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Ali Al Sayed Hussain
Healthcare Policy
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A Review of Healthcare Policy
Presentation of Newly Created Hospital-Wide Policies and Procedures


The basics of any healthcare policy are related to three key elements (1) Access; (2) Cost; and 3) Quality.

Health policy occupies an important place in the domestic policy agenda of any country. A nation's health policy is part of its general overall social policy. As a result, health policy formulation is influenced by the variety and array of social and economic factors that impact social policy development (Kronenfeld, 1993). 

The nature and history of existing institutions, the general climate of opinion, ritualized methods for dealing with social conflict, attitudes and behavioral characteristics of key political actors, and the general goals and values of a society all play a role in the formulation of social policy (Kronenfel, 2002).

Many experts in health care policy believe that this century will bring fundamental reform and change in the health care system, and therefore in almost all of the health care policy issues and trends related to the health of the population, the overall health care system, the people who work within health care, and the institutions in which care is provided.
Health care has grown into a multibillion-dollar industry. Health care-related stocks and companies experienced rapid growth and large gains in values during the late 1980s and early 1990s, and stock in for profit health care companies were seen as valued holdings in the 1990s decade of stock market expansion in the US.  Moreover the United States has become the premier nation among all nations in the provision of high-quality, comprehensive medical education (Todd et al, 1990). Physicians come from all over the world to receive the most advanced training and learn how to use the newest medical equipment. (Kronenfeld, 1993).
Health care in the United States is far less simple than it was in 1900, and any simple, positive statement about the quality of health care is likely to be contradicted by accurate but negative facts from other sources. Some of this confusion is not new. Each decade for the last 40 years has included some discussion of a “health care crisis,” making this a most overused phrase. Current descriptions of problems and crises in the U.S. health care system abound.
According to some of the most recent data from the Agency for Healthcare Research and Quality (AHRQ) in the first half of 1999, 15.8 percent of the people in the United States, or 42.8 million people, were without health insurance coverage, up from estimates of between 33 and 38 million citizens in the early 1990s (Health Insurance Status of the Civilian Non-institutionalized Population, 1999, 2001).
Among people under 65, around 17 percent or 42.6 million people are uninsured; but for people 65 and over, almost everyone has health insurance coverage, demonstrating the success of the Medicare program to provide health insurance for the elderly. Among those under 65, many of the uninsured people are currently working or are spouses or children of people working.
These figures reflect the trends in the United States for some employers to either not provide health insurance or provide it at so high a cost that some workers may feel purchasing protection for their families, often much more expensive than the more heavily subsidized main employee health insurance benefit, is impossible.
Certain groups of people such as young adults are more likely than others not to have health insurance. Almost one-third of young adults in the United States are currently not insured. Hispanics and African-Americans are also much less likely to have health insurance. Among people under 65 years of age, 36 percent of Hispanics and 21 percent of African-Americans do not have health insurance versus only 14 percent among whites (Health Insurance Status, 2001).
These large numbers of uninsured occur despite the fact that the United States is one of the countries in the world that has been spending the most on health care for many years.
In 1990, the United States spent over 695 billion dollars on health care, or 12 percent of its gross domestic product. By 2000, the projected figure was up to over 1,311 billion dollars, and this figure represented 13.1 percent of the gross domestic product. If we try to relate this huge figure to individuals, the amount is enough to spend an average of 2,736 dollars per person in the United States on health care in 1990 and 4,681 dollars per person on health care for the year 2000 (National Healthcare Expenditure Projections, 2001). Compared to almost all other countries, our nation is a high spender on health care.
The United States spends 38 percent more per capita on health care costs than does Canada, 88 percent more than West Germany and 124 percent more than Japan; these three large, industrialized countries all have good health care systems and healthy populations. Thus, these countries spend less on health care and yet cover their total populations more comprehensively than the US. In fact, on many of the indicators typically used to rank countries on health status, the United States does not do as well as one would expect for a country of its wealth, education, and technological sophistication (Kronenfeld, 2002).


1. Access
While lack of health insurance coverage is widely and appropriately recognized as the key barrier to accessing health services, many other barriers also exist.

These can be broken down into three categories:

  1. Other financial barriers
  2. Sociocultural barriers
  3. Organizational barriers.

(McDonough, 1999)

1. Other financial barriers include the use of co-payments and deductibles in insurance policies that discourage patients from receiving timely and appropriate care.

2. Sociocultural barriers are increasingly recognized as substantial deterrents to healthcare access, and—even more than financial barriers—may account for much of the persistent and distressing racial disparities in health care.

Some key ones are:
(a) Language Incompatibility: Many health facilities are not equipped to handle language differences. While language compatibility has been demonstrated to positively affect health outcomes, many health providers and programs address this problem on an ad hoc basis, relying on family members to translate.

(b) Provider/Staff Attitudes: Differences in the socioeconomic and cultural backgrounds of providers and patients contributes to communication difficulties. Hurried and impersonal caregiving, fostered by healthcare organizations that push providers to see large volumes of patients, leads to sub optimal care and poor outcomes.

(c) Cultural Preferences: Fear of provider disapproval can result in lack of necessary communication that is vital to effective diagnosis and treatment.

(d) Immigrant Status: Undocumented residents are frequently unwilling to seek service from traditional providers because of deportation fears. These fears can result in unnecessary morbidity and mortality as well as increases in healthcare costs.

3. Organizational barriers to access result from the structure of the healthcare delivery system; they are also increasingly recognized as contributors to good or poor outcomes.

These barriers include:
(a) Inadequate Capacity: Capacity issues involve shortages of health professionals. Even when personnel are available, poorly funded and organized delivery systems can pose barriers because of long waiting times for appointments, inadequate numbers of appointment slots, inconvenient clinic hours, and an inadequate number of clinics.

(b) Transportation Barriers: Lack of adequate transportation is closely tied to income level and poverty status and can pose a substantial barrier to obtaining appropriate healthcare services. Individuals with limited incomes who are required to travel long distances to obtain needed services may find public transportation systems inadequate or unavailable, while others are unable to afford the cost. Many individuals do not obtain necessary care because of transportation barriers.

(c) Child Care Barriers: The unavailability of affordable and convenient childcare can be a major obstacle to obtaining adequate healthcare services. Mothers may be forced to bring their children to medical appointments, which lead some to forego obtaining services.

