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PubMed1996

Lost in the market? A survey of senior public health service managers in New Zealand's 'reforming' health system.

In 1993, New Zealand implemented radical health sector reform, separating purchaser from provider and creating a competitive market. This paper reports on a 1994 survey of senior managers' perceptions of how well public health services were adapting to this more commercial environment. An initial questionnaire to chief executive officers of Crown health enterprises, the main providers of public health, as well as secondary treatment services, was followed by a telephone survey of managers of public health services. Chief executives expressed generally positive views about the importance of public health, especially health promotion, within their organisations. Public health managers indicated a wide range of negative and positive views about the new system. They were concerned especially about service fragmentation, diminished information-sharing and decreased collaboration, especially with Maori and general practice providers. Questions were raised about the compatibility of competition with the need for collaboration in public health. The major issue was the inefficient, costly, conflicting and fragmented purchasing arrangements for public health. Managers wanted united systems and fewer purchasers. More positive views were expressed on an improved focus on outputs and clearer directions, and none wanted to return to the former era of an entirely separate system for public health services. The abolition of the Public Health Commission during 1995 should lead to increased integration of purchasing and policy making, but important questions remain about the place of public health services, especially in their links with primary care.

Administrative Personnel↗

PubMed1991

Information systems for the analysis of drug prescriptions in Spain.

The Spanish National Health Service, largely represented by INSALUD, covers at present over 98% of the Spanish population. Services are free at the point of delivery with exception of prescription charges. The patients contribution towards the price of their medicines is approximately 40% of the cost of the drug for most ethical preparations. Non-prescription drugs are not reimbursed by the National Health Service. Pensioners and the disabled are exempt from prescription charges. Prescription analysis or monitoring is possible within INSALUD because of the necessity to reimburse pharmacists for the prescriptions they dispense, monthly batches of prescriptions are processed. The Drug Data Bank possesses three databases that may be used for prescription analysis, these are ESPES, ECOM and PACTIV. Information from these databases is used by external workers in: drug Monitoring Centres for Adverse Drug Reactions; the Spanish Collaborative Study on drug-induced birth effects; drug utilization research workers; INSALUD also produces reports on drug prescribing and these have a particular emphasis on expenditure; the General Directorate of Pharmacy also use these databases for their policy making on issues related to, and derived from prescribing.

Adverse Drug Reaction Reporting Systems↗

PubMed1986

The federal response to the AIDS epidemic.

The response of the U.S. government to the AIDS epidemic is reviewed within the context of health policy making in the U.S.A. in general and the reduced role of the federal government in domestic social programs in particular. This review involves multiple levels of government, the relationship of government to the private sector, the diffusion of authority within a federal system, the long delays in policy implementation because of the absence of mechanisms to deal with emergency situations, the tendency to fund the response to AIDS from reallocation of appropriated funds, thereby creating financial distress for existing programs. The federal response to AIDS is considered uncoordinated, insufficient and inadequate in particular with respect to the support of public health education and the financing of health care for AIDS patients. These are needed while a vaccine may still be years away.

Acquired Immunodeficiency Syndrome↗

PubMed2005

A conceptual model of community capacity development for health promotion in the Alberta Heart Health Project.

PURPOSE: The objective of this study was to derive a conceptual model of community capacity development for health promotion based on the 5-year demonstration phase of the Alberta Heart Health Project. METHOD: Community actions associated with successful implementation and uptake of initiatives in four diverse target sites were identified by case study evaluation. RESULTS: Thirteen common elements of capacity development were found across the projects and categorized to define three primary dimensions of the process: (a) leadership that provided a driving force for implementation, (b) policy making that ensured diffusion and sustainability, and (c) use of local community resources and infrastructure. A conceptual model was constructed using these 3 dimensions and their interactions. CONCLUSION: Effective implementation of community health initiatives to promote heart health can be conceptualized as the involvement of local leadership, policy advocacy, and enhancement of existing infrastructure. The model highlights building these dimensions of community capacity development for health promotion.

Alberta↗

PubMed1990

Health policy and the politics of research in the United States.

