Abdominal incision healing, no redness or drainage Difficulty speaking with decreased short-term memory and recall Trying to climb out of bed Oriented to person only Difficulty focusing attention, and disorganized thinking Answer the following questions thoroughly and cite resources appropriately in APA format. What type of cognitive impairment does M.C. likely have? How can this diagnosis be confirmed? Are there any other issues that you need to consider as possible causes for his mental state? What is the nurse’s priority regarding M.C.’s mental status? What is the next priority for the nurse caring for M.C.? What diagnostic tests may be ordered and what would each contribute? How will you support M.C.’s family at this time? Complete the attached CAM worksheet for this patient and discuss the results here