(d) Lack of Service Coordination: Disadvantaged families and individuals often need an array of additional services related to housing, transportation, nutrition, and other social and supportive services that make the difference between obtaining and not obtaining care. Patients and systems of care can be overwhelmed by the number of competing demands and needs, all of which can result in failure to obtain needed services.

(e) Managed Care: Some managed care plans have rigid rules requiring members to get all of their specialty care through referrals from a primary care “gatekeeper.” Although coordination of care by a single physician is an ideal of managed care, in practice this can sometimes work as a barrier to seeking care (McDonough, 1999).

2. Cost
It is beyond dispute that societies everywhere are spending more and more on health care.
Infant mortality and life expectancy are affected by much more than the amount of resources spent on medical care. Therefore, it may not be fair to blame the medical care system for our poor performance on these measures. But these data reinforce the disconnection between investments in medicine and improvements in the health of the population.

Private spending on healthcare services accounts for slightly more than half of system financing, with the bulk of it—more than $337 billion—coming from health insurance premiums paid by private employers and their employees, and by individuals who purchase coverage for themselves and their families. The cost of co-payments, deductibles, and direct consumer payments for health services is substantial—about one-half the amount spent on premiums.

Public sources of spending fall into several basic categories. The largest public expenditure in the US is for the federal Medicare program, which accounts for about one of every five dollars spent nationally on healthcare services. Medicaid is the other major public health services program, accounting for about one-seventh of health system spending, divided between the US federal and state governments. Medicaid funds health services for various low-income groups, including welfare recipients, the disabled, and seniors in need of nursing home services who have exhausted their assets. In recent years, some US states have expanded the Medicaid programs to cover larger portions of health care for other low-income adults and children. Low-income parents and their children account for three-quarters of enrollees but only one-third of program costs. This is because it is much more expensive to provide services to disabled persons and elderly persons in need of nursing home care.

The cost of drugs has been increasing so rapidly in recent years that some predict it will outstrip the cost of physician services early in the 21st century (Masia, 2002).

The Canadian-style “single payer” health insurance program, whereby most services are financed through taxes without the administrative costs associated with private health insurance. Because healthcare costs have risen so dramatically over the past 30 years, much public policy is focused on attempting to slow the rate of growth (McDonough, 1999).

The first necessary step to controlling the growth of health system costs is to understand what drives the increases.
Four factors account for most of the growth in health costs:

  1. General economy-wide inflation;
  2. Additional inflation in medical prices;
  3. Increases in the quantity of health services provided to patients, including both volume and intensity of services;
  4. Population growth and demographic changes.

The last is a small contributor to cost increases. The other three categories loom large but vary considerably in their share from one year to the next.

Market forces have not successfully controlled health prices. Economists believe several factors have accounted for “market failure” in health care.
Key among these are:

  1. The unique nature of medical care that makes it difficult for consumers to judge its “value”
  2. The prevalence of insurance that insulates consumers from paying, or even knowing, the full price for services.

In the US, Health insurance first emerged during the 1930s with the creation of Blue Cross plans to help individuals pay for the costs of hospitals and physician services. Hospitals began the earliest plans so that patients would be better able to use their services. These plans were “community rated,” meaning that all participants paid the same premium regardless of their age or health status.

During World War II, private employers began to buy health insurance for their workers as a way to increase compensation without violating the federal government’s wage and price freeze—and thus began the important American pattern of employer-sponsored coverage. Americans have been complaining about the high cost of medical care for most of this century.

Beginning with the creation of the Medicare and Medicaid programs in 1965, public policymakers in Washington, D.C., and in state capitals, became more concerned about increases in health costs and the effect of those increases on the rest of the economy. Employers who paid the bulk of private costs also expressed concerns. During most of the 1970s and 1980s, government responded to the health cost “crisis” through public sector regulation.

The regulatory responses included the following:

  1. Certificate of need (CON) laws that required hospitals to go through a state-based, public process before building new facilities or adding expensive new services;
  2. Health systems planning boards that included health providers, consumers, business leaders, and government officials to review CON proposals and to plan local health service delivery systems;
  3. State hospital rate setting programs that required hospitals to submit to state cost control regulations; and
  4. Financing and support for the development of health maintenance organizations (HMOs).

These four efforts were cooperative arrangements involving the federal government, state governments, employers, consumers, insurers, and providers.

On the federal level, the regulatory response included the prospective Payment System (PPS), created in 1983 to pay hospitals a set amount for services provided to each Medicare patient in a particular diagnosis related group, or DRG, rather than for each service individually based on the hospital’s cost. HMOs only took off after the federal program was abandoned and the private sector and Wall Street began to invest in them in the mid-1980s (McDonough, 1999).


3. Quality
Substantial progress has been made in defining and understanding quality over the past 30 years.

The Institute of Medicine, suggested that quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

A shorter definition of quality is less precise. Quality is “doing the right thing, and doing it right.” This definition can apply to the quality of almost anything, including health care. It incorporates the two key elements of good service—choosing the most appropriate and effective intervention and applying that intervention in the best way. Not explicitly stated in this definition is a recognition that our understanding of the “right thing” evolves over time (McDonough, 1999).

Avedis Donabedian of the University of Michigan (Donabedian, 2001), identified three key attributes that laid the foundation for how researchers still analyze and understand healthcare quality today.

(i) Structureis the physical environment in which care is delivered as well as other setting characteristics (provider credentialing, staffing patterns, ownership arrangements, etc.).

(ii) Processattributes are the components of the encounter between the patient and the provider, including what treatments were used, how well they were administered, and how well or poorly the provider communicated with the patient.

(iii) Outcomeis the result of the encounter and the patient’s subsequent health status.

Process aspects can be more difficult but are obtainable: patients can fill out surveys that determine how well physicians and other providers followed appropriate processes; studies on waiting and treatment times can be conducted (McDonough, 1999).

The problem is that neither aspect necessarily determines whether the patient received quality care. One can visit a sparkling, modern medical facility and receive excellent service, yet still obtain poor-quality technical care and have an adverse outcome. In fact, survey data show that patients who receive poor-quality technical care from a provider with good interpersonal skills will rate that care more highly than excellent technical care from a physician with poor personal skills.

Frustrations with the recognized inadequacies of structure and process measures lead many to favor outcome-based measures. The problem here is that one can receive excellent technical care from someone with great personal skills and yet still have a poor outcome, as well as the converse.

Though much effort is now being applied to investigating and understanding what works, we still have a long way to go and will continue to rely on a mix of all three elements to evaluate healthcare quality.

