Alberta: The Next Reform Is Always Just Ahead.

Analyzing The Pace and Direction of Primary Health Care Reform in Ontario, Canada: Transformative Change or Tranformation Lite?

In this paper we consider the extent to which strategies to improve access to acute care services have been integrated with national strategies to improve Aboriginal health outcomes. To do this we review the primary and secondary sources and provide an overview of current national strategy in Aboriginal health and identify where policy and strategic issues relevant to acute care have been developed. In particular we consider the extent to which national policy processes have focussed on the interface between the primary and acute sectors. It is our contention that nationally integrated strategies to improve access to the acute care sector require the development of an Aboriginal health focus in hospital based quality assurance processes and a comprehensive engagement with Aboriginal issues across the acute care sector.

Opportunities in mental health services research.

Health reform is now moving beyond academic dialogue toward governmental implementation. Across the nation, a consensus has emerged that the nation's health system is in need of repair. President Clinton has made health reform one of his top priorities, and Hillary Rodham Clinton headed the task force that developed the administration's proposal for reform. Many other key players, including members of Congress, business leaders, health care providers, health insurance companies, and professional organizations have made it clear that they, too, are ready to work together toward a plan for the reform of the nation's health system. While it is not yet clear precisely what form the new American health system will take, we do have some indications as to what it might include based on recent discussions and debate. To date, discussions of health reform have focused almost exclusively on questions of how to extend health insurance to the nation's 35-40 million uninsured and, at the same time, bring medical care costs under control. These are, unquestionably, issues of great importance. There is danger, however, in limiting the discussion to issues of access and financing within the medical care sector. While the importance of increasing efficiency and improving access cannot be overstated, these issues alone do little to address the broader mission of the nation's health system--improving the health of the American people. While improvements in the medical care sector may contribute to better health outcomes for some individuals, it is unlikely that such changes alone will have a significant impact on measures of the nation's health. For health reform to be successful, health care reform must be accompanied by reform of the nation's public health system. That is: Health Reform = Health Care Reform + Public Health Reform Taken together, health care reform and public health reform can produce a more efficient, more equitable health system that actually improves the health and quality of life of the American people. We appreciate the opportunity to comment on this timely topic, in conjunction with Rundall's article, Integration of Public Health and Medicine. In many respects, our thinking, which reflects many discussions during 1992 and 1993 at the Centers for Disease Control and Prevention, parallels that of Rundall. We believe that health (care) reform offers a real opportunity to reform our overall health system, bringing public health and medical care into proper focus and integrating them in a sensible fashion. WHAT IS PUBLIC HEALTH? The American health system can be viewed as the union of two components--the health care (or medical care) system and the public health system. These two components are not independent and should not be viewed in such a way; indeed, the more independent each is, the less effective both become. Rather, the health care and public health systems do, and must, complement and interact with each other. Whereas the health care system tends to focus on the treatment of medical problems, the public health system's emphasis is on disease prevention and health promotion. While the health care system provides medical services to individuals seeking care, the public health system targets health services through community programs directed at population groups. Indeed, many definitions of public health exist, but nearly all share the recognition that prevention and the health of the community are central to public health. While most people have a general idea of what public health is, the public health system's organization and scope of activities are unclear even to many health professionals. In broad terms, as described in the Institute of Medicine's report, The Future of Public Health (1988), public health agencies perform three core functions: 1. Assessment: regularly and systematically collecting, assembling, and analyzing information on the health of populations, factors affecting people's health, and the health system itself. …

