Donald S. Shepard Schneider Institute for Health Policy

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Projects

Cost-effectiveness studies in the US
Managed care in the US
International health economics

Current and recent projects follow.

Cost-effectiveness studies in the US

  1. Evaluation of Medicare Lifestyle Modification Demonstration.
    Supported by the Centers for Medicare and Medicaid (formerly the Health Care Financing Administration) from 2000-2007, this evaluation studied national demonstrations for selected Medicare beneficiaries of lifestyle changes around diet, exercise, and stress reduction on cardiovascular disease. The evaluation examined implications to participants' health, health costs, and feasibility.

  2. Enhanced MI with Alcohol Positive Trauma Patients
    The main goal of this study was to conduct a cost-effectiveness analysis as part of a randomized trial of three alternative treatments for alcohol-positive patients in a trauma unit or emergency department. The three treatments were "significant other" motivational interviewing, individual patient motivational interviewing and standard care. . (Brandeis subcontract from Brown University. Supported by NIAAA, 2005-2010.)

  3. Evaluation of the Illinois and Wisconsin State Pharmacy Assistance Waivers
    This evaluation examined the achievements as well as the difficulties inherent in the implementation of the Illinois and Wisconsin Pharmacy Plus programs. This five-year study included a descriptive evaluation of the program, a survey of a total of 2,200 program participants (1,200 in Illinois and 1,000 in Wisconsin), and analyses of prescription drug and medical claims to determine drug utilization and expenditures as well as the cost impact on the Medicaid and Medicare programs. This study provided a critical opportunity to evaluate how well such programs achieve their goals and provided lessons for other states and the federal government as a national policy evolved. (Supported by the Centers for Medicare and Medicaid Services, 2002-2007.)

  4. Profiling and Incentives in Behavioral Health Care - Research Center on Managed Care and Drug Abuse
    This research evaluated the contribution of provider profiling and incentives to improving the quality of managed behavioral health care. Combining a quasi-experimental interrupted time series and randomized-controlled designs, the study used existing data from public sector general assistance (GA) clients who received substance abuse treatment under the state of Connecticut’s managed behavioral health care (MBHC) program. In October 2001, the Connecticut Department of Mental Health and Addiction Services (DMHAS) initiated provider profiling. DMHAS incorporated four standards of care and effectiveness measures into the contracts of all 452 providers (sites) who provided substance abuse and mental health services. The profiles measured each provider’s success in enhancing continuity of care, avoiding rapid readmissions to acute treatment services, documenting treatment plans, and referring high-risk clients appropriately.

  5. Organizational and Resource Assessments for Treatment Providers
    The main goal of this "Roadmap" supplement was to extend a cost analysis workbook used in the parent grant beyond data entry. The enhanced version under this supplement, the on-line Treatment Cost Assessment Tool (TCAT) is a computerized cost-analyst interview and an Internet-based prototype of methods to conduct cost analyses in drug abuse treatment facilities. It checks the data automatically for consistency with other items, logical relationships, and industry norms. (Brandeis subcontract from Texas Christian University. Supported by NIDA, 2005-2007.)

  6. Long-Term Cost-Effectiveness of Drug Abuse Treatments.
    Funded by NIDA from 1993 through 2000, with related studies supported by NIDA and NIAAA on other populations, these studies were founded on randomized trials of alternative approaches to aftercare, one of the most important approaches to substance abuse treatment. In addition to measuring the effectiveness of each approach, the studies also assessed the costs. The results are intended to help policy makers better allocate resources across alternative modalities and services in substance abuse treatment.

  7. Aftercare for Cocaine Patients: Effectiveness and Costs.
    This study compared three approaches of varying cost for delivering aftercare to drug users: relapse prevention through individual sessions (most expensive); relapse prevention through group sessions (less expensive); and telephone-based aftercare counseling (least expensive). The study compared outcomes (through interviews and laboratory values) and costs over two years. (Brandeis subcontract to University of Pennsylvania, Philadelphia, Supported by NIDA, 1996-2002.)

  8. Efficacy and Cost-Effectiveness of Aftercare Plans for Alcoholic Patients.
    This study compared three approaches of varying cost for delivering aftercare to alcohol abusers: relapse prevention through individual sessions (most expensive); relapse prevention through group sessions (less expensive); and telephone-based aftercare counseling (least expensive). The study compared outcomes (through interviews and laboratory values) and costs over two years. (Brandeis subcontract to University of Pennsylvania, Philadelphia. Supported by NIAAA, 1996-2002.)