During the past decade research has been more important to the health policy-making process in the United States than at any time in the past. This article describes and assesses three competing normative models for research on health affairs: economizing, social conflict, and collective welfare. The three models provide a context for the history of research bearing on health policy in the past half century, with particular pertinence to the years since 1980. The article concludes with a discussion of some of the consequences of the new legitimacy of research.

Conflict, Psychological↗

PubMed1994

Recent public policies in The Netherlands to control pharmaceutical pricing and reimbursement.

In The Netherlands, the rate of consumption of medicine is low compared with that in other member states of the European Community. Nevertheless, expenditure on medicines is high in this country, because of a high price level. In the past decade, the cost of medicines has been growing more rapidly than the total expenditure on healthcare in The Netherlands. This prompted The Netherlands government to take action against the rise in the cost of medicines. Some policies were directed at the volume of consumption, but most focused on price. All had in common that they failed to produce lasting cost containment or did not stand up in court or to political debate. As a result, the measures proposed and implemented by the government have become increasingly harsh, departing from the Dutch tradition of harmonious policy-making carried out jointly by government and societal groups. The latest step has been the introduction (as of July 1, 1993) of a new version of a price reference system, which discourages the prescription of innovative but expensive drugs. It is too early to tell whether this policy will have a more enduring effect on cost than the previous measures.

Cost Control↗

PubMedDate not supplied

The complexities of multi-level governance in public health.

This article reviews some of the challenges to developing national public health programs, focussing on the distribution of constitutional authority for public health and governance challenges that arise from this. Constitutional authority for public health resides primarily with the provinces. The federal government has obtained the authority to legislate in this area primarily through its power over criminal law. Challenges facing the establishment of national public health programs include the ambiguity over constitutional responsibility, challenges in managing externalities and spillovers, and issues related to funding and data ownership. Policy-making is also complicated by the importance of municipal and supranational governments in public health. National programs need to be structured in a way that balances the advantages of regional approaches to public health challenges with the benefits of a coordinated central response. To do so, policy-makers need to address unique challenges to public health governance.

Canada↗

PubMedDate not supplied

[A research agenda for health policies and services in northeast Brazil].

The aim of this paper is to gather elements for a discussion on health policies and services in northeast Brazil. The author begins with an analysis of the population's main health problems, the health system's limitations, and current opportunities for implementing health programs. She highlights the following research priorities: people's health situations according to their material living conditions and life styles; the private health sector's characteristics and development; the current decentralization process; and proposed innovations in services, programs, and systems. The author points out further that the policy-making process in science and technology should assure a balance between researchers' freedom and people's health needs, regional focus, and universal issues.

Brazil↗

PubMed2006

Service integration and co-ordination: a framework of approaches for the delivery of co-ordinated care to children with disabilities and their families.

This article clarifies the nature of 'service integration' and 'service co-ordination' and discusses how these aspects relate to the fundamental goal of providing co-ordinated care for children with disabilities and their families. Based on a review of the service delivery literatures in the fields of health, social services and rehabilitation, a framework is presented that outlines the scope of the co-ordination-related functions and activities encompassed in three common types of approaches to the delivery of co-ordinated care. These are a system/sector-based service integration approach, an agency-based service integration approach and a client/family-based service co-ordination approach. The functions outlined in the framework include aggregate-level planning of services (designed to map out the scope and plan for service provision in a community or geographical area), administrative functions (designed to ensure wise and equitable access to resources) and client-specific service delivery functions (designed to link clients/families to needed services). The framework is a tool that can be used to support policy making and decision making with respect to the design of efforts to provide co-ordinated care. It provides information about commonly used approaches and the essential elements of these approaches, which can be used in making choices about the scope and nature of an approach towards service integration/co-ordination.

Child↗

PubMed2000

[Mapping the scientific evidence for bedside care to unstable angina. A preliminary step to develop clinical guidelines. The name of the study group CAMBIE Change in the Medical services based on the clinical practice guidelines].

