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PubMed2005

Assessing ethics and animal welfare in animal biotechnology for farm production.

This paper addresses the ethical issues involved in animal biotechnology. Considerable advances in this field have been made with transgenic fish, which may be the first real test case for regulatory bodies. Intrinsic concerns about animal biotechnology are often voiced in public debate, and the paper presents and critically discusses these issues. Even though these concerns may be hard to reconcile with standards of rational argument, they might still have practical consequences for ethical policy making. Animal welfare and environmental issues are discussed as the most salient extrinsic concerns about animal biotechnology. The most serious obstacle to a good risk assessment of animal biotechnology is the extent of scientific uncertainty. Ethical assessments need to address these uncertainties upfront, and the precautionary principle provides a good criterion for responsible policies. At the end of the paper, a practical method for the ethical assessment of animal biotechnology, the so-called ethical matrix, is briefly presented and discussed.

Animal Husbandry↗
PubMed1987

The cost of saving a life through cervical cytology screening: implications for health policy.

Through a review of the published literature on routine cervical cytology screening, this paper seeks to establish a likely range for the cost of saving a life through this screening programme as presently organised in England and Wales. The current performance of the programme may be expressed in several ways: a cost of 270,000 pounds to 285,000 pounds per life saved, 40,000 smears and 200 excision biopsies per death averted, or 1000 to 1500 avoidable deaths annually in England and Wales alone. The policy problems are thus of two kinds. First, there is a substantial misallocation of the limited resources available to an insurance based system of health care. Further, the money which is spent on this service does not avoid the mortality and morbidity which could reasonably be expected if the system were performing adequately. It is suggested that substantial improvements in the performance of the programme may well be possible if managers are appointed. Nevertheless a deeper policy issue is raised: to be delivered efficiently, any service based on population rather than individual considerations will require some acceptance by the medical profession of a limit to their traditional view of clinical freedom. The unresolved clash between population and individual considerations which poses such a fundamental challenge for policy making in insurance based health services is particularly well illustrated by the dilemma of publicly funded cervical cytology screening.

Costs and Cost Analysis↗
PubMedDate not supplied

The use of claims databases for outcomes research: rationale, challenges, and strategies.

Health care payers and policy makers need information about the cost and effectiveness of medical treatments. While randomized controlled trials historically are the primary source of medical information, they are expensive and labor-intensive, and often have limited utility for answering questions about "real-world" patient populations. These problems have led to an increasing reliance on claims database research in making policy decisions about treatment options. However, both researchers and decision makers should recognize the limitations and unique features of claims databases. Recommendations for avoiding or minimizing threats to internal validity, construct validity, and external validity are: (1) use of a study design that includes comparisons; (2) ensuring that the study design and conclusions are consistent with the database; (3) a priori conceptual modeling of the research question; (4) use of appropriate constructs; (5) explicit examination of alternative explanations for study findings; (6) sensitivity analyses of key assumptions; (7) awareness of the distinction between statistical and practical significance of findings; (8) generalization only when appropriate; and (9) reporting of relevant information. Given that any study design or data source has limitations, we hope that this paper will encourage a philosophy of methodological pluralism in outcomes research. Awareness and accurate reporting of validity issues will strengthen and extend the information resources currently available to decision makers.

Decision Making↗
PubMed2003

Complementary and alternative medicine: a pharmacist's perspective on patient needs.

The use of complementary and alternative medicine (CAM) is pervasive throughout the Canadian healthcare landscape. The lead paper offers recommendations on research, regulation and funding based on accepting evidence beyond that found through randomized clinical trials. Unfortunately, the efforts that go into policy-making are unlikely to reflect the ever-evolving and plastic nature of CAM. Pharmacists have long been the most easily accessible healthcare professional and a natural bridge between CAM and conventional medicine. The role of CAM, and specifically herbal medications, in conjunction with conventional therapy is a dilemma faced by pharmacists every day. Policy-makers need to be creative in order to collect data on safety first and then efficacy for a public that is already using these services. The quandaries pharmacists face on these issues are a microcosm of what researchers and governments must deal with in creating policies that respect patient autonomy and at the same time protect public safety.