  9. Cost-Effectiveness of Substance Abuse Treatment in Connecticut Prisons.
    This 3-year study compared the four tiers, or intensities, of treatment provided to inmates in Connecticut prisons. They ranged from Tier 1, a 2-session orientation, to Tier 4, a residential program in a treatment cell block of at least 6 months. The study compared the costs of the approaches and evaluated the impact on problems while in prison (e.g. disciplinary tickets) and after release (e.g. recidivism). (Brandeis subcontract to Brown University, Providence, RI. Supported by the Robert Wood Johnson Foundation Substance Abuse Policy Program, 1996-2000.)

  10. Motivating Alcoholics to Quit Drinking.
    This study evaluated a program to motivate patients in treatment for alcohol abuse to consider smoking cessation. Brandeis was responsible for the cost-effectiveness component. (Brandeis subcontract to Miriam Hospital, Rhode Island. Supported by NIAAA.)

  11. Cost-Effectiveness of Extended Case Monitoring in Alcohol Abuse.
    This study evaluated telephone follow up for patients in a Health Maintenance Organization treated for alcohol abuse. The case monitor provided support to help patients remain abstinent, and provided detection and prompt referrals in the event of relapse. Brandeis was responsible for the cost-effectiveness component. (Brandeis subcontract to Brown University, Providence, RI. Supported by NIAAA.)

  12. Restructuring Services for Drug-Abusing TANF Women.
    Brandeis is conducting the economic analysis of intensive case management (ICM) for women on public assistance with substance abuse disorder to determine whether interventions delivered in routine care settings lead to improved outcomes compared to usual care. A previous phase of the study showed that ICM delivered within a welfare setting increased access, engagement, and retention in substance abuse treatment, as well as improved outcomes for drug abusing TANF mothers when compared to usual care (UC). Under the current study, Brandeis is conducting an economic evaluation of ICM including a cost of illness study and cost benefit study. Results from this study should guide dissemination of this promising intervention Funded by NIDA/Center on Addictions and Substance Abuse (CASA).

  13. Cost-Effectiveness of Dietary Interventions to Reduce AIDS Wasting.
    AIDS patients were randomly assigned to several interventions (nutrition counseling alone, exercise regimens, or appetite stimulants) to reduce AIDS wasting. Brandeis was responsible for the cost-effectiveness analysis. (Brandeis subcontract to Tufts University, Boston. Supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, 1997-2000.)

  14. High Performing Community Health Centers: What It Takes.
    This two year study examines the role of community health centers (CHCs) in the states of California, Massachusetts, and Texas, and in particular, the degree to which they provide high quality care to low income and racial/ethnic minority populations, and by extension reduce disparities. Medicare claims allow comparison of CHCs against other care settings to identify the highest performing CHCs and what factors make them successful. The results will help to inform policy makers, funders, and providers on ways to improve health system performance. The two sponsors are Commonwealth Fund and Texas Association of Community Health Centers.

  15. Asian Tiger Mosquito Area-Wide Project: Economic Analysis.
    Monmouth and Mercer counties in New Jersey are implementing pest control against the Asian tiger mosquito (ATM) This aggressive, day-biting mosquito can be a vector for several diseases, including dengue fever. Brandeis is a member of a collaborative project designed to (1) demonstrate a strategy for area-wide ATM control, (2) measure the public health and socio-economic benefits of the suggested area-wide mosquito control, and (3) transfer the strategy to end users. Brandeis is conducting the economic analysis, including a willingness-to-pay survey. Funding from the US Department of Agriculture.

  16. Economic Analysis of Dengue in Puerto Rico.
    Building on previous multi-country studies on the burden of dengue illness, Brandeis is combining patient interviews, surveillance data, and a novel hand-held data acquisition to study the cost of dengue in Puerto Rico. This study will provide further statistical analysis and extensions of multi-country data and refinement of important country studies to develop country-level manuscripts for submission for publication. This work is being conducted in cooperation with the US Centers for Disease Control. Funding is from Sanofi Pasteur.