Responsibilities for monitoring the quality of healthcare services
A large number of organizations—both governmental and non-governmental —have responsibilities for monitoring the quality of healthcare services.

In the United States at the federal level the largest health-related entity is the U.S. Department of Health and Human Services (HHS). This department contains numerous agencies responsible for measuring and monitoring the quality of health care, in addition to financing, regulating, and directly providing it.

Key agencies within HHS include the Healthcare Financing Administration (HCFA), which enforces quality standards in the Medicare and Medicaid programs it administers; the Agency for Healthcare Policy and Research (AHCPR), which funds and conducts research on how to measure quality; the Health Resources and Services Administration, which focuses on expanding the capacity of health professionals and facilities providing care to underserved and vulnerable populations; and the Centers for Disease Control and Prevention (CDC), which conducts research and provides services that promote public health and the prevention of disease, injury, and disability.

Every state also has a set of agencies with some role in quality of care, though every state organizes these responsibilities among their agencies differently.

Usually, the following responsibilities will be addressed within each state bureaucracy, each with a quality monitoring function:

Public Health: Every state has some agency in charge of public health functions that may include health facility licensure for hospitals, nursing homes, and other health institutions. Revoking a facility’s license is one of the most serious steps taken to address quality of care deficiencies.

Physician and Other Professional Licensure: Every state has some administrative structure to license physicians, nurses, and other health professionals. Licensure is a key governmental power. All licensure boards were created in response to pressure by the affected group of professionals seeking licensure to control entry into their profession—this process helps keep poor-quality providers out and also enhances the earning power of licensed professionals. Licensure boards are invariably dominated by the affected professionals.

Medicaid and Other Health Reimbursements: Every state has some entity that manages the federal/state Medicaid program. Because Medicaid is so important to many providers, it makes an enormous impact by requiring its providers to meet certain quality standards. For many other providers, however, Medicaid is not an attractive program, is a small part of the provider’s income base, and can be easily ignored.

State Insurance Departments: Because the “business of insurance” has been left to the states, each has its own insurance department that can have significant impact monitoring the activities of insurance companies and managed care entities such as HMOs.

Traditionally, these departments have focused most of their attention on insurer solvency issues, making sure that the companies can pay claims. In recent years, many of these departments have aggressively asserted themselves into quality of care concerns.

Attorneys General: Every state has an attorney general who enforces its consumer protection statutes.  Additionally, attorneys general usually oversee a state’s not-for-profit, charitable corporations.

Among the private organizations, two of the more important ones include:

(i) The Joint Commission on Accreditation of Healthcare Organizations:
JCAHO accredits hospitals across the nation and is jointly sponsored by the American Hospital Association and the American Medical Association. Many states and the federal Medicare program require that hospitals have JCAHO accreditation. Joint Commission also accredits international hospital organizations.

(ii) The National Committee on Quality Assurance
NCQA accredits managed care plans and developed the most widely used “report card”—an instrument called “HEDIS” (Health Plan Employer Data and Information Set)—to compare and evaluate HMOs and other managed care organizations. NCQA was established by the managed care industry but has separated itself in order to act more independently (McDonough, 1999).
Quality is the third leg of the three-legged stool of essential elements in health services research and health care delivery. No evaluation of a health care system or discussion of health care policy issues is complete without attention to it. One difficulty in the quality area, as compared to the cost one, is that measurement is less clear and not easily amenable to evaluation. No clear and complete consensus exists about how to measure health care system outputs or quality. In part, this is due to a lack of clear definition. The linkages between the health care system and the production of health, even if we simplistically define health as the reduction in the amount of death, also is not always clear. Cost and quality issues are inextricably linked (Kronenfeld, 2002).


General Analysis



It is undeniable that the United States has the most technologically advanced medical care system on the planet, and that that system has demonstrated extraordinary capacities to diagnose and treat disease. But it is also arguable that other nations have done a good job in emphasizing health promotion, disease prevention, and primary care services.

The one area in which the U.S. healthcare system undeniably falls behind the health system of every other advanced industrialized nation is in providing access to health services for all citizens.

Canada, Denmark, France, Germany, Greece, Japan, and the United Kingdom all have less than 1% of their respective populations without coverage, while 16.1% of the U.S. population did not have coverage in 1997, totaling 43.4 million Americans, according to data from the U.S. Bureau of the Census. In 1980, the United States had about 25 million uninsured, and that number has grown by about one million per year ever since, during good and bad economic times (McDonough, 1999)

The trend that has existed for more than 30 years continues in the late 1990s: the United States leads the world in its rate of expenditures for healthcare services but shows a mediocre performance on key health status measures such as infant mortality and life expectancy.

In addition, unlike the United States, the other countries provide coverage to virtually all of their citizens.


Increased health care spending has created extraordinary value in the US by extending life expectancy, improving quality of life, increasing employee productivity, and lowering the cost of addressing a wide range of diseases.

Change is a defining characteristic of health care. In order to know whether the “price” of good health is going up or down, one must look not only at the amount of money being spent but also at the quality of the care being delivered and the outcomes that result from spending on health care (Masia, 2002).

Industrialized societies have increased their spending on health care over the past few decades and reaped the benefits, including substantially longer life spans, healthier populations, and increased productivity.

Treatment regimens have certainly changed over time. For example, consider how asthma treatment has changed. Major new therapies have been introduced in recent decades to treat childhood asthma, with a resultant increase in drug spending.

But research has shown that increased spending on the right asthma therapy can keep children out of the hospital, prevent excess visits to the doctor, and reduce overall health care costs  (PhRMA, 2002).

Perhaps the most tangible evidence is that average life expectancy at birth in the US has increased more than 10 years since World War II.

Health conditions have improved tremendously since the early 1900s. Valuable life span extensions, which are an indicator of overall health improvements, translate into concrete gains in economic output, mainly because healthier workers are more productive.

Researchers at Harvard estimated recently that each added year of life span adds roughly 4% to national output (Bloom et al, 2001).

Other research suggests that improved health can be an especially potent driver of economic growth for poor countries. For example, economists have shown that health improvements (in particular, a major reduction in infant mortality due in large part to the development of antibiotic and antimicrobial drugs) led to a dramatic increase in the working-age population in many formerly poor Asian nations, and that the resulting increase in productive output accounted for perhaps one third of the Asian “economic miracle.” The same researchers estimate that if a country increases life expectancy by five years, its annual growth rate will increase by 0.3-0.5 percentage points, a 20-25% increase over the average national growth rate between 1965 and 1990 (Bloom & Canning D, 2000).