1. Family planning occupied a subordinate position in the medical and health bureaucracy almost two decades after its introduction. Senior Ministry officials accorded low priority to formal program objectives, while the State Family Planning Officer, the highest state official concerned solely with the family planning program, suffered from a relatively subordinate position in the Directorate and a lack of authority and support. Within the medical profession, family planning was held in low esteem, and the medical and health bureaucracies did not have a mechanism for selecting personnel on the basis of interest and commitment. 2. Organizational adjustment to family planning in the Ministry of Health was a slow and painful process, absorbing the energy and attention of Ministry officials for almost a decade. The repeated reorganizations of the district setup revolving around the division of labor between medical, health, and family planning acitvities and between the rural and urban program, led to months of almost total inertia and detracted substantially from the supervisory capacity of the officials involved. 3. Decision making and guidance suffered from the quick turnover of the Secretary, the most powerful administrator in the Ministry. In Uttar Pradesh Secretaries stayed barely long enough to begin to understand the complex organizational setup of the program. 4. Multiple and often conflicting lines of authority characterized the relationships between the higher and lower echelons within the Ministry. This was accentuated when the District Family Planning Officer was placed under the administrative control of the District Magistrate. While intended to "energize" family planning through the association of the most prestigious and powerful district official with the program, this organizational arrangement resulted in conflicting instructions to the staffs of the primary health centers. 5. The organizational behavior of the Ministry of Health was shaped by the interplay of the various "professional cultures" of its key actors. The generalist administrators' short time horizon and eagerness to produce quantitative results clashed with the specialists' emphasis upon long-term goals and technical constraints; the politician's defense of the interest of his constituents clashed with the administrator's desire to defend his autonomy. The calculus of political survival made support for family planning goals a costly burden that few politicians have been willing to shoulder. As the party system does not reward the advocacy of family planning, ministers emphasize those programs within their ministry or those decisions within their discretion that correspond to the demands of their constituents.

A key limiting factor in the scale up and sustainability of HIV care and treatment programmes is the global shortage of trained health care workers. This paper discusses why it is important to move beyond conceptualising health care workers simply as 'inputs' in the delivery of HIV treatment and care, and to also consider their roles as partners and agents in the process of health care. It suggests a framework for thinking about their roles and responses in HIV care, considers the current evidence base, and concludes by identifying key areas for future research on health care workers' responses in HIV treatment and care in low and middle income settings.

Clinicians and health bureaucrats often find themselves on opposite sides of the fence. As a clinician with an interest in management, I was offered the opportunity to work with health bureaucrats in the Victorian Department of Health and Community Services to redevelop public child and adolescent mental-health services (CAMHS). Recent mental health reforms in the Australian state of Victoria required a blueprint to outline the future directions of services to under-19-year-olds and to help planners, purchasers and providers communicate. My article reports on the general features of the new framework for service delivery in Victoria, describes some of the thinking behind the policies and makes comments on the experience of working with health-policy planners.

The competency of the Chinese health bureaucracy has long been questioned in light of past healthcare reform failures. This article, however, by analysing the case of the Fujian Provincial Health Bureau and a policy intervention led by it aimed at curbing rampant cost inflation, demonstrates that with a conducive political environment and firm policy determination, it is possible to achieve effective cost containment without touching fundamental economic levers. The health bureaucracy is not inherently incapable. It still possesses essential authority and policy instruments to exercise strong stewardship. The reassertion of its legitimacy, reinforcement of government stewardship, restoration of the collapsed accountability mechanisms and realignment of government tools epitomise the experiences of Fujian's healthcare reforms. © China: An International Journal.

The Impact of Health Sector Reform on State and Society in Bangladesh, 1995-2005

On November 4, 2008, Sen. Barack Obama (D-IL) made history by becoming the first African-American elected president, the first sitting senator in 48 years to be elected president, and the first Democratic presidential candidate to receive a majority of the popular vote since Jimmy Carter. He also saw his party solidify their majorities in the House and the Senate, giving Democrats control of government for the first time since 1993. Democrats padded their existing majorities in the House and Senate, but not as much as they had hoped before the elections. Importantly, Democrats will not have a 60-vote filibuster-proof supermajority in the Senate, meaning they will still have to get support from a handful of Senate Republicans on most legislation. The expanded majority will give Democrats additional leverage to sculpt the new president's agenda and pass it through the House and the Senate. President-elect Obama has identified reform of the healthcare system as a priority. Any healthcare system reform will likely contain a solution for the Medicare physician payment fee schedule and possibly include additional changes to the end-stage renal disease (ESRD) program. However, the exploding budget deficit will be a major impediment to the Democratic agenda, especially with the increased number and influence of the conservative Blue Dog Democrats and their emphatic support of the Pay-As-You-Go Rule. This rule requires that if spending is increased or tax revenues are decreased, spending must be cut or revenues must be raised in other areas to ensure that the legislation does not increase the deficit. Any healthcare system reform will likely contain a solution for the Medicare physician payment fee schedule, and possibly include additional changes to the ESRD program. In the House, Democratic Leader- ship and Committee Chairmanships had not been expected to change from the 110th Congress, but Energy and Commerce Chairman John Dingell (D-MI) is being challenged for leadership of the panel by the Democrat next in seniority, Henry Waxman (D-CA). Regardless of the chairmanship contest, the committee roster will change because seven members retired from the House. The retirees include two Democrats, Tom Allen (ME) and Darlene Hooley (OR), and five Republicans, Barbara Cubin (WY), Mike Ferguson (NJ), Vito Fossella (NY), Charles “Chip” Pickering (MS), and Heather Wilson (NM). The most significant committee changes will be on the Ways and Means Committee, where Congressman Jim McCrery (R-LA) retired, leaving open the ranking Republican position. Congressman Wally Herger (R-CA) is the most senior Republican on the panel, but he faces a challenge from Congressman Dave Camp (R-MI), chairman of the Health Subcommittee and an original cosponsor of the Kidney Care Quality and Education Act. House Republican leadership will have four additional openings to fill on the committee as a result of five retirements and two incumbents losing their bids for reelection. There are also changes to the committee's Democratic roster. On November 6, committee member Rahm Emanuel (D-IL) accepted the position of White House chief of staff, adding to the Democratic vacancies left by the retirement of Congressman Michael McNulty's (NY) and the death of Congresswoman Stephanie Tubbs Jones (OH) earlier this year. Additionally, the change in the committee ratios should create four additional openings for Democrats. In the Senate, there likely will be two openings on the Finance Committee resulting from the November elections. Senator John Sununu (R-NH) lost his Senate race. Senator Gordon Smith (R-OR) was also defeated; although there may be a recount that could alter the outcome. With his emphasis on healthcare reform during the campaign, it is expected that Obama and his administration, coupled with strengthened Democratic majorities in the House and Senate, will ensure that healthcare reform will be high on the legislative agenda. However, the kidney-care community will have to wait and see what impact reform will have on the ESRD program.