  17. Study of Frozen Embryo Donation and Adoption: Economic Analysis.
    Under this 18-month subcontract, Brandeis is conducting the economic analysis related to the donation and adoption of frozen embryos as an additional alternative for infertile women to become parents. In addition to general contributions to the study, Brandeis’ role relates primarily to the delivery, costs, and financing of frozen embryo donation and adoption services. Support is from the US Department of Health and Human Services/QED Group LLC.

  18. Reinforcing Therapist Performance.
    Under this 3-year study, Brandeis is conducting the economic analysis of a randomized trial of incentives to counselors providing an evidence-based treatment to adolescents with substance misuse. Specifically, Brandeis researchers are collecting time utilization and financial data, leading to the economic analysis of the data, and collaborating on the preparation and delivery of scientific presentations and publications. This project is being conducted as a subcontract with Chestnut Health Systems / NIAAA.

  19. Developing and Testing Intervention Costing Tools for Substance Abuse Treatment.
    Brandeis is developing two tools (called Planner and Analyst) for the economic analysis of evidence-based practices of substance abuse treatment. Following developing the costing tool and the collection and analysis of data, a manuscript will be submitted to a peer-reviewed journal. This project is supported by the Robert Wood Johnson Foundation. / Substance Abuse Policy Research Program.
Managed care in the US
  1. Treatment Needs: Research and Evaluation Specialists
    Under a contract with the Massachusetts Bureau of Substance Abuse Services (BSAS), a Brandeis team studied unmet need for substance abuse treatment in the state by region and level of care needed. The team collaborated with BSAS on the analysis and interpretation of data from the Behavioral Risk Factor Surveillance System (BRFSS) that will assist in treatment service planning. Researchers also provided on-going technical assistance to BSAS Office of Statistics and Evaluation staff to assist the Commonwealth in policy development and economic analyses, and performed specialized analyses of the BRFSS and other measures compiled by BSAS.

  2. Review of the Massachusetts Behavioral Health Program
    This conference award supported a scientific conference on February 5, 2004 at Brandeis to review and synthesize findings from the study of Managed Care in Michigan and Massachusetts and related studies. The organizers guest-edited the March 2005 issue of Administration and Policy in Mental Health summarizing the findings.

  3. Impact of Managed Care for Medicaid Recipients with Alcohol Disorders in Michigan and Massachusetts.
    Michigan and Massachusetts, two industrial northern states, adopted contrasting approaches for managing substance abuse treatment for Medicaid recipients. For all recipients not in HMOs, Massachusetts carved out the services to a private managed care company which assumed partial risk for the cost services. Michigan also carved out substance abuse services, but used public agencies, each responsible for one or more counties, for this role. Initially, regional Centers for Diagnosis and Referral served as gatekeepers, but thier successors, coordinating agencies, aassumed a range of managed care functions in 1998 and 1999. This 6-year study had three specific aims: (a) To describe and evaluate how the introduction of public-sector managed care affects utilization, cost and outcomes of alcohol treatment; (b) To evaluate how managed care has affected outcomes, as judged by admissions, provider surveys, and key informants; and (c) To evaluate whether managed care impacts on alcohol treatment costs and utilization differ for subpopulations (e.g. women, adolescents, and people of color). The study analyzed claims data and surveying substance abuse providers in both states. (Supported by NIAAA, 1996-2002.)
International Health Economics

International health activities focus on strengthening the financial health of public sector health activities in developing countries.
  1. Cost-Effectiveness Analysis of Pneumococcal Pneumonia Vaccination in Singapore
    Pneumococcal pneumonia and other diseases caused by the pneumoccal organism are important causes of illness and death affecting children and elderly adults worldwide. While the vaccine for adults is long established and relatively inexpensive, the pneumococcal vaccine for children is new and expensive. The cost-effectiveness of a pneumococcal vaccine for children, particularly in a country with good access to medical services, remains controversial. The purpose of this study was to conduct a cost-effectiveness analysis on pneumococcal vaccinations jointly with the Singapore Ministry of Health (MOH), and develop recommendations to build capacity within the MOH for economic analysis. (Supported by the Singapore Ministry of Health, 2007-08).

  2. Cost-Effectiveness of the Children's Vaccine Initiative
    The Children's Vaccine Initiative, created by the UNDP, WHO, UNICEF, and the Rockefeller Foundation, seeks to foster the development and implementation of new and improved childhood vaccines worldwide. The Institute for Health Policy conducted cost-effectiveness studies to help the program set priorities among alternative vaccine candidates. Funded by the World Health Organization.