New pharmaceutical products are perhaps the most visible and most widely distributed category of new medical technology and have quite clearly played a substantial role in the overall march toward better health. In the United States alone, over three billion prescriptions were filled in 2000, and that rate is forecasted to increase dramatically as baby boomers reach their retirement years and develop increased need for prescriptions (IMS Health, 2002). The FDA has approved over 600 new drugs since 1980 (PhRMA, 2002).

The Value of Pharmaceutical Innovation Medical advances provide at least four important types of value. First, new treatments can directly and indirectly reduce treatment costs overall by offsetting spending elsewhere in the health system, sometimes months or years after treatment.

For instance, new treatments for Alzheimer’s disease are initially costly but may save thousands of dollars per patient by helping patients avoid or reduce nursing home.

Second, improvements in health care can increase worker productivity. Unhealthy employees often miss work or may drop out of the labor force entirely, leading to lost income and workdays, retraining and rehiring costs, and reduced productivity on the job. Further, a healthy workforce expands the pool of available labor, leading to not only improved productivity but also lower labor costs (Walsh, 1991).

Third, medical innovations can reduce the incidence of disease and improve the quality of life for those living with disease (and those who care for them).

Consider, for example, the value of improvements such as advanced prosthetic devices for amputees or antiemetic therapies to ease nausea for chemotherapy patients. Such improvements often provide value far beyond the price of treatment, though the tangible value can be difficult to measure precisely (Masia, 2002).

Finally, and most dramatically, advances in medicine save lives. The economic benefits of improved longevity, in fact, are among the key drivers behind multitrillion-dollar estimates of the value of medical technology.

Economists at Harvard and Stanford, for example, found that after controlling for differences in death rates due to heart attack over time (a blunt but effective measure of quality improvement), the real price of heart attack treatments dropped by 1.7% per year between 1983 and 1994 (Cutler et al, 2001).

In the United States, spending on health care accounts for roughly 15% of gross domestic product (GDP) and is by most measures the country’s largest industry (Health Care Financing Administration, 2002).




It is undeniable that the United States has a technologically advanced medical system that can create wondrous cures and that saves lives every day. But it is also true that our system is rampant with examples of poor quality.

In 1998, the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry (which included many health sector leaders) concluded that too many patients receive substandard care.

These shortcomings endanger the health and lives of all patients, add costs to the healthcare system, and reduce productivity. The major quality problems they identified include:

  1. Avoidable errors in the practice of medicine. A 1990 study of New York hospital discharges found that adverse events occurred in 3.7% of hospitalizations, and that 27.6% of them were due to negligence and resulted in more than 3,000 unnecessary patient deaths annually. Errors in the administration of medications led to more than 7,000 unnecessary deaths in 1993 alone.


2.  Overuse of unnecessary services. One study of hysterectomies found that 16% of the 510,000 performed in 1994 were unnecessary. Several studies have documented that many thousands of radical mastectomies are performed each year on breast cancer victims when far less severe lumpectomies lead to the same outcomes. A study on the appropriateness of carotid endarterectomies (a procedure to remove harmful material from heart arteries) found that 18% were inappropriate, 49% were of uncertain clinical value, and 33% were appropriate.

3.   Underuse of needed services. 1995 data show that only 76% of children had received the appropriate set of immunizations by 18 months of age. Among adults over age 65, only 52% received an annual influenza vaccine and only 28% received a pneumococcal vaccine, despite compelling evidence of the ability of these vaccines to save lives. Another study found that between 20 to 30% of patients with depression were prescribed Antidepressant medications and among those prescribed, 30% received a sub therapeutic dose.

4.   Inexplicable variation in the practice of medicine. In 1994, hospital admission rates were 49% higher in the Northeast than in the West, and lengths of stay were 40% higher.  Ceasarean section rates varied from 19.1% to 42.3% in a study of affluent women cared for by different obstetricians at the same community hospital. Children with asthma in Boston have a 3.8% chance of being hospitalized, while children in New Haven have a 2.3% chance (McDonough, 1999).


One of the important goals of the Department of Health & Medical Services (DOHMS) is to achieve the Joint Commission International Accreditation. The main objective of this exercise is to meet the international requirements and obviously be counted among the top hospitals in the region. There are important benefits in the pursuit for the Joint Commission or any other hospital or departmental accreditation requirements. The final outcome is the upgradation or harmonization of services. This adds up to the mission and vision of the establishment and therefore a great deal of work and effort is needed to contribute to the attainment of the accreditation. For DOHMS it is a priority issue and the Joint Commission representatives from USA visited our infrastructure and made recommendations on how we could improve and align ourselves for the specific requirements in the accreditation process.

Being the Leader of Care of Patient Team, the responsibility has been tremendous. The preparation is in full swing since the past couple of years and my team members have been very cooperative and contributive towards the final shape of the hospital-wide policies targeted for completion before the JC inspection team arrives.

The creation of policies, which were non-existent, is a strenuous process. From scratch many policies were proposed and many of these recommended policies and procedures have been approved by the higher authorities in DOHMS and consequently implemented in the hospitals, health centers and clinics of DOHMS.

Enumerated below; some in depth and some summarized, are examples of the policies, that I was instrumental and responsible for creating, proposing and implementing in DOHMS.

The selection of policies presented below is random and constitutes only a part of the Care of Patient policies implemented in DOHMS. It has to be mentioned here that most of the policies have been implemented and some are in the process of their final approval.


The policies are formatted in the following pattern as stipulated in the guidelines from JCIAHO:


1. Introductory Block

  1. Policy Title
  2. Policy No.
  3. Approved by
  4. Approval Date
  5. Revision Date

II. policy statement

  1. NAME
  2. DATE


  1. NAME
  2. DATE






The timely implementation of the Breast Feeding Policy cleared the doubts of many involved on the stance of the department on this issue. The international references and protocols were referred and a conclusion made to formulate a policy, which avoids confusion on the use of Ready to Feed (RTF) formulas and importantly enhances the confidence of the lactating mothers on the policy of the hospital.


Verbal Medication Orders is an important policy and its implementation has streamlined the communication procedures between pharmacists, physicians and nurses, which interpolates to reduce probability of medication errors.