Canada↗
PubMedDate not supplied

Beyond the categories: human service managers view the new federal aid.

Social agency chief executives in six program areas--welfare, health, mental health, community action, model cities, and community mental health centers--were surveyed to determine their reaction to the recent revenue sharing/block grant efforts to decentralize the federal aid system. Despite their strong belief that social initiatives and values were advanced principally by federal action, and that excessive reliance on state and local officials could severely jeopardize social programs with weak constituencies, agency executives also recognized major weaknesses in traditional categorical grant policy and, to varying degrees, supported revenue sharing and block grant alternatives. Those agencies largely dependent on federal support for their survival--model cities, community action programs, and community mental health centers--tended to support the new aid efforts only reluctantly. Those agencies more fully integrated into the regular policy-making arrangements of local government--health, welfare, and mental health agencies--were considerably more positive in their endorsement of greater decentralization.

Administrative Personnel↗
PubMed1997

Determinants of change in Medicaid pharmaceutical cost sharing: does evidence affect policy?

Since 1980, many Medicaid programs have instituted, adjusted, or abolished pharmaceutical copayments or limitations on the number of prescriptions per patient (caps). Studies indicate that prescription caps can harm patients and increase Medicaid costs. However, because there is little information on how state policy makers select and evaluate such policies, in-depth telephone interviews were conducted with key informants in Medicaid programs that had recently made changes in cost-sharing policies. Among the barriers to evidence-based policy making were lack of political power, skills, and infrastructure; crisis-oriented decisions; compartmentalized budgeting; lack of advocates for disadvantaged patients; and the absence of timely research. Research was applied successfully when the interests of patient advocates and the drug industry were aligned and when Medicaid analysis were able to identify and communicate relevant research to policy makers at the time, or "teachable moment," that policy was being changed.

Cost Sharing↗
PubMed2004

Recruiting and developing an effective workforce in the British NHS.

The British NHS faces major challenges recruiting, motivating and retaining staff in a period of sustained growth and change. This paper examines the prevalence of skill shortages and organisations' coping strategies, as well the factors that motivate staff in the workplace and in the NHS in particular. It argues that the evidence base for informed policy-making needs radical improvement. It then considers a number of approaches to pay that are being used or suggested to attract, motivate and retain staff. These include performance pay, team pay and local pay determination, as well as considering broader factors such as morale and staff development. The paper then draws together some conclusions for policy-makers. These argue that better evidence is needed as to what is happening in the public sector labour market in order to frame appropriate responses and that thorough evaluation of policy initiatives is necessary to establish their utility before their widespread implementation.

Employment↗
PubMed1994

Violence against women: a neglected public health issue in less developed countries.

Violence against women is a significant public health issue in countries of both the industrialized and less developed world. This paper describes the magnitude and health consequences of domestic violence and rape, with an emphasis on developing countries; it recognizes, however, that there is a dearth of documentation regarding the wide range of activity opposing violence against women which is taking place in less developed countries. It briefly explores the factors that perpetuate violence against women and the strategies that have evolved to respond to the problem. It analyses the constellation of factors that may assist violence to emerge as a legitimate public health concern, and explores opportunities and obstacles to further progress in this field. Particular attention is devoted to the role of research in the policy-making process; research areas which may assist those opposing violence against women in all its forms are tentatively suggested.

Battered Women↗
PubMed1996

The role of perspective in defining economic measures for the evaluation of medical technology.

Perspectives in an economic analysis of medical technology reflect who makes decisions about the use of or payment for medical resources. Commonly used perspectives include those of providers, insurers, the individual, and society. Perspective is a critical determinant of study design, affecting the time horizon, types of resources considered, and economic cost measures assigned to those resources. Individuals involved in technology assessment for either research or policy-making purposes should be aware of the complexities of defining costs from different perspectives.

Costs and Cost Analysis↗
PubMed2004

How traditions of ethical reasoning and institutional processes shape stem cell research in Britain.