  3. Cost-Effectiveness of Vector Control against Lymphatic Filariasis (LF).
    Working with the LF Support Program, Brandeis is conducting economic studies that document the costs and benefits of vector control. In addition, we are assessing the added value of vector control by comparing changes in the indicators of LF program effectiveness and helping to define the most appropriate techniques and most appropriate situations in which supplemental vector control strategies can be utilized most cost-effectively. This research is being supported by the Bill and Melinda Gates Foundation through the Task Force for Global Health .

  4. Dengue Burden of Illness Studies
    Brandeis University served as the Program Management Team for studies on the burden of dengue. The work was supported by the Bill and Melinda Gates Foundation through the Pediatric Dengue Vaccine Initiative, a project under the International Vaccine Institute fostering the development and adoption of a safe and effective vaccine against dengue. Selected as the Project Management Team, Brandeis assisted and managed investigators in eight countries studying the burden of dengue (a viral illness transmitted by mosquitoes) in their countries. Three of the countries (Cambodia, Malaysia, and Thailand) are in Southeast Asia, where dengue has long been established, while five (Brazil, Guatemala, El Salvador, Panama, and Venezuela) are in South America, where dengue has re-emerged within the past three decades. Brandeis developed research capacity, a common core research protocol, and local data around this disease. These data have helped domestic policy makers in each country, and donors and vaccine producers internationally, in developing policy around the development, production, price, and implementation of a dengue vaccine. Supported by the Pediatric Dengue Vaccine Initiative (with major support from the Bill and Melinda Gates Foundation).

  5. Application of Data Envelopment Analysis to Resource Estimation Addressing HIV/AIDS
    Over the last decade, the global initiative to control the HIV/AIDS epidemic has expanded beyond prevention to include widespread anti-viral treatment. Despite the growth in domestic and donor support, many developing countries still fail to provide sufficient services to meet their population's needs. Severalcosting tools have been developed to determine the amount of funding required to control HIV/AIDS, however the estimates from the different models vary considerably. The objective of this study was to apply an innovative estimation method, Data Envelopment Analysis (DEA), to estimate the financial requirements for HIV/AIDS control among the roughly 20 low- and middle-income countries where data is available for analysis. This study is a first step in the application of this technique with available data. (Supported by the United Nations Programme on HIV/AIDS, UNAIDS, 2007-08.)

  6. Workshop on HIV Prevention among Intravenous Drug Users in Uzbekistan
    With intravenous (IV) drug use as the major risk behavior behind Uzbekistan’s growing use of intravenous drugs, this workshop first identified factors that promote and dissuade IV drug users from participating in preventive and harm reduction activities (e.g. condom use and syringe exchange programs), developed promising approaches that built on the strengths and overcame barriers, and designed a study to test the effectiveness, cost-effectiveness, and replicability of the most promising approach. Funded by the U.S. Civilian Research and Development Foundation.

  7. Cost Effectiveness of Harm Reduction Strategies for Injecting Drug Users in Uzbekistan.
    The study is evaluating substitution therapy and other approaches, such as peer-driven incentives in syringe exchange programs in Uzbekistan. Retrospective analyses are being performed for patients who received maintenance treatment with methadone or buprenorphine. Brandeis is collaborating with a national partner the, Bukhara State Medical Institute, using client interviews, budget reviews, modeling, prospective data analysis, and literature review. Funding is from the Civilian Research and Development Foundation.

  8. Impact of AIDS on Health Expenditures
    The prevention and treatment of AIDS poses enormous challenges to health policy makers around the world. This study compiled and analyzed expenditures related to AIDS in five countries across four continents: Mexico in North America, Brazil in South America, Cote d'Ivoire and Tanzania in Africa, and Thailand in Asia. In each country, the study ascertained AIDS expenditures by object and source of funding, relating them to overall health expenditures, and identifying the determinants of the existing patterns of expenditures. The study was designed to give policy makers an empirical base for improving resource allocation. Funded by the World Bank and the European Commission.