A brief summary of the other policies and procedures created in context of the JCIA accreditation requirements:

1.  Unit Dose Drug Distribution System
Unit dose drug distribution system, which caters to inpatients and facilitates the provision of medicines for each specific patient for a single day in an exclusive cassette, is one of the important measures taken to control the increase in medication errors. It was first started in the United States and many countries followed in a similar manner with slight modifications depending on the resources available.
Overall the implementation of the Unit Dose Drug Distribution System avoids the stocking of medicines in bulk at the wards and minimizes medication errors. The Nurse at the wards has at her disposal individualized cassettes that specify the patient. This provides the opportunity for the pharmacist to keep constant check on the distribution of medicines to the wards on daily basis. The only deterrent being the increased requirement of human resources.

Preparation, dispensing, storage of unit dose system
Preparation, storage, labeling, distribution of a 24-hour supply medicine. It is supplied in unit dose packages and labeled and placed in the cassette of each patient as available.
policy statement

  1. Pharmacy department shall prepare, label, store, and dispense medicine to the inpatient in unit dose.
  2. Unit dose distribution system shall be implemented throughout the hospital in the inpatient services.


  1. To have a control on drug distribution.
  2. To minimize medication errors.


  1. Pharmacy staff shall verify the order after receiving or before filling the prescription.
  2. Pharmacy staff shall prepare and dispense the order.
  3. All preparations shall be checked by a Pharmacist before dispensing.
  4. Pharmacist shall verify the discontinued medication and return them to the pharmacy.
  5. Pharmacy staff shall store the unit dose medicine in a separate area.
  6. Items requiring refrigeration shall be labeled with the patient name and placed in the refrigerator by the pharmacist.
  7. Nurse shall verify the medicine with physician’s order and name of the patient before administering the medication.


ME No.11.4.  JCIA Standard COP


2.  Expired or Outdate drugs
The cost of medicines is increasing by the day. In order to provide the best healthcare facility, it is very essential to keep upgrading the quality of the medicines available for patients. Medicines form the major bulk of expenditures to DOHMS. Expired medicines have caused great losses in the past. The implementation of policies and procedures to avoid unnecessary wastage of medicines has proved very cost effective and resulted in savings for the department compared to previous years apart from maintaining a high quality stock.

POLICY TITLE: Expired or outdated drugs
Expired medications are those medicines that are expired as per the manufacturing date and they cannot be used either because they are inert or they may be toxic or part of their potency is lost.
policy statement
Expired drugs shall not be used in the hospital and health facilities of DOHMS.
Expired or outdated drugs shall be collected and sent to CSC Stores (drugs) for destruction.
The United States Pharmacopoeia expiry system shall be exercised in the expiration dates.
To avoid expiry of medicines, rotation of the near expiry drugs shall be exercised within DOHMS.

  1. To protect patient and community from the hazards that result from the use of expired or outdated medicines.
  2. To assure quality of medicine supply and high standards of health care services.


Near expiry items shall be prepared by CSC Stores and Pharmacy Department in advance and sent to other departments to avoid expiry.

  1. The near expiry drugs shall be checked by pharmacy department and rotated amongst the DOHMS hospitals in order to avoid expiry.
  2. The Pharmacy Department shall routinely check and replace expired or outdated drugs in all sites with fresh supplies on monthly basis.
  3. The nurse in the unit shall inform the pharmacy department any expired medicine on daily basis.
  4. The Pharmacy Department shall prepare a list of expired drugs to CSC for information.
  5. Approval from the Higher Authority shall be obtained by the Chief Pharmacist for the destruction of expired medicines.
  6. The Pharmacy Department shall collect, account and return all expired medicines to CSC (drugs) for destruction or replacement and compensation whenever possible by suppliers on an annual basis.
  7. The CSC Stores shall destroy the expired medicines after approval of the Higher Authority and in the presence of a witness of the committee.
  8. All expired narcotic drugs shall be sent to CSC Stores for further action by Pharmacy Department.
  9. The expiration of the medicines shall be considered upto the last day of the month as per the USP Standards.

ME No. 11.3.l & m., JCIA Standard COP

3.  Use of Medication brought into the organization by the patient

POLICY TITLE  Use of Medication brought into the organization by the patient


Any medication brought by the patient to be used in the hospital when he is admitted as an inpatient.

policy statement

  1. Use of medicine brought by patient when admitted is discouraged by DOHMS.
  2. Only the non-formulary items can be permitted to be administered after evaluating and prescribing by the physician.
  1. On discharge, if the physician requires the patient to continue on that medication, pharmacy department is not obliged to make that medication available to the patient.


To control medication use brought by the patient and assure patient safety.


  1. On admission the physician shall take the patient’s medication history and assure that all the medication he is taking is available in the Department, if not alternatives are available.
  2. The physician shall verify the usage of the medication brought by the patient.
  3. The physician shall check for any interaction, adverse effects, side effects, indications, contraindications for the medication brought by the patient.
  4. After approving the usage of the medication for the patient the physician shall write the medication order.
  5. Pharmacists shall check the order with the medicine and verify it for any interaction, duplication, and contraindications.
  6. The medication shall be locked under the supervision of the nurse and should be administered by the nurse.

ME No. 11.3.f, JCIA Standard COP

4. Adverse Drug Reactions (ADRs) Reporting System


POLICY TITLE        Adverse Drug Reactions Reporting System

POLICY No.              PH021


An adverse drug reaction is any unexpected, unintended, undesired or excessive response to a drug that

  1. Requires discontinuing the drug (therapeutic or diagnostic)
  2. Requires changing the drug therapy
  3. Requires modifying the dose (except for minor dosage adjustments)
  4. Necessitates admission to a hospital
  5. Prolongs stay in a healthcare facility
  6. Necessitates supportive treatment
  7. Significantly complicates diagnosis
  8. Negatively affects prognosis
  9. Results in temporary or permanent harm.

policy statement
Any Adverse drug reaction (ADR) shall be recorded and reported.
All reported ADRs shall be evaluated and action shall be taken.
To improve quality of health care services.

  1. Any staff or patient who identifies an ADR shall report to the physician.
  2. ADR when reported shall be recorded in the patient’s file by the physician.
  3. ADR Reporting Form shall be filled by physician and sent to the pharmacy department for evaluation.
  4. ADR data collected shall be screened and evaluated by the Chief Pharmacist or his delegate before forwarding to the hospital P & T Committee.
  5. The hospital P & T committee shall review the reported ADRs for evaluation and action; send a copy to the Central P & T Committee and to the patients file. A copy shall be sent to the Quality & Change Dept.
  6. The Central P & T committee shall screen and evaluate the reported ADRs and take further action.
  7. Any ADR Report received shall be confidentially recorded by the physician.
  8. The Hospital and Central P & T Committee shall publish and distribute ADR Reports to the medical and nursing staff.
  9. The Hospital and Central P & T Committee shall provide feedback to physicians, nurses, patients and family members about ADRs and action taken.

