Health sector reform: lessons from China

As a result of China's transition to a socialist market economy, its rural health services have undergone many of the changes commonly associated with health sector reform. These have included a decreased reliance on state funding, decentralisation of public health services, increased autonomy of health facilities, increased freedom of movement of health workers, and decreased political control. These changes have been associated with growing inequality in access to health services, increases in the cost of medical care, and the deterioration of preventive programmes in some poor areas. This paper argues that the government's strategy for addressing these problems has overemphasised the identification of new sources of revenue and has paid inadequate attention to factors that influence provider behaviour. The strategy also does not address contextual issues such as public sector employment practices and systems of local government finance. Other countries can learn from China's experience by taking a systematic approach to the formulation and implementation of strategies for health sector reform.     

Chromatographic behaviour in reversed-phase high-performance liquid chromatography with micellar and submicellar mobile phases: effects of the organic modifier

The study analyzes the traditional beliefs and practices concerning leprosy of the Limba people of Sierra Leone. It shows that this dialectally diverse ethnic group has two views of leprosy and its cause, and two varieties of stigma associated with the disease. The Limba have abandoned their traditional treatments for leprosy in response to an effective leprosy control programme, but retained their traditional world view, including its definition of illness, which holds a person seriously ill only when he has severe pain or disability. Thus, they seek treatment from the programme, but often at a relatively advanced stage of the disease. The study shows that the Limba have reinterpreted the notion of 'germs' as introduced by medical workers, and that leprosy control workers have their own misunderstandings of Limba beliefs and practices. The study points the way to improved communication between leprosy workers and Limba patients by focusing on the points at which their views differ, and by identifying concepts within Limba world view that can be adapted by leprosy workers to help convey their message. The study emphasizes the importance of world view as a key to understanding patient attitudes and behaviour in developing countries, and to making valid cross-cultural comparisons, but notes that it can take years for an investigator to understand the world view of a particular culture. It argues that in short-term research projects there is an advantage to working with an anthropologist who has in-depth knowledge of the culture, but who may not be a specialist in medical anthropology.     

Public health crises of cities in developing countries

During the decade and a half after Alma Ata hundreds of projects were started in developing countries to implement the principles of PHC and start community based health care programs in the rural areas of developing countries. Until the past five years urban health was not seen as a special health problem. Population pressure in the rural areas has created shortages of land, food and employment opportunities. These forces have generated major population movements to the urban centres. The population movements have encouraged unprecedented expansion of urban centres. This sudden concentration of large populations in small geographical areas has resulted in the urban health crises of the developing world. The poor who live in the slum areas have no access to adequate health services, they experience frequent epidemics of communicable diseases like cholera, they live within a heavily polluted environment, and their children have very poor health because they are not immunized and are malnourished. The paper agrees with approaches which have been championed by development agencies to address the urban health crises. These approaches propose the reorientation of urban health systems to include adoption of PHC for urban health programs, intersectoral collaboration and extra budgetary support. The paper argues for further strengthening of the reorientation approach by adjusting the development planning model. It is proposed that the urban plan be integrated into the national development plan so that emerging urban health crises can receive special attention in resource allocation.     

Strategic planning of the master programme in health informatics at Aalborg University: targeting and updating the programme, to meet explicit customer needs

Education is essentially giving people new skills and qualifications to fulfil certain tasks. In planning and managing educational programmes it is crucial to know what skills and what qualifications are needed to carry out the tasks in question, not to mention the importance of knowing what tasks are relevant to carry out. The programme in health informatics at Aalborg University produces health informatics professionals. The students are developing skills in solving informatics problems in health care organisations. The programme has been running for 3 years now and to maintain the perception of the aim for the programme a number of activities have been launched. In the following, the programme will be presented, the activities to obtain information on how to keep the programme targeted and updated will be described and the changes that are going to be introduced will be outlined.     

The 20th Kellersberger Memorial Lecture, 1994. Leprosy and tuberculosis combined programmes: an uneasy partnership?

One of the purposes of this memorial lecture is to relate progress and difficulties in the field of leprosy to work in other fields. Tuberculosis is a disease closely related to leprosy and in 1982 the Kellersberger lecture was given by Dr. Styblo, someone whose name is synonymous with the development of effective Tuberculosis Control Programme in Africa. His title was "Tuberculosis and its control: lessons to be learned from past experience, and implications for leprosy control programme" (1). Many countries in Africa, including Ethiopia, have adopted the strategy of a combined leprosy and TB control programme. In this lecture then, I will examine more closely the strategy of combining the two programmes. I want to look at some of the problems that may arise and then draw out the ways in which each side of the partnership can contribute to the other, so that the combination can be more effective than either programme could hope to be on its own. This lecture will focus mainly on management issues, which are currently the most important barriers to effective control of both diseases, but the socio-economic aspects of disease, so much a part of Dr. Kellersberger's working life, will also be prominent.     

