Care Policy Development Research Articles

Change and Continuity in State Administration: Administrative Leadership across Four Decades

governments are the keystones of the federal system. This assertive metaphor takes on added significance as the states are increasingly challenged by Supreme Court decisions, fiscal pressures, federal mandates, selective devolution, and policy implementation complexities. The political challenges must be addressed in the broad arena of electoral politics by governors, legislators, courts, and other constitutional or institutional actors. But few, if any, political problems do not translate into policy issues that pose questions of administrative organization and implementation. It is therefore appropriate to focus on administrative structures and leaders in the American states. Governors may set the tone and the temper of major issues on a state's agenda. Legislators and courts regularly address a panoply of particular problems. Most of what state government does from the standpoint of public policy and problem resolution, however, passes through the operational structures of state administrative agencies. The number, variety, and significance of these agencies, and especially their leadership, deserve greater attention. The quantitative and qualitative growth of state government has been visible but largely neglected in the administrative arena. We argue for enhanced attention to administration in the states. Our point about the neglect and inattention to state administration should be placed in proper context. The Public Administration Review (and many other journals of the same kind) reflect an increased awareness of state policy issues and functions. State finances have gained a deserved share of visibility, including borrowing (Hildreth, 1993), debt (Bahl and Duncombe, 1993; Regans and Lauth, 1992), fiscal stress and financial crises (Bahl and Duncombe, 1992; Cahill and James, 1992; Kee and Shannon, 1992; Joyce and Mullins, 1991), and budgeting (Lee, 1991, 1997; Rodgers and Joyce, 1996; Stanford, 1992, 1993; White, 1993). Major domestic policy issues have likewise been addressed from a state-level orientation. These issues include health care policy (Jones and Johnson, 1995; Leichter, 1992; Shumaker, 1995), Medicaid (Buchanan, Cappelleri, and Ohsfeldt, 1991; Schneider, 1988; Schneider, Jacoby, and Coggburn, 1997), and economic development (Burnier, 1991; Reed, 1994; Waits, Kahalley, and Heffermon 1992;). The states have also been the focus of an array of particular cross cutting issues that are common or longstanding administrative questions. Included in this category are issues such as strategic planning (Berry, 1994; Berry and Wechsler, 1995), gender (Bullard and Wright, 1993; Guy, 1993; Kelly, et al., 1991; Riccucci, 1994), and personnel practices (Hays and Kearney, 1992; Jaegal and Cayer, 1991). Despite the range and relevance of the above issues to state government and administration, there are significant gaps in this literature. Limited focus on state administration exists from two standpoints: (1) the overall structure(s) for administration in the states, and (2) the characteristics or attributes of administrative leadership in the states. Also missing is a long-term perspective on state administration. Recently, selective attention has been devoted to short- and long-term shifts in state administrative structural and organizational features (Bowling and Wright, 1998; Cox, 1994; Elling, 1992; National Commission, 1993; Thompson, 1993). Changes in those structural features form the context for this micro-level analysis of administrative leaders in the American states. We document trends, features, and qualities of top-level state executives (agency heads). Prior to presenting findings and interpretations about state administrators we offer brief observations about the general significance of public administration in state government. The Significance of State Administration There are multiple reasons why the administrative status and capacity of the states are of major significance. …

Neuroleptic drugs and good practice in care homes

The development of community care policies has enabled many older people to remain in their own homes, supported by a range of health and social care services. However, for some older people, care in a residential or nursing home may eventually be necessary. As the average age of older people in care homes has risen, so too has the prevalence of dementia among residents, which is variously estimated at occurring in between 50% and 80% of older people in care homes (Schneider, 1997). This raises many issues about best practice in caring for people who may have complex needs relating to both physical and mental health and to social care. One such issue is the use of neuroleptic drugs, which are also known as antipsychotics or major tranquillizers.