ME No. 11.6.2, JCIA Standard COP








5.  Medication Recall System

POLICY TITLE        Medication Recall System

POLICY No.              PH018


A recall system is a systematic procedure followed to recall any medicine issued whenever a problem arises.
policy statement

  1. Any drug having a hazardous outcome shall be recalled.
  2. Notification for medication recall should be initiated from DOH&MS through Higher Authority in Head Quarters, Hospital Directors or CSC stores (drugs).
  3. All the clinical departments and nursing units shall be informed about the recalled medications.

In order to protect the patients and enduser from any hazardous mishaps.

  1. A notification shall be issued from the concerned authority of Head Quarters, Hospital Directors or CSC (Drugs) when a medication is to be recalled.

Notification shall include:

  1. Brand and generic names of the medicine.
  2. Form of the medicine.
  3. Strength.
  4. Batch Number
  5. Expiry date.
  6. Reason/s for recall.
  7. The concerned authority shall distribute a copy of the notification to all heads of pharmacy sections and head of the departments mostly using that drug.
  8. Head of pharmacy sections shall immediately stop dispensing such medicines and check the availability of that drug in the pharmacy and pharmacy store.
  9. According to the ward’s drug list, pharmacy department shall notify wards and clinics where the recalled drug is stored as a stock or non-stock item.
  10. A memo by the Head of Pharmacy Department concerning the recalled medication shall be sent to Assistant Hospital Director – Nursing.
  11. The Assistant Hospital Director – Nursing, shall circulate the memo regarding the recalled medication to different wards and clinics
  12. The Assistant Hospital Director – Nursing shall instruct nursing staff in wards and clinics to return their stock, if available, to the pharmacy department with a delivery note immediately.
  13. Nurses shall return any recalled medication available in the unit to the pharmacy.
  14. Pharmacy department shall collect all the recalled medications and send them to CSC store (drugs) with a delivery note for further action.
  15. CSC Stores (drugs) shall send notification and follow up the recollection of the drug and to take further action.


Higher Authority at Head Quarters is responsible to issue a notification for recall of drugs.

  1. Hospital Directors are responsible to issue a notification for recall of drugs.

Responsibilities of the Head of Pharmacy Department

  1. Head of Pharmacy Department is responsible to immediately stop dispensing the recalled drugs and check the availability of those drugs in the pharmacy and pharmacy store.

Head of Pharmacy Department is responsible to send a memo concerning the medication recall to the Assistant Hospital Director – Nursing.

Responsibilities of the Pharmacy Department

Pharmacy Department is responsible to notify wards and clinics where the recalled medication is stored as a stock or non-stock item.

  1. Pharmacy Department is responsible to collect all the returned recalled drugs and send them to CSC Store (drugs) with a delivery note for further action

Responsibilities of the Assistant Hospital Director – Nursing

  1. The Assistant Hospital Director – Nursing, is responsible to circulate the memo of the recalled drugs to different wards and clinics.
  2. The Assistant Hospital Director – Nursing is responsible to instruct wards and clinics to return their stock of recalled drugs, if available, to the pharmacy department with a delivery note immediately.
  3. Nurses are responsible to return any recalled medication available in the unit to the pharmacy.
  4. Responsibilities of CSC Stores (drugs)
  5. CSC Stores (Drugs) is responsible to issue a notification for recall of drugs.
  6. CSC Stores (Drugs) is responsible to follow up the recollection of the recalled drug and take further action.


ME No. 11.4.3, JCIA Standard COP


6.  Self-administration of medications

POLICY TITLE        Self-administration of medications

POLICY NO.             PH008


Medicines that the patients are authorized to administer by themselves.
policy statement
Medications that can be self administered by the inpatients in the wards are:

  1. External use preparations.
  2. Eye, ear and nasal preparations.
  3. Inhalers.

To encourage patient’s participation and education in his own therapy.

  1. All medicines shall be kept with the nurses.
  2. Nurse shall educate patients regarding the use of their medications needed to be self-administered.
  3. Patients shall administer the medicine in the presence of the nurse.
  4. Nurse shall watch for proper administration and any adverse reactions.
  5. Pharmacist shall communicate and educate the patient regarding the adverse effects, precautions, and contraindications, of medications to be self administered, if necessary.


Responsibilities of the nurse

  1. Nurse is responsible to keep all medicines to be self-administered.
  2. Nurse is responsible to educate patients regarding the use of their medications needed to be self-administered.
  3. Nurse is responsible to watch for proper administration by the patient and any adverse reactions.

Pharmacist is responsible to communicate and educate the patient regarding the adverse effects, precautions, and contraindications, of medications to be self-administered, if necessary.
ME No. 11.3.d, JCIA Standard COP

The following list of polices and procedures created reflect the policy of the Department of Health & Medical Services and hence the Government of Dubai. All these policies are also in accordance with Joint Commission International Accreditation of Hospitals – USA.






Medication use in the organization

COP 11


Process for obtaining, utilizing and safeguarding medicines

COP 11.2.1


Obtaining medicine when pharmacy is closed

COP 11.2.3


Availability, monitoring and safety of emergency medications stored outside pharmacy

COP 11.2.4


Verbal medication orders

COP 11.3


Prescribing, ordering and administration of medicines in the organization

COP 11.3


Identification of those permitted to prescribe and administer medications

COP 11.3.1


Self administration of medications

COP 11.3.2


Control of medication samples

COP 11.3.2


Use of Medication brought into the organization by the patient

COP 11.3.2


Dispensing of medicine on discharge

COP 11.3.2


Preparation, handling, storage and distribution of Parenteral Nutrition.