BACKGROUND: The uncertainty in clinical practice arise from the need of physicians to make decisions on a limited ground of knowledges. Guidelines are supposed to facilitate clinical decisions in such circumstances. Sharing knowledges on natural history of diseases and clinical expertise allow to define and array of steps structured on a formal flow-chart. The node of algorithms identifies decisions to analyze. This paper presents a taxonomy of specific questions related to each decision nodes for management of unstable angina and assesses the level of evidence available for each question. MATERIAL AND METHOD: A flow chart diagram display the conceptualized key nodes for clinical management of unstable angina. A set of specific question related to clinical exclusive circumstances, diagnostic approach, utility of diagnostic procedures, definition of prognosis and outcomes was raised for each decision node. From a systematic literature review the best available evidence was gathered. Each recommendation was linked to a level (A-C) of evidence, and to a body of consensus expert panel decisions. RESULTS: 34 decision nodes were identified, related with at least 1 question for appraisal of the best evidence. The solution to these questions yielded 40 recommendations scored by the strength of the evidence available. Five recommendations of diagnostic, 20 at prognostic and 15 at therapeutic step. The strength of evidence was A for 73% of recommendations at therapeutic step versus 40% at the two other steps. CONCLUSIONS: A clinical complex problem can be displayed in a continuous process, to allow identification and appraisal of decisions at different clinical nodes. The work-up to achieve a conceptualization of a clinical problem is the preliminary step to develop clinical practice guidelines. Identification of decision nodes allows to manage uncertainty in a explicit way and make policy statement more acceptable by managers and physicians.

Algorithms↗

PubMed2002

Food for thought?: the relations between the Royal Society Food Committee and government, 1915-19.

This paper traces the relationship between the food committees of the Royal Society and government during the First World War, concentrating on the period up to the resignation of Lord Devonport as first Food Controller. It argues that, in the context of a radical public science discourse emanating from some sections of the scientific community and greatly increased contacts between scientists and the government, the food scientists of the committees were moved to press for a formalization of the committees' role in food policy. The members constantly manoeuvered to achieve this aim, but also used a network of alternative channels into the heart of the policy process to get their findings translated into hard policy. In doing so, they explicitly rehearsed characteristic 'public science' arguments. In the institutional blur of wartime state-science relations, scientists often got close to the policy-making process. Post-War, the state swiftly moved to clarify the position: science was to be given more money, but was to be specifically blocked by new administrative arrangements embodied in the Haldane Report on the Machinery of Government from having any say in the core areas of general policy, the expert domain of the generalist policy-maker.

Food Supply↗

PubMed2006

Waiting lists in Dutch health care: an analysis from an organization theoretical perspective.

PURPOSE: To develop propositions on why public policies towards decreasing waiting list in health care can be expected to be unsuccessful. DESIGN/METHODOLOGY/APPROACH: On the basis of a case study of public policies directed towards the reduction of the waiting lists in health care a number of propositions are formulated explaining why this policy has turned out to be ineffective. The propositions are based on theoretical insights form the field of organizations studies about the behavior of organizations and professionals. FINDINGS: It is demonstrated that public policies on reducing waiting lists in the Dutch health care system are likely to be ineffective because the policy-making strategies used are based on unrealistic assumptions about the behavior of organizations and professionals who are expected to reduce the waiting lists. RESEARCH LIMITATIONS/IMPLICATIONS: Although the propositions are based on established organization literature, empirically they are only based on one case study. PRACTICAL IMPLICATIONS: In order to develop effective policy interventions it is important to be realistic about the behavior and strategies of the actors towards which the policy is directed. Moreover, rather than directing exclusive attention to those waiting, it is important for policy makers to address the interdependencies of the organizational field in which waiting lists occur. ORIGINALITY/VALUE: This paper gives directions to policy makers who need to deal with complex and interdependent problems.

Delivery of Health Care↗

PubMed1978

Consumer attitudes toward health policy and knowledge about health legislation.

Consumer attitudes toward key issues affecting health policy decisions in the local community have been ignored both by local health policy makers and by medical sociologists. The authors report an empirical analysis of: (1) consumer attitudes towards federal intervention in health care; (2) consumer perceptions of the free market philosophy of health providers; (3) consumer perceptions of their involvement in health policy making; (4) consumer confidence in present systems of health services delivery; and (5) consumer awareness of recent major health legislation. It was found that consumers are poorly informed about recent health care legislation. The authors compared the attitudes of consumers with those held by local hospital board members toward health policy issues. The differences for all comparisons were statistically significant. The authors argue that hospital board members attribute problems in health services delivery to demand dysfunctions while consumers perceive the problems to be a result of supply dysfunctions. Thus, failure to include consumers on health policy boards guarantees the absence of a solution-oriented dialogue and promotes the continuing predominance of a provider-biased ideology.