  9. Costs of Anti-Retroviral Therapy in Botswana
    At the time of this study (year 2000), the prevalence of HIV infection in Botswana was about 14% of the entire population, one of the highest rates in the World. Institute researchers examined alternative policies for anti-retroviral therapy. Results showed that Treatment of pregnant women to reduce the risk of vertical transmission, would be affordable and, under certain scenarios, even cost-saving. Treatment of the adult population generally with anti-retroviral therapy would be extremely costly, however. Funded by the Government of Botswana.

  10. Feasibility of Home-Based AIDS Care in Botswana
    AIDS is a growing problem in Botswana, with seroprevalence rates among pregnant women in sentinel sites averaging 33%. If present patterns of hospital-based treatment were not modified, then AIDS patients would exhaust all remaining hospital capacity by 1999, bringing hospital occupancy to 90% nationally. This study developed a model of home-based care, in which clinic staff would train family members to provide support at home. A spreadsheet model estimated the reductions in hospital care and resulting savings in costs. It showed how the share of the cost of home-based care offset by these savings depended on the design of the program. Funded by the World Bank.

  11. Economic Analysis of HIV/AIDS.
    Despite the growth in domestic and donor support, many developing countries still fail to provide sufficient services to meet their population's needs. Several costing tools have been developed to determine the amount of funding required to control HIV/AIDS; however the estimates from the different models vary considerably. The objective of this study is to apply an innovative estimation method, Data Envelopment Analysis (DEA), to estimate the financial requirements for HIV/AIDS control among the low- and middle-income countries where data is available for analysis, and among health centers in Rwanda. The aim of this study is to improve the efficiency of HIV/AIDS control programs in Rwanda and worldwide, and to examine how AIDS funding impacts other diseases. Funded by UNAIDS.

  12. Health Economics and Policy in Samoa
    In collaboration with the Health Resource Planning Information Research and Development Division (HRPIRD) of the Samoa Department of Health since 2000, this project studyied costs of health services in Samoa and overseas, resource utilization and financing to strengthen the health sector in this small island nation. Supported by the World Bank and the Government of Samoa.

  13. Cost-effectiveness of Regional versus Bilateral Approaches to International Assistance in West Africa
    From 1994 to 1996, as the US Agency for International Development (USAID) closed 11 country missions in Subsaharan Africa due to budget constraints, it introduced a sub-regional approach in Burkina Faso, Cameroon, Côte d'Ivoire, and Togo. We related the cost-effectiveness of this sub-regional approach against the traditional approach in terms of the contraceptive prevalence rate (CPR) for women aged 14-45, adjusted for other factors. The study examined CPR in the 4 sub-regional countries and 4 neighboring control (mission-based) countries (Ghana, Guinea, Mali, and Senegal) from 1989 through 1999. We derived expenditures per woman on family planning by USAID and other donors for each year were from agency databases for new program obligations, allowing for lags between obligations and expenditures, and incorporating operating expenditures. The study applied multivariate regression to a cross-sectional, retrospective time-series for eight countries over eleven years. To control for socio-economic and political factors, we adjusted each country’s annual CPR based on its Gender Development Index (GDI) reported by the UNDP. The sub-regional approach was significantly less expensive than the mission-based approach, averaging $12 per woman per year compared to $30 in the mission approach. Under both specifications examined, the sub-regional approach was more cost-effective than the mission-based approach. With comparable spending and controlling for other factors, the sub-regional approach was 42% more effective than the mission-based approach under the absolute specification (p<.10) and 30% more effective under the relative specification (p<.05). The sub-regional approach is applicable to many social programs in small developing countries. Funded by the US Agency for International Development in collaboration with Tulane University.

  14. Hospital Costs: A Manual for Managers
    Hospitals consume the majority of resources in developing countries. Typically, however, the officials responsible for their management, both in the hospitals themselves and in provincial and national government offices, have little idea of the cost and efficiency of their services. The institute wrote a manual on estimating hospital costs and has used it for workshops for managers in both Bangladesh and Zimbabwe. The World Health Organization published the manual in English [Shepard, D.S., Hodgkin, D., Anthony, Y.E. Analysis of Hospital Costs: a Manual for Managers. Geneva, Switzerland, World Health Organization, 2000 (ISBN 92 4 154528 3). Shandong Medical University has published a translation in Mandarin Chinese. [Earlier version published in Mandarin Chinese under The Network for Training and Research in Health Economics and Financing (Bian Ying, translator). Jinan, Shandong Province, China: Shandong Medical University, National Institute of Hospital Cost Accounting, School of Public Health, 1998.] Funded by the World Health Organization.