COP 11.3.3


Storage, handling, distribution and dispensing of Investigational drug

COP 11.3.4


Preparation, dispensing, labeling and storage of I.V. Admixture.
Unit dose system & TPN

COP 11.4
COP 11.4


Handling, storage and distribution of Vaccines and Medicines that require refrigeration

COP 11.4.1


The Storage, labeling, dispensing, administration and utilization of Controlled Substances

COP 11.4.1


Reviewing prescriptions and Contacting physicians

COP 11.4.2


Medication Recall System

COP 11.4.3


Expired or outdated drugs

COP 11.4.3


Preparation, dispensing, storage of unit dose system

COP 11.4.4


Adverse Drug Reactions Reporting System

COP 11.6.2


Medication errors reporting system

COP 11.6.3


Food brought from outside the hospital

COP 12


Food provided in the hospital

COP 12.1


Preparation, handling, storage and distribution of enteral nutrition

COP 11.3.3


Preparation, handling, distribution and storage of food

COP 12.3


Food Storage on the Units

COP 12.3


Patients at nutrition risk receive nutrition therapy

COP 13



Throughout the twentieth century, Americans have joined together from diverse backgrounds and perspectives to reform the healthcare system in particular to establish national health insurance.

In each of these efforts, reformers faced strong opposition from the American Medical Association and other powerful interests. It was during this period that other industrialized nations such as Great Britain and Canada set up their national health frameworks.

In the 1960s, American reformers achieved their greatest success with the creation of Medicare for senior citizens and Medicaid for some portions of the poor. The architects of these programs explicitly hoped that expansion of coverage for all Americans would follow shortly. It did not happen.

This lack of health insurance is documented to lead to a lack of access to timely, quality health care, which in turn means poorer health. Federal and state governments consider this connection an important enough issue of public concern to have instituted policies, in a variety of categories, to address the problem (McDonough, 1999).

Some of the major reforms that have been implemented, and the reform opportunities that are available for healthcare:

It is divided into four sections:
1. Access initiatives,
2. Managed care consumer protections
3. Senior citizen healthcare needs
4. Other healthcare reform opportunities.

These reforms look both to the private sector, to expand or improve coverage through market mechanisms, and to the public sector, to cover or provide care to more of the uninsured (McDonough, 1999).

Expanding Coverage in the Private Sector

Private health insurance markets: The federal and some state governments have attempted many reforms and implemented some of them. Senior citizens are a particular group that could benefit from further reform.

As the cost of health insurance rose, insurance companies increasingly avoided the riskiest consumers. During the 1990s, many states implemented insurance market reforms to address problems faced by small businesses and individuals in obtaining and keeping private health insurance. Generally, states sought to provide:

    1. Guaranteed issue,ensuring that individuals or businesses that met appropriate criteria could obtain coverage from insurers;
    2. Guaranteed renewal, ensuring that individuals or businesses that met appropriate criteria could not be denied renewal;
    3. Modified community rating, ensuring that all policy holders within certain defined groups would be charged the same rate;
    4. Limitations onpre-existing condition exclusionsthat insurers used to deny coverage to persons who may cost the plan large sums of money and more (McDonough, 1999).


Health Insurance Portability and Accountability Act of 1996 (HIPAA) came into being to increase the access, portability, and renewability of private health insurance by setting minimum standards for individual, small group, and large group markets.

These insurance reforms—small and non-group—have enabled many individuals to obtain coverage who otherwise would have been unable to, and have allowed many ill individuals to retain coverage. The reforms have also led to premium increases for young and healthy individuals whom insurers desire because they cost so little.

Whether healthcare system needs reforming and how to reform it are clearly among the most important health care policy issues for the coming decades, just as, in many ways, they have been the most important policy issues of the past 10 years. One reason for this is that reform of the system always begins a discussion of who now has access to health care and whether that access varies across the population. This leads to insurance coverage and its variation, along with the major national programs already in place to deal with issues of access to health care services and to help provide insurance coverage to certain population groups. The role of the Medicare program with the elderly as well as the role of Medicaid and newer programs such as CHIP with those having lower incomes, especially children.  Patterns of health insurance and access to care, earlier attempts to reform the health care system, current issues related to managed care, and some of the political issues involved all have a role to play (Kronenfeld, 2002).

General Recommendations

Prior to the 1990s, hospitals typically had a department in charge of “quality assurance.” The assumption behind the term is that quality already exists, and that a separate administrative team is needed to “assure” that quality levels are maintained.

Over the course of this decade, a new approach has taken hold within the healthcare industry that is more helpful and hopeful. This approach recognizes that healthcare quality is not where it could be. It recognizes that problems are found in systems more than in individuals, that the practice of medicine is complex, and that practitioners need to be encouraged to report quality problems in a supportive environment.

This approach has several names, including total quality management (TQM) and continuous quality improvement (CQI). Its assumption is that however good or bad any organization may be, there is always room for improvement—and the challenge is to create an environment in which professionals and consumers encourage and support each other in finding and fixing these opportunities. The health industry has moved away from the notion of “quality assurance” and toward “quality improvement” (McDonough, 1999).

An increasing share of attention and resources to ensuring that pharmaceuticals are available and affordable to clients is paramount apart from promoting initiatives to identify and treat population-based conditions and to provide culturally competent care.

Improving the quality of health care for the uninsured and underserved by:

  1. Increased number of people in care.
  2. Increased percentage of communities’ uninsured population in care.
  3. Increased numbers of community systems that have been established.
  4. Reduced costs for hospital admissions.
  5. Reduced emergency room visits.

Through measures such integrated systems, pharmaceuticals, culturally competent care; cost savings will be even greater in the long term. Yet, the true measure of the reforms is in the improved quality of life (McDonough, 1999).

The three imperative qualities cited in the IOM report: creating health care delivery systems that are patient-centered, and evidence-based with equitable access.

Systems Focus: An integrated approach. For e.g. the 100% Access/Zero Disparities campaign is built around an integrated model of health care. The model is designed to ensure that every patient is in a primary care medical home and to provide a full complement of resources afterthe patient’s initial visit to a primary care provider. And it is organized around a central referral point, so that a patient is not caught in a dead-end corner of the traditional health care maze.

The lack of a systems approach is a problem throughout the health care system, but it is especially difficult for uninsured and underserved patients to reach appropriate care.

For example, primary care providers cite the frustration of finding specialist physicians to whom they can refer low-income and uninsured patients. Health centers and doctors cite the futility of treating symptoms of chronic illness when they know that patients will not have the pharmaceuticals necessary to manage their condition.
By offering a broader range of services to address issues that impact on health. These services include dental, mental health, and substance abuse care.

Patient-centered: Case management. Case management applies the resources of an integrated health care system to serve patients who need ongoing intervention.

E.g. A program supports chronically ill patients referred by hospital and primary care providers by providing:

  1. Intensive disease state monitoring,
  2. Care coordination with various providers,
  3. Health education programs and support groups, and
  4. Provision of free diabetic supplies.