Public and private responsibility for mental health services.

Relative to public services, private sector corporate mental health care has significantly increased since the late 1960s. The many tensions encountered in assigning public and private responsibility for mental health services give rise to significant value-laden questions for psychologists. These questions go to the heart of community mental health, deinstitutionalization, mental health policy development and evaluation, and many other areas in which psychologists are playing major roles. The public–private issue should be understood historically, from the twin vantage points of developments in general medicine and in mental health. Among the many public interest and public policy matters psychologists and others concerned with mental health should address are the emergence of corporate chains; the nature, cost, and quality of private sector services; the compatibility of profit motivation and the motivation to provide care; and patient selection issues (e.g., cream-skimming). Public and private cooperation and planning are certainly in order if the public interest is to be served in addressing the nation's mental health problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Women's health and the privatization of fertility control in Brazil

In Brazil, privatization of the public sphere and neglect of public health is part of a conservative modernization strategy that is dominated by elite groups. The politics of human reproduction, consistent with this pattern, have left women dependent on the private sector for access to the means of fertility control, in spite of the existence of a conceptually-advanced public programme for comprehensive health care for women--a programme which expressed the demands of, and is widely supported by, the women's movement. While both the rate of contraceptive use and the types of methods used (oral contraceptives and surgical sterilization) are modern, the privatization of fertility control has resulted in a complete separation between fertility control and health care for poor women, who are the vast majority. Evidence indicates that many, perhaps most, women accumulate the health effects of totally uncontrolled and incorrect use of oral contraceptives, including unwanted pregnancies and illegal abortions, in the end resorting to clandestine surgical sterilization, which is usually performed through unnecessary caesarean section. Data on reproductive morbidity and mortality, however, are virtually non-existent. International women's reproductive rights networks and alternative services for women have advocated greater empowerment for women, in terms of improved standards of self-care and increased power in the use of health services. As a result, a gender approach to reproductive health care is now being proposed for government programmes. The Brazilian case services as an example of the limits faced by such programmes when adopted in a wider context of unfavorable political conditions.     

Health policy reforms and their impact on the practice of tropical medicine

This paper addresses the consequences of reforming health policies on the practice of tropical medicine. It briefly reviews the historical development of health systems in poor, tropical countries before summarising current trends in the reform of financing and management. Reforms considered include decentralising management, broadening choices in health financing, particularly introducing user fees, introducing 'managed competition' principles, and working with the private sector. Experiences in different countries are used to highlight some of the dangers inherent in current reform trends. It is suggested that while monopolistic and centralised systems of public provision are unlikely to come back into fashion, much can be done to build on the more positive aspects of current reforms and to minimise their undesirable side effects. Key issues are developing mechanisms that ensure that services are responsive to users, avoiding polarisation of services between rich and poor, and improving systems of regulation, supervision and monitoring.     

Three cases of methylmercury intoxication which eluded correct diagnosis

Guidelines and standards are not only of increasing importance for clinical medicine, but also for public health services. Their influence is strengthened by a trend from reorientation of public services to well-established modern public service business. Being part of total quality management they particularly challenge organisation development and planning of human resources in the public sector.     

A survey of the Hong Kong health sector: past, present and future

This paper considers the involvement and performance in the health sector of the Hong Kong government prior to and beyond the transfer of sovereignty from Britain to China in July 1997. The paper commences with a historical survey of health services development, which provides insights into why the health system functions in its present haphazard manner. This section culminates by discussing the 1991 establishment of the statutory Hospital Authority which was an attempt to alleviate escalating problems in the administration of hospitals and public health services. Next, the paper surveys the present, discussing, respectively, the roles of government and private service providers, health care outcomes and the contribution of traditional Chinese medicine. Finally, the paper outlines a range of pressing issues which Hong Kong's future policy-makers will need to confront: the organization of the health sector, health financing and the health policy deficit. In the conclusion, it is posited that there is a need for government to formulate a health policy and to clarify its role in the provision of services.     