What are the experiences and perceptions of physical restraint policies and practices by health professionals, administrators and policy makers in the acute care sector?

Valuing the paradigm of nursing: Can nurse practitioners resist medicalization to transform healthcare?

Medical professionalism in the new millennium: a physician charter.

This paper reports on a structured facilitation program where seven interdisciplinary teams conducted projects aimed at improving the care of the older person in the acute sector. Aims To develop and implement a structured intervention known as the Knowledge Translation (KT) Toolkit to improve the fundamentals of care for the older person in the acute care sector. Three hypotheses were tested: (i) frontline staff can be facilitated to use existing quality improvement tools and techniques and other resources (the KT Toolkit) in order to improve care of older people in the acute hospital setting; (ii) fundamental aspects of care for older people in the acute hospital setting can be improved through the introduction and use of specific evidence-based guidelines by frontline staff; and (iii) innovations can be introduced and improvements made to care within a 12-month cycle/timeframe with appropriate facilitation. Methods Using realistic evaluation methodology the impact of a structured facilitation program (the KT Toolkit) was assessed with the aim of providing a deeper understanding of how a range of tools, techniques and strategies may be used by clinicians to improve care. The intervention comprised three elements: the facilitation team recruited for specific knowledge, skills and expertise in KT, evidence-based practice and quality and safety; the facilitation, including a structured program of education, ongoing support and communication; and finally the components of the toolkit including elements already used within the study organisation. Results Small improvements in care were shown. The results for the individual projects varied from clarifying issues of concern and planning ongoing activities, to changing existing practices, to improving actual patient outcomes such as reducing functional decline. More importantly the study described how teams of clinicians can be facilitated using a structured program to conduct practice improvement activities with sufficient flexibility to meet the individual needs of the teams. Conclusions The range of tools in the KT Toolkit were found to be helpful, but not all tools needed to be used to achieve successful results. Facilitation of the teams was a central feature of the KT Toolkit and allowed clinicians to retain control of their projects; however, finding the balance between structuring the process and enabling teams to maintain ownership and control was an ongoing challenge. Clinicians may not have the requisite skills and experience in basic standard setting, audit and evaluation and it was therefore important to address this throughout the project. In time this builds capacity throughout the organisation. Identifying evidence to support practice is a challenge to clinicians. Evidence-based guidelines often lack specificity and were found to be difficult to assimilate easily into everyday practice. Evidence to inform practice needs to be provided in a variety of forms and formats that allow clinicians to easily identify the source of the evidence and then develop local standards specific to their needs. The work that began with this project will continue - all teams felt that the work was only starting rather than concluding. This created momentum, motivation and greater ownership of improvements at local level.

AimThis presentation is regarding a study of the ways in which living with cancer is being formulated by acute sector nurses.IntroductionMore complete definitions of cancer survivorship are emerging as evidence...