The program offers prescription assistance (McDonough, 1999).

Evidence-based: Targeting risks groups. While the goal is universal – 100% access to health care and health disparities – it uses targeted approaches. Rather than aiming at some least common denominator, communities are applying sophisticated knowledge of risk factors to target groups with that can benefit most from intervention.

Many communities are taking approaches similar to those of “population risk management firms.” One such firm is FutureHealth, which manages 400,000 people in insurance pools nationwide. It operates under the revolutionary principle that identifying the small percentage of patients in an insurance pool who are most likely to land in the hospital and then devoting resources to keeping them healthy can significantly reduce the cost of caring for the entire group.” (FutureHealth).

Two examples of these kinds of efforts are programs for asthma and for expectant mothers at risk for pre-term births.

(i) Asthma: - HealthNet Community Health Centers in Indianapolis is piloting a program to attack high rates of asthma among African American women. Design elements include clearly identifying medical records of asthma patients, following up on planned care visits, and providing self-management support. Program goals include the following: 100% of patients with persistent asthma receive treatment and long-term control medication; less than 1% of patients make an ER visit for asthma; and less than 2% will be admitted to the hospital for asthma.

After approximately 10 months, nearly 60% of patients had a written asthma action plan, up from zero when the pilot program began. There has been a significant decline in the percentage of patients with ER visits, from around 20% through the first 26 weeks of the program to the low single digits. The percentage of patients with hospital admission has steadily declined from 10% at the beginning of the program to about half that amount. But much progress is still to be made in measures of self-care and symptom control.

(ii) Pre-term Births: The Prematurity Prevention Program in Asheville, North Carolina, identifies pregnant women who have had a prior pre-term delivery or who display other risk factors, such as age under 17, weight below 100 pounds, or cigarette smoking.

Once a provider to the system refers a woman, she is contacted by phone, and a home visit is scheduled if the patient desires one. Women who agree to participate in the program receive calls every one or two weeks, and targeted reports are prepared at specific points in the pregnancy.

Access: Linking Resources to Needs
Access is the necessary correlate of efficient resource utilization. Enhanced access is the result of linking those resources to the people who need them.
Three approaches for expanding access to care:

  1. Reducing complexity and barriers,
  2. Increasing entry points, and
  3. Coordinating providers of care.

Reducing complexity: Improving access means seeing the health care system through the eyes of those who are – or are not – being served. Complicated enrollment procedures place barriers in the way of people who are embarrassed to ask questions – or to even seek treatment (McDonough, 1999).

Measuring savings and returns on investment

Measuring the benefits means comparing the cost of ad hoc uncoordinated health care services for underinsured patients, to coordinated service delivery for those patients. The key determinant in this process is getting all the community stakeholders to agree on what kinds of results they are aspiring to, what their shared values resemble, and to capture progress on these components through a coordinating mechanism.

Objective measures include decreases in direct and indirect health care costs and increased leverage of funds. Direct costs are those incurred in providing health care for the target population. Indirect costs include those incurred by the community to support the sick and injured, other social services for targeted population, and lost taxes due to people not working.

An important step in achieving an optimal return on investment is to properly allocate fiscal responsibility among taxpayers, providers, employers and others in the community. The goal is to ensure that costs help achieve the best possible return.

Funding leverage can be increased through the draw down of state and federal government funds, coordination with other payers, and access to private sector funds.

Also, success in a given community can create benefits that go beyond that community, such as replication in other communities.

Turning to the issue of how benefits are achieved, there were at least three alternative models for investment in improved health care:

  1. The volunteer model, in which providers bear responsibility;
  2. The tax-supported model, in which providers are paid by a tax-supported plan; and
  3. The shared-cost model, in which the taxpayer subsidized model, is supplemented with incentives for employers to provide health coverage to employees, often with employee contributions (McDonough, 1999).


  1. Advisory Commission on Consumer Protection and Quality in the Healthcare Industry.
  2. Agency for Healthcare Policy and Research (AHCPR).
  3. Bloom D.E. & Canning D. (2000). The Health and Wealth of Nations.Science, Vol. 287, Issue 5456.
  4. Bloom et al (2001). The Effect of Health on Economic Growth: Theory and Evidence. NBER Working Paper Series, No. 5.
  5. Centers for Disease Control and Prevention (CDC).
  6. Cutler, D. et al (2001). Pricing heart attack treatments. Medical Care Output and Productivity. University of Chicago Press.
  7. Donabedian, A. (2001). Health Affairs, January/February 2001.
  8. FutureHealth.
  9. Health Care Financing Administration (2002). National Health Care Expenditures.
  10. Health Insurance Status of the Civilian Non-institutionalized Population, 1999, 2001.
  11. Healthcare Financing Administration (HCFA).
  12. Health Resources and Services Administration.
  13. Hein, J. (2001). “Better Health…For More People…At Less Cost”. Communities in Action: Reforming the Health Care System from the Inside Out. A Report for the U.S. Bureau of Primary Healthcare.
  14. IMS Health (2002).
  15. IOM Report (2000). Institute of Medicine Report, Crossing the Quality Chasm.
  16. Kronenfeld (1997). The Changing Federal Role in US Health Care Policy. Prarger. Westport, Connecticut. London Publication.
  17. Kronenfeld (2002). Health Care Policy: Issues and Trends. Praeger Publication. Westport, CT.
  18. Masia, A. N. (2002). Pharmaceutical Innovation. Lowering the price of Good Health. Economic realities in Health Care Policy. Volume 2. Issue 2.
  19. McDonough, J.E. (1999). Healthcare Policy. The Basics. The Access Project.
  20. National Healthcare Expenditure Projections (2001).
  21. Pharmaceutical Research and Manufacturers of America (2002). The Value of Medicines, Washington, D.C. PhRMA, Vol. 5.
  22. PhRMA (2002). The 1990s: A Great Decade for Patients. Backgrounders and Facts.
  23. The Prematurity Prevention Program in Asheville (1988). North Carolina. American Journal of Public Health, Vol. 78, Issue 11. American Public Health Association.
  24. Todd et al. (1990). "Problems With Incentives", Access to Health Care, Annals Int. Med. J. Am. Med. Assoc. Vol.264
  25. U.S. Department of Health and Human Services (HHS).
  26. Walsh D.C. (1991). Costs of illness in the workplace. Work Health and Productivity. New York: Oxford University Press.


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