Attitude to Health↗

PubMed2003

Harm reduction: a social work practice model and social justice agenda.

Efforts in the United States to eradicate drug use through supply reduction (that is, the War on Drugs) have increasingly violated the principles of social justice and human rights, both locally and globally. This has created ethical conflicts for social workers in policy making, practice, and research. Harm reduction has been conceptualized as a peace movement and is aligned with the humanistic values around which social work is organized. The authors examine how social workers may reduce the ethical conflicts associated with efforts to address substance abuse by adopting a harm reduction approach to policy, practice, and research. They examine current drug policies, the consequences of the policies, and, in particular, how the policies affect social workers as practitioners, agents of social control, and guardians of social justice.

Drug and Narcotic Control↗

PubMed1990

Immigration and the French state: problems of policy implementation.

"Why is it so difficult for a liberal-democratic state to regulate immigration? Although control of a territory is part and parcel of the definition of state sovereignty, labor-importing countries have found it increasingly difficult to regulate the flow of noncitizens across their borders. This article seeks to address the difficulties of regulating immigration by focusing on the policy-making process and the interaction of politics and markets in France, one of the principal countries of immigration."

Demography↗

PubMed1992

Debates, divisions, and decisions: recombinant DNA advisory committee (RAC) authorization of the first human gene transfer experiments.

Possibly the most far-reaching, controversial research currently being conducted in the international biological science community involves human gene therapy experimentation. In this paper, I report the dynamics of the political process which ultimately found the Recombinant DNA Advisory Committee (RAC) of the National Institutes of Health approving for the first time protocols of this genre. A full appreciation of the policy-making dialogue shows that significant participants perceived the process from very different vantage points regarding the way in which the American political system works and the way in which it ought to work. I argue that, if we are to understand how the RAC should proceed in orchestrating a human gene therapy policy agenda, then we must flesh out and critically analyze these competing vantage points. To that end, I postulate seven possible "action models" for characterizing how protocol assessments of the type at issue might be developed given the nature of our politics, reaching the conclusion that one of these models holds out the most promise for synthesizing efficaciously the key factors involved. In conclusion, I discuss how the RAC might profitably employ this preferred strategy in these and other cases.

Advisory Committees↗

PubMed2006

Social, political, and epistemological aspects of genetics and genomics.

The papers in this special issue were first given at a conference in Toronto, Canada, in April 2004 entitled 'Genomics, Genetics, and Society: Bridging the Disciplinary Divides'. The papers fall into four intersecting themes. (1) The introduction of genetic and genomic technologies into communities. (2) Governance, the morals of scientific discourse and policy making. (3) What is a gene? (4) Public knowledge, public trust and improved dialogue between the public and scientists.

Bioethics↗

PubMed2000

People, pesticides, and the environment: who bears the brunt of backward policy in South Africa?

Whereas international trends show that many developed countries are adopting policies that promote pesticide reduction, use of pesticides in South Africa continues to expand. In particular, macroeconomic policies encourage pesticides use among emergent small-scale black farmers, while potential exposures of workers on commercial farms remain high. Despite having legal controls that seem to conform to international standards, the present health and environmental impacts of pesticide use in South Africa are substantial and generally underestimated. The reasons lie in the fragmentation of regulatory mechanisms as well as the absence of public awareness and participation in policy-making related to pesticides. Failure to enforce existing legislation, an ambivalent relationship between government and industry, and the existence of a "pesticide culture" will continue to prevent implementation of meaningful control measures. As a result, it is marginalized groups, such as small-scale farmers and farm workers, who bear the brunt of policies that have not kept pace with a growing international awareness of the hazards of widespread pesticide use for human health and for the environment. Opportunities for fundamental transformation of the legal and policy framework relating to pesticides in order to promote environmental justice are explored.

Journal Article↗