This article aims to show how the traditions of ethical reasoning and policy-making shape stem cell research in Britain. To do so I give a detailed account of the earlier developments of regulations on embryo research and the specific scientific advances made in Britain. The subsequent regulation of stem cell research was largely predetermined by those structures and the different and partly opposing orientations of a utilitarian approach to policies on biomedicine. The setting up of the first stem cell bank and the directing of public funding into not only bioethical but also sociological guidance of the development of the new science field are aspects of the particular British way of supporting stem cell research. However, there is also an ongoing philosophical and juridical debate on the possible erosion of fundamental values caused by incremental regulatory weakening. Although I am highly sympathetic to the critical position that there is a need for a metaphysical anchor to secure individual human rights, one has to admit that the British mode of handling the inevitable ethical problems we face with biomedical progress is rather successful in terms of securing some of the basic needs and values of a modern democratic society.

Bioethics↗
PubMed2006

Informal payments for health care: definitions, distinctions, and dilemmas.

There is increasing interest in the issue of informal payments for health care in low- and middle-income countries. Emerging evidence suggests that the phenomenon is both diverse, including many variants from cash payments to in-kind contributions and from gift giving to informal charging, and widespread, reported from countries in at least three continents. However, cross-national research is hampered by the lack of consensus among researchers on the definition of informal payments, and the definitions that have been proposed are unable to incorporate all forms of the phenomenon that have been described so far. This article aims to overcome this limitation by proposing a new definition based on the concept of entitlement for services. First, the various forms of informal payment observed in practice are reviewed briefly. Then, some of the proposed definitions are discussed, pointing out that none of the distinctive characteristics implied by these definitions, including illegality, informality, and corruption, is adequate to capture all varieties of the phenomenon. Next, an alternative definition is formulated, which identifies the distinctive feature common to all forms of informal payments as something that is contributed in addition to the terms of entitlement. Then, the boundaries implied by this definition are explored and, finally, the implications for research and policy making are discussed with reference to the lessons developed countries can learn from the experiences of transitional countries.

Delivery of Health Care↗
PubMed1991

Older women in the post-Reagan era.

This article explores the social, economic, and institutional factors that affect older women throughout the life cycle, and recent policy and ideological changes that will continue to affect older women in the decades ahead. The situation of the older woman is shown to result from lifelong patterns of socioeconomic and gender stratification in the larger society. The consequences for women flow from the complex and often subtle relationships in the social institutions of the family, the labor market, and the state and its social policy. The female roles of worker, unpaid caregiver, and beneficiary of public policies continue to be systemically unequal to those of men. The patriarchal structure of (and control over) the labor market and policy-making promotes the informalization of long-term care, ageism and sexism toward older women attempting to reenter the labor market, and the devaluing of female work that is not economically remunerated. The failure of social problems to address the underlying structural inequities of women perpetuates their disadvantaged economic and health situation throughout old age. Changes in social policies are required to address the problem of access to basic resources, including Social Security, housing, health, and long-term care, but most importantly, to abridge and compensate for the gendered division of labor and the lifelong discrimination that women experience.

Aged↗
PubMed2006

Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes.

OBJECTIVE: To compare the maternal implications of strategies of vaginal birth after caesarean section (VBAC) attempt versus elective repeat caesarean section in women with one previous lower segment caesarean section. DESIGN: Decision model. POPULATION: Women with one prior low transverse caesarean section who are eligible for trial of labour. METHODS: Two decision models were built: the first one applying to women planning only one more pregnancy, the second one applying to women planning two more pregnancies. Probability estimates for VBAC success rate and risks of uterine rupture, placenta praevia, placenta accreta and hysterectomy were extracted from the available literature. MAIN OUTCOME MEASURES: Hysterectomy for uterine rupture, placenta accreta or other indications. RESULTS: In the first model VBAC attempt led to a higher hysterectomy rate (267/100,000) compared with repeat caesarean section (187/100,000). However, in the second model a policy of elective repeat caesarean section led to higher cumulative hysterectomy rate: 1465/100,000 versus 907/100,000 for VBAC. The first model was robust to all but one variable in sensitivity analyses. The second model was robust to all variables in sensitivity analyses. CONCLUSIONS: These results indicate that long term reproductive consequences of multiple caesarean sections should be considered when making policy decisions regarding the risk-benefit ratio of VBAC.