  15. Health Insurance in Cote d'Ivoire
    In the Cote d'Ivoire, public and private hospitals offer a wide array of hospital services. As 97% of the population lacked private health insurance at the time of this study (1998), financial access is more problematic than physical access. Subsidies to hospital care consume over half the government health budget, but still leave tertiary hospital care extremely expensive for ordinary citizens. This study is helping the Government of Côte d'Ivoire develop options for health insurance both for people in the modern sector and in the rest of the country. Funded by the World Bank.

  16. Cost-Effectiveness of Disease Control Options
    As part the World Bank's Health Sector Priorities Review, the Institute provided the economic analysis and conceptual framework for control of two major diseases -- acute respiratory infections, one of the world' major killers, and dengue fever, a growing problem in Asia and South America. Both preventive and case management strategies were examined. With computerized models, sensitivity analyses were performed, combinations of strategies were considered, and the incremental cost-effectiveness of alternative strategies was compared. Funded by the World Bank.

  17. Health Financing in Sierra Leone
    Sierra Leone, an impoverished country of 4 million people in West Africa, enacted an innovative National Health Action Program in 1993 to strengthen the core services of its public health system. Although the government promised regular increases over its recent health spending of only US $0.80 per capita per year, additional sources of funding were required. This study assessed the potential of three other sources: higher fees for curative health services in government facilities, fees for drugs, and health insurance for the employed population. Funded by the World Bank.

  18. Health Economics Curriculum for CESAG
    Institute researchers served as part of a design team for the first graduate degree program in health economics in sub-Saharan Africa. The program, conducted at the Centre d’Etudes Superieures Africaine de Gestion (CESAG) in Dakar, Senegal, admitted its first class in the fall of 1998. Funded by the U. S. Agency for International Development.

  19. Health Quality Indicators in Jamaica
    Patient satisfaction surveys, used extensively by sophisticated health providers in the United States, are being implemented in a sample of six hospitals in Jamaica. The data have been used to monitor the impact of ongoing efforts to strengthen quality and management, such as the appointment of Chief Executive Officers and the divestment of selected hospital support services, such as laundry and portering. Funded by the U. S. Agency for International Development.

  20. Evaluation of the Health and Population Program of the Carvajal Foundation
    The Carvajal Foundation is a private institution created to improve the welfare of low-income residents of Cali, Colombia. One of its innovative health programs is a network of "health volunteers," women who provide teaching, monitoring, and referrals to health and family planning facilities. The Institute led an evaluation of the health and population programs of the foundation's health and population programs, which assessed the costs and effects of the system. The evaluation surveyed 1000 households and about 100 providers. Funded by the Rockefeller Foundation.

  21. Economic Analysis for Caribbean Regional Health Study
    The Caribbean Regional Health Study for Caribbean Group for Cooperation in Economic Development was a diagnostic analysis of health problems of the Caribbean region. The study emphasized problems that are common to many countries in the region, or that would lend themselves to regional solutions. Brandeis University was responsible for the portions of the study related to economic analysis. Funded by the Inter-American Development Bank.

  22. Cost Recovery in Jamaica
    In the face of declining real resources, the Jamaican Ministry of Health had difficulty maintaining quality of care. To increase resources and to give more autonomy to hospitals, Brandeis researchers worked with the Ministry of Health to revise its fee schedule for care in public facilities. With a new fee schedule, hospital income more than doubled, while graduated fees and exemptions helped maintain access to the poor. Fees were developed to favor the most cost-effective services, reducing subsidies to tertiary care. Funded by the U. S. Agency for International Development.

  23. Cost and Value of Hospital Accreditation.
    This study addresses key elements of the need for a quantitative, economic assessment of hospital accreditation through a multi-year study of value and impact of selected standards. The pilot study is selecting two or three clinical and two or three management standards for which procedures and data for measurement appear feasible. In comparing accredited to non-accredited hospitals in several countries, the study hypothesizes that the improvements in value and impact will be greater in the accredited hospitals than the non-accredited comparison hospitals. Data gathering has begun in Jordan in conjuction with the Hcalth Care Acceditation Council, Jordan. Funding is provided by the Joint Commission International.


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