Isssues in Developing Control Zones for International Space Operations

As the number of space‐faring nations and orbiting spacecraft increases, it is desirable to develop an international traffic‐management strategy to coordinate, monitor, and control the interactions of spacecraft in orbit. Successful strategies will facilitate cooperative missions while still supporting each nation's unique goals and objectives in space. The potential benefits of such a strategy include: reductions in future program costs and increases in mission success through the standardization of space operations and equipment; increased safety through development of a coordinated collision avoidance strategy for active spacecraft and debris; and establishing a basis for legal and economic compensation agreements. One means of implementing such a strategy is to utilize a control zones technique that assigns different types of orbital operations to specific regions of space surrounding a vehicle. This paper considers the issues associated with developing a control‐zones technique to regulate the interactions of spacecraft in proximity to a manned vehicle. It includes discussion of technical and planning issues, flight hardware and software issues, mission‐management parameters, and other constraints. It addresses manned and unmanned vehicle operations, and manual versus automated flight control. A review of the strategies utilized by the Apollo‐Soyuz Test Project and the Space Station Freedom Program is also presented.     

Health care needs in a nontraditional university setting

This paper describes early planning stages of a nurse-managed clinic to offer primary health care services in a nontraditional university setting. A community needs assessment was conducted with quantitative and qualitative findings reported. This unique setting triggered a number of considerations in planning for services. Recommendations for health services and resources for the university community are discussed.     

A case-control study of the effectiveness of BCG vaccine for preventing leprosy in Yangon, Myanmar

BACKGROUND: Five randomized trials, a follow-up study, and six case-control investigations of BCG vaccine's effectiveness (VE) for preventing leprosy have been conducted internationally, with widely varying estimates of VE. Because of the difficulty of generalizing from disparate results, local estimates of VE are needed for health planning purposes and are currently particularly relevant, given the World Health Organization's (WHO) goal to eliminate leprosy by the year 2000. METHODS: We conducted a case-control study in Yangon, Myanmar. Residents of Yangon between the ages of 6 years and 24 years who were listed in the National Leprosy Registry as being on active treatment for leprosy between December 1992 and April 1993 were eligible to participate in the study as cases. Control subjects were matched to the cases on age, sex, and neighbourhood. RESULTS: One or more doses of BCG were associated with a VE of 66%. The results show a significant trend of increasing VE with increasing number of BCG doses (one dose, VE = 55%; two doses, VE = 68%; three doses, VE = 87%). One dose of BCG vaccine appeared to provide protection substantially higher than that found in an earlier vaccine trial in Myanmar, but consistent with results from case-control studies in other countries. CONCLUSIONS: These data suggest that BCG reduces the risk of leprosy in Myanmar, and that BCG vaccination of infants, along with early case-finding and treatment, should be considered an important part of the leprosy intervention strategy.     

Public health advocacy on behalf of women in S?o Paulo: learning to participate in the planning process

In 1988, a new Constitution was adopted in Brazil in which guidelines for community participation in the development and implementation of the national health system were delineated. The health and welfare of women and children were given priority. Implementation of these guidelines presents a major challenge in a city such as S?o Paulo with a population of 15 million, of which an estimated 5.8 million are women of childbearing age. In order to determine the extent to which community organizations are actively participating in planning health services for women and children in S?o Paulo, a study was undertaken to examine the experience of community and professional organizations in public health advocacy. This paper describes a sample of these organizations, their constituents, membership, history, funding, advocacy objectives, and strategies used and results obtained. The information gathered indicates that the community organizations are involved in activities that include major efforts to improve access to health care by providing specialized courses in women's health, including the status of women's work, sexuality, discrimination, family planning, and the politics of health; publishing newsletters; producing radio programs; engaging in legal action; and using petitions, demonstrations, and public meetings to garner public support on specific issues.     

A community-based public-academic liaison program

OBJECTIVE: The authors discuss obstacles and incentives associated with successful community-based public-academic liaison activities and illustrate their conclusions by describing their public-academic liaison program, which received the American College of Psychiatrists' first annual Award for Creativity in Psychiatric Education. METHOD: The first 8 years of a state/university collaboration are described in which the parties involved first developed a variety of innovative services designed to fill specific gaps in the public service delivery system and subsequently integrated academic research and training components. RESULTS: The carefully planned and monitored process resulted in the exponential growth of interest in public sector work, the realization of the university's primary goals of developing high quality training and research sites, a substantial increase in the number of graduates accepting positions in the public sector, several projects funded by the National Institute of Mental Health, and two national awards. CONCLUSIONS: These collaborations illustrate the highly complementary relationship of public-academic liaison activities and their potential capacity to improve access to services, substantially improve the quality of these services, generate extramural support for services research, and increase the number of well-trained professionals in the public sector.     