Cesarean Section, Repeat↗
PubMed2006

An illustration of whole systems thinking.

The complexity of policy-making in the NHS is such that systemic, holistic thinking is needed if the current government's plans are to be realized. This paper describes systems thinking and illustrates its value in understanding the complexity of the diabetes National Service Framework (NSF); its role in identifying problems and barriers previously not predicted; and in reaching conclusions as to how it should be implemented. The approach adopted makes use of soft systems methodology (SSM) devised by Peter Checkland. This analysis reveals issues relating to human communication, information provision and resource allocation needing to be addressed. From this, desirable and feasible changes are explored as means of achieving a more effective NSF, examining possible changes from technical, organizational, economic and cultural perspectives. As well as testing current health policies and plans, SSM can be used to test the feasibility of new health policies. This is achieved by providing a greater understanding and appreciation of what is happening in the real world and how people work. Soft systems thinking is the best approach, given the complexity of health care. It is a flexible, cost-effective solution, which should be a prerequisite before any new health policy is launched.

Communication↗
PubMed2003

Science, politics and animal health policy: epidemiology in action.

Public policy decisions underlie society's response to current animal health issues ranging from emerging diseases and public health threats to food safety concerns and sustainable animal agriculture strategies. Despite strong calls for "science-based" decisions, animal health policy most commonly emerges at the interface of science and politics. Too often scientists' disdain for politics limits their involvement in formulating policy. By contrast, epidemiologists are ideally qualified to bring scientific skills to complex policy issues through analytical, macro-epidemiological approaches that consider the economic, legal, and cultural context of policy issues as well as the biological and medical aspects. Risk analysis provides a systematic approach to evaluating animal health issues and comparing policy options. Capturing these opportunities for applied epidemiology requires an understanding of the policy-making process as well as the basic principles of epidemiology. Furthermore, epidemiology training programs must incorporate communications skill building and experiential learning opportunities in a team environment.

Animals↗
PubMed1994

Homelessness in rural areas: causes, patterns, and trends.

Although homelessness in urban areas has been examined extensively, little attention has been given to the problem of homelessness in rural areas. This article reports the findings from a 1990 statewide study of rural homelessness funded by the National Institute of Mental Health. During the six-month data collection period, 919 homeless adults were interviewed; 247 were heading family units, and 480 children were in these families. More than two-thirds of these families were headed by single parents. Implications of the findings for providing short-term emergency assistance and longer-term policy-making are presented.

Adolescent↗
PubMed1998

A tale of two (low prevalence) cities: social movement organisations and the local policy response to HIV/AIDS.

In the field of HIV/AIDS, social movement organisations (SMOs) have been identified as powerful potential catalysts for change through their impact on formal organisational structures and the policy process. In addition, they have the capacity to be important providers of services in their own right, through the community resources they are capable of mobilising. In the United Kingdom, however, their role in policy formation is disputed. Previous studies have concluded that they have been most influential at national policy and ward level. At the level of local policy making, their influence has been found to be patchy and confined largely to securing recognition of HIV as an issue. Most previous research has, however, been conducted in high prevalence, metropolitan settings with functional SMOs. This paper presents the results of a comparative case study of two neighbouring provincial low prevalence district health authorities (HAs) in England. We describe the changing national policy context from 1986 to 1995 and use a strategic change model to analyse the local development of care and treatment services for people with HIV/AIDS, in particular the relationship between SMOs and HAs. Despite being demographically, socioeconomically and epidemiologically similar, and sharing an identical national policy framework, the two districts demonstrate completely divergent organisational responses to the HIV/AIDS epidemic. We conclude that the level of prior social movement mobilisation and the degree of receptivity for change within the HA are the key variables for explaining variations in the scale of strategic change observed in the two districts.

Adult↗