Implementation of Aged Care Policy in the Australian Federal System

In 1983–84 the Commonwealth and state governments trialled the introduction of the geriatric assessment team (GAT) program. Twenty years of Australian Health Ministers' Conference (AHMC)1 minutes and records (1969–88), files within the Queensland and Commonwealth health departments (1983–88) and interviews with major stakeholders revealed that implementation can extend over many years and can require a confluence of factors for a policy idea to come to fruition. This article examines the dynamics involved in the implementation of the GAT policy and reveals that expert advisers played a central role in policy innovation and implementation and that the federal system could both obstruct and facilitate policy implementation. While there was evidence of delay and conflict, the Australian states through their expert advisers were significant contributors to the development and implementation of aged care policies. Many of the intergovernmental relations were often characterised by a high degree of cooperation at least at the officer to officer level. The ‘coercive’ nature of the federal system may need to be revisited.

Child Care in Canada and Sweden: Policy and Politics

An analysis of child care arrangements provides a window into the varying gender asumptions that underpin different welfare states. This paper examines policies affecting child care (both daycare and maternal or parental leave) in Sweden and Canada. Child care arrangements in the two countries differ in ways that the literature on welfare states leads one to expect. It would be a mistake, however, to stop here with the “liberal” Canadian and “social democratic”. Swedish models frozen in time and space. Child care arrangements are historical products, and unfinished ones at that. In this paper I analyze the politics surrounding the development of postwar child care policies in Sweden and Canada. I argue that, although child care arrangements in the two countries appear to fit the models developed by theorists who focus on the relative strength and strategic capacity of national labor movements, feminists, organizing in ways appropriate to the political conditions in which they found themselves, had an important role to play. The final part of the paper examines the contemporary developments in both countries.

The Relationship Between Ethnicity and Advance Directives in a Frail Older Population

To assess the relationship between ethnicity and Health Care wishes, including Advance Directives, in a group of frail older persons in PACE (Program For All Inclusive Care Of The Elderly). Retrospective chart review of 1193 participants in the PACE program. Program of All Inclusive Care Of The Elderly (PACE), a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation. A total of 1193 older adults, all of whom met state criteria for nursing home level of care. There were 385 non-Hispanic whites, 364 blacks, 156 Hispanics, and 288 Asians. Presence or absence of advance directives, type of health care wishes selected including living will, durable power of attorney, and health care proxy. Frail older white, black, Hispanic and Asian Americans differ significantly in their health care wishes and how they choose to express them. Blacks were significantly more likely to select aggressive interventions and less likely than non-Hispanic whites and Hispanics to utilize a written instrument for expressing health care wishes. Whites were significantly more likely to utilize written documents for advance directives, whereas Asians were more likely to select less aggressive interventions but were unlikely to use written advance directives. In this population, we found significant ethnic variations in choice of health care wishes. Although health care wishes are an individual decision, an awareness of cross cultural patterns can assist practitioners in addressing the concerns of their patients, as well as assisting Health Care Policy Development.

Continuing care: policies and implications

Continuing care policy developments are affecting nurses in all sectors. The RCN District Nurses’ Forum invited Hazel Heath, Chair of the Association for the Care of Elderly People (ACE), to lead a seminar at RCN Congress to discuss the implications

The development of Ontario's Home Care Program: A critical geographical analysis

In order to gain a greater breadth of understanding medical geographical issues, such as medically underserviced regions, medical geographers are paying more attention to health policy. Using existing evaluations, an historical analysis of home care programs in Canada's largest and most populous province informs how developments in long-term health care policy have contributed to the geographical inequalities that exist in home care services throughout the province. The geographical bias in the testing, planning and implementation of home care programs has influenced their availability, accessibility and quality in the underserviced region of northern Ontario. Exploring the history of long-term care policy in Ontario also sheds light on the contemporary politics of welfare reform taking place in much of the western world. In many western countries, home health care has moved from being a complementary or alternative form of long-term care, to the favored form of long-term care. The most recent long-term care policy reform in Ontario points to the decentralization of long-term care, a strategy that has already been in affect in some western countries.

Developing a plan for primary health care facilities in Soweto, South Africa. Part I: Guiding principles and methods.

The new political era in South Africa offers unique opportunities for the development of more equitable health care policies. However, resource constraints are likely to remain in the foreseeable future, and efficiency therefore remains an important concern. This article describes the guiding principles and methods used to develop a coherent and objective plan for comprehensive primary health care facilities in Soweto. The article begins with an overview of the context within which the research was undertaken. Problems associated with planning in transition are highlighted, and a participatory research approach is recommended as a solution to these problems. The article goes on to describe how the research methods were developed and applied in line with the principles of participatory research. The methods were essentially rapid appraisal techniques which included group discussions, detailed checklists, observation, record reviews and the adaptation of international and local guidelines for service planning. It is suggested that these methods could be applied to other urban areas in South Africa and elsewhere, and that they are particularly appropriate in periods of transition when careful facilitation of dialogue between stakeholders is required in tandem with the generation of rapid results for policy-makers.