Ethics of resource allocation in developing countries: the case of Sri Lanka

The issues of prioritization of health care services and allocation of resources have recently received increasing attention and discussion. Several reports have been published by governments in different countries and the issues are discussed in many recent books and papers. In this paper the focus is on the problems faced by a developing country when allocation of health care resources is considered. We consider these issues under three headings and exemplify the situation in a developing country by taking Sri Lanka as an example. Firstly the evidence to formulate an ethical basis for the existing health care system in Sri Lanka is discussed, in particular the problem of defining a minimum quality of health care for the population. Secondly, we consider the issues which arise when we want to formulate the ethical basis for health sector reform. In particular, we examine current World Bank proposals. We shall argue that there are a number of important conceptual and ethical issues that have not been properly addressed in the various policy documents. Finally, we introduce our own alternative ethical framework for policy reform.     

Criteria for the health surveillance of workers exposed to repetitive movements

In the light of the experience and guidelines developed by other countries and of Italian legislative and operational conditions, the authors outline a strategy for a health surveillance programme for work-related musculoskeletal disorders of the upper limbs. In particular, the paper defines the various aims of the health surveillance programme and identifies significant relevant criteria for its implementation (i.e. existence of risks or effects). A screening schedule is presented based on subsequent investigations (first and second level surveillance); the authors discuss the principal methods used for processing the results of the health surveillance programme, in collective (i.e. statistical comparisons, planning of periodical investigations) and individual terms (job fitness judgements, reporting of suspected occupational diseases).     

Pathways of dependence: the impact of health and social care restructuring--the voluntary experience

The current emphasis on community over institutionally based modes of health and social care delivery in the UK, together with legislative change, has placed a renewed emphasis on the role of the informal sector in service provision. Simultaneously, there has been an attempt to modify the provider-role of the statutory sector, in favour of an evolving role as purchaser and enabler of independently provided services. Drawing on material that forms part of a 3 year study into health and social care restructuring, and its effect on the caring networks of elderly dependent populations, this paper focuses on the changing role of the voluntary sector. Using empirical material drawn from the Scottish environment, it illustrates how the restructuring process may be modifying the voluntary sector and contributing to a growth in geographical inequity in voluntary service provision. In doing so, it considers four main factors affecting local voluntary organisations--the growth of contracting, external constraints on voluntary provisioning, the influence of the local authority and Wolch's concept of the "Shadow State". It highlights the emerging social and spatial manifestations arising from such change, and how these modifications may also be contributing to a growth in geographical inequity for service recipients linked within the dependence network.     

Innovative service redesign and resource reallocation: responding to political realities, mental health reform and community mental health needs

General hospital mental health programs in large inner city communities face challenges in developing responsive services for populations facing high rates of serious mental illness, substance abuse, homelessness, and poverty. In addition provincial political pressures such as Mental Health Reform and hospital restructuring have caused general hospital mental health programs to reevaluate how services are delivered and resources are allocated. This paper describes how one inner city mental health service in a university teaching setting developed successful strategies to respond to these pressures. Strategies included: (a) merging two general hospital mental health services to pool resources; (b) allocating resources to innovative care delivery models consistent with provincial reforms and community needs; (c) fostering staff role changes, job transitions, and the development of new professional competencies to complement the innovative care delivery models; and (d) developing processes to evaluate the effects of these changes on client.     

Bilingual professionals in community mental health services

OBJECTIVE: This paper presents results from research that explored the roles of bilingual professionals in community mental health services in the Sydney metropolitan area of New South Wales. There were two main objectives to the research: (i) to identify and describe the roles of bilingual professionals that are important in improving the quality of community mental health services for clients from non-English-speaking backgrounds (NESB); and (ii) to identify and describe the factors that facilitate and inhibit the conduct of these roles. METHOD: Data collection involved indepth interviews with bilingual professionals and team leaders in community mental health services and various other community health services; and various staff responsible for policy and service development with regard to cultural diversity. RESULTS: Bilingual mental health workers were found to have at least four critical roles. These were (i) direct clinical service provision to NESB clients; (ii) mental health promotion and community development; (iii) cultural consultancy; and (iv) service development. Respondents reported that the latter three roles were seriously underdeveloped compared to the clinical service provision role. CONCLUSIONS: It is critical that service managers implement strategies to make better use of the linguistic and cultural skills of bilingual professionals. In addition to their role in clinical service provision ways must be found to facilitate the community-focused, cultural consultancy and service development roles of bilingual professionals employed in mental health services.