Becoming strangers: the changing family caregiving relationship in Alzheimer's disease

Alzheimer-type dementia (AD) is an insidious pervasive debilitating disorder that destroys the affected person's capacity for self-care. In this grounded theory study, we explored the reciprocal process of becoming strangers in which eastern Canadian family caregivers and care recipients with AD interact on a continuum from intimacy to alienation through dimensions of dawning, holding on and letting go. The findings illuminate the experiences of family members who struggle on a daily basis with their commitment to the person they knew and their increasing detachment from the stranger that person has become. With the increasing emphasis on home care, these findings offer insights for individual care and health policy development.

Primary Health Care: A Darling Downs Focus

ABSTRACT: Primary health care is a policy model Which integrates social principles into the functioning of the health system at the local level. There is increasing interest in primary health care policy development and in the implementation of primary health care due in part to: the challenge which primary health care raises to existing practice in health service planning and delivery; the changes in roles of health service professionals and consumers which primary health care demands, and the claims on resources which the implementation of primary health care may engender.The conceptual basis of primary health care demands that decision‐making be devolved to the local level. The organisational structure of the public health care system in Queensland, since regionalisation in July 1991, provides an environment which favours this localised decision‐making. The Darling Downs Regional Health Authority, one of 13 regional health authorities in Queensland, released a ‘Primary Health Care Discussion Paper’ as an element in its strategy for primary health care implementation at the regional level. This paper was intended to demystify the concept, raise the level of debate and stimulate discussion about how primary health care might affect health professionals and the community.This article analyses that discussion paper to illuminate the concept of primary health care emerging in the region and in Queensland Health. It also identifies potential barriers to the implementation of primary health care and outlines activities being undertaken in the region which illustrate ways in which primary health care can be manifested in local communities.

Giving Consumers a Say in Policy Development: Influencing Policy or Just Being Heard?

This paper focuses on the trend to involve consumers in public policy-making and implementation. The development of long-term care policies for elderly people in Ontario is examined as an illustrative case to explore the purposes and accomplishments of such initiatives. Building upon analysis of policy documents, observation of a community consultation process and debates in the literature on consumer participation and on the politics of needs interpretation, it is suggested that government-initiated participatory strategies elicit only particular kinds of information from consumers and do not live up to their democratizing promise.

The influence of class on aging policy: Why catastrophic was repealed

Though painful for many in the political arena, the events leading to the repeal of the Medicare Catastrophic Act of 1988 were an inevitable outcome of social and political forces. Passage of the act implied a presumption by political leaders and others that older Americans should be more altruistic than other age groups, abandoning their interests and ideologies for the good of those in need. The repeal represents a benchmark in future social policy development, particularly as it pertains to the development of long term care policies.

An Evaluation of the First Public Health Service Primary Care Policy Fellowship

In June 1991, the U.S. Public Health Service sponsored a 3-week Primary Care Policy Fellowship to establish an interdisciplinary cadre of primary care leaders. The fellowship was designed to introduce senior-level practitioners, academicians, researchers, and adrninistrators to the dynamics of primary care policy development, the legislative process, and resource identification. An evaluation was conducted to determine expectations and reasons whyfellows participated in the fellowship, analyze the degree ofperceived learning, identify the sessions of most value, and describe the personal goals achieved by thefellows relating to their future leadership responsibilities in primary care. The 18 fellows most highly valued the networking across primary care disciplines, the sessions with constituency groups, and discussions about influencing decision makers. The leadership skills development activities particularly met their expectations. Theirskills were improved in identifying ways to influence policymakers, in locating resources for primary care research, and in networking with primary care leaders.

Developments in alcoholism treatment.

Alcohol treatment systems expanded and diversified considerably over the past decade. This reflects adaptation to a variety of forces, including developments in national health care financing and policy, changes in other health care systems with which alcohol treatment had strong ties, the more diffuse effects of social movements and a "drying trend" in American public opinion, as well as agitation by advocacy and provider groups within the alcohol field. Drawing on national monitoring data, this chapter reviews developments at the levels of financing policy, organizations, client populations, and treatment modalities, documenting expansion in private sector alcohol treatment units, a growing emphasis on providing outpatient treatment, a merger between services for alcohol and drugs at the organizational and conceptual levels, increases in service delivery to coerced populations, as well as demographic change in alcohol treatment caseloads during the 1980s.

Contemporary health care and the colonial and neo-colonial experience: the case of the Dominican Republic.

This article traces the development of health care policies in the Dominican Republic from their colonial and neo-colonial roots to contemporary times. The Dominican case exemplifies the unique historical processes by which its health policies were created and maintained, and simultaneously, reflects the political and historical forces that shape the Caribbean as a whole.

Who's taking care?

This paper presents a profile of 1,337 caregivers of brain impaired adults in California. The findings are based on the first statewide descriptive study of caregivers and patients across diagnostic categories of brain impairment. Regardless of the type of patient brain impairment, caregivers were found to have similarly high levels of depression, burden, and fair to poor physical health. Implications for long term care policy and service development are discussed.

Gender equality versus motherhood ideology: Child care policy implications

Recent early childhood care and education policy developments in New Zealand provide a clear example of how the unresolved conflict between a recently emerged ideology of gender equality and a deeply entrenched ideology of motherhood has affected child care policy developments in a number of industrialised nations. In New Zealand, optimistic reviews of the policies proved to be unfounded. The lack of interface with other policy areas, poor methods of implementation, and policy reversals have dampened the anticipated gains in funding, worker status, quality and equity of access. As the New Zealand example shows, despite a great deal of activity in the area, progress towards a public model of child care, as towards a changed role for women in society, has been minimal.

Understanding the central–local relationship in health care: A new approach

One of the basic assumptions of governmental health planning policy is that the government can effectively take final responsibility for the development of the health care system. Failure to reach policy goals is explained in terms of inadequate planning technology and instruments to control implementation. In this article an alternative explanation is offered, based on the theory of strategic organizational behavior. According to this theory, the government must be seen as but one actor in a complex interorganizational network. From this, a different perspective on effective health planning policy is developed. Policies will fail if they are not based on a valid analysis of the policy space of health care institutions and the interdependencies between government and health care organizations. This article starts with an outline of the nature of the central-local relationship as seen from the perspective of strategic organizational behavior theory. Next, this theory is used to frame two cases in which Dutch health care institutions successfully pursued their own strategies that ran counter to the existing health planning policies. The article ends with a discussion of the implications of the theory of strategic organizational behavior for the development of effective central health care policies. This development starts with a thorough analysis of the policy space and interdependencies of all relevant actors in the health system, the government included. Following, policy makers can set the governmental goals and then have to start negotiations with health care institutions about mutual adaptation of their strategies and the governmental goals. The result is a negotiated health care order.

Caring for Caregivers: The Multicultural Respite Care Project

As part of an evaluation of Adelaide's Multicultural Respite Care Project, a sample of thirty caregivers was interviewed to obtain information about their needs, responsibilities and expectations, their assessment of the Project and its impact on their caregiving role and their knowledge of available support systems. A profile of caregivers was also obtained, yielding information about such factors as age, gender, health status, the nature of the care being provided and the range of responsibilities faced by caregivers. The findings emerging from the study are described and their implications are related to current aged care policy development.

The development of health care policies in Trinidad and Tobago: autonomy or domination?

This article is part of a study that described and analyzed the development of nursing education in Trinidad and Tobago from self-government in 1956 to 1986, with special emphasis on the forces that helped to shape the society from colonial times, and consequently, nursing education. Adaptation and application of major concepts from theories of underdevelopment and development and colonialism formed the basis of the study's theoretical framework. The article focuses on the impact of the metropolitan countries on the development of health care policies. Because of the nation's historical legacy of colonialism and its current linkages with the United States and Canada, a major area fundamental to the analysis was to determine whether those two countries had superseded traditional British influences in determining health care policies. This raised the issue of whether or not health care policies could be autonomously developed to meet the needs of the people.