Health Policy Objectives Research Articles

Challenging Themes in American Health Information Privacy and the Public’s Health: Historical and Modern Assessments

Protecting the privacy of individually-identifiable health data is a dominant health policy objective in the new millennium. Technological, economic, and health-related reasons substantiate the development of a national electronic health information infrastructure. Through this emerging infrastructure, billions of pieces of health data of varying sensitivities are exchanged annually to provide health care services and service transactions, conduct health research, and promote the public’s health. These multi-purpose, rapid exchanges of electronic health data, far removed from the typical disclosure of health information through the doctor/patient relationship of yesteryear, contribute to heightened individual concerns about identifiable health data. Responding to American fears and perceptions of actual and potential privacy abuses, policymakers have recently developed new, modern privacy protections through legislative and regulatory laws, as well as ethical and industry codes.Modern health information privacy protections are reflected in federal regulations developed by the federal Department of Health and Human Services (DHHS) pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Maternal drug use and the timing of prenatal care.

This paper explores the role of maternal drug use and the timing of prenatal care. The study data were collected from women delivering live births at eight participating hospitals in the Washington, D.C., Metropolitan Area Drug Study. An estimated 16.9 percent of the women in this sample initiated prenatal care in their third trimester or received no prenatal care. After adjusting for age, race/ethnicity, education, parity, and attitude toward pregnancy, cocaine use was strongly associated with the timing of prenatal care. Using multivariable ordinal logistic regression, the data suggest significant barriers to prenatal care for substance abusers, especially cocaine users. Increasing access to prenatal care continues to be an important public health policy objective, particularly in urban areas where substance abuse is prevalent. Health services research must test strategies that address the timing of prenatal care among drug-dependent, urban women.

How will urology cope with the new health care system?

According to the report 2000 issued by the expert advisory committee on the health care system, improvement in performance requires, among other things, awareness of the need for more economic efficiency, better quality of medical care, and definition of targets. Disease prevention and early diagnosis are the main objectives of health policy and practice. Data mining becomes an important tool in epidemiological and clinical research. Urologists are called upon to engage in clinical studies to establish therapeutic standards and guidelines. Results of research must be put in to practice faster. Doctors ought to respond to changes in patients' attitudes.

Governing the Healthy Body: Discourses of Leisure and Lifestyle within Australian Health Policy

In the past 30 years there have been significant shifts in the way Australian public health policy has problematized the role of leisure, recreation and physical activity in relation to the WHO identification of lifestyle disease risks to individual and social wellbeing. This article offers a cultural analysis of the way discourses of leisure and healthy lifestyles have been produced through the governmental objectives of health policy and promotion aimed at the body (Foucault, 1991; Rose, 1999). Two campaigns (1970’s Life be in it! and 1990’s Active Australia) are examined in relation to the rationalities and ethics through which individuals are encouraged to govern their own healthy lifestyle practices in the name of freedom.

Trends in the rural-urban distribution of general pediatricians.

A major objective of national and state health policy has been to increase primary care physician supply in rural areas. It is not known whether this objective has been met for general pediatricians. This study examines trends in the rural-urban distribution of general pediatricians in the United States from 1981 to 1996. Descriptive serial cross-sectional study. At selected 5-year intervals, all clinically active general pediatricians in the United States listed in the American Medical Association Physician Masterfile. The proportion of pediatricians practicing in rural counties and the ratio of pediatricians to the child population (per 100 000 children <18 years old) for US counties. Between 1981 and 1996, the total number of general pediatricians increased from 19 739 to 34 100. However, rural pediatrician-to-child population ratios (PCPRs) remained well below urban ratios. Although rural counties of all population sizes experienced some gains over time, only those over 25 000 populations had a meaningful increase in their PCPR. Overall, the urban PCPR increased by 14.0 (or an additional pediatrician for every 7150 children) whereas the rural ratio only increased by 4.1 (an additional pediatrician for every 24 400 children). The percentage of recent residency graduates opting for rural practice declined by half (14.6% to 7.4%) over the 15-year study period. Women and international graduates were consistently less likely to practice in rural counties than were men and US graduates, respectively. The near doubling in general pediatrician numbers from 1981 to 1996 yielded only a modest increase in pediatrician availability for rural children. The discrepancy between urban and rural pediatrician supply increased during this period and should continue growing based on the increasingly urban location of recent residency graduates and the continued growth of women in pediatrics. New policy strategies are needed to improve rural pediatrician availability, including focusing on larger rural counties and addressing barriers to rural practice for women. pediatrics/manpower, pediatrics/trends, rural health, physicians/supply and distribution, medically underserved area.

On health inequality.

The UK Labour government has attempted to bring the issue of health inequality into the public policy debate. For example, soon after its election in 1997, the government commissioned the independent Acheson inquiry. The Acheson inquiry team had a remit to review the latest available evidence on health inequalities and were also asked to identify priority areas for future policy development. The resulting Acheson report proposed 39 recommendations to alleviate health inequalities, with the recommendations relating to a broad array of public policy (e.g. measures relating to poverty, education, housing, nutrition and the health service, among others). In the year that the Acheson report was published, the government released the consultation paper, Our healthier nation. The two key health policy objectives stated within the consultation paper are to improve general population health and to narrow health inequalities. This provided further evidence of the government's concern in this area. The government's interest in alleviating avoidable health inequalities has also led it to review the capitation formulae that are used to allocate funds to health authorities. Traditionally, these formulae have been based on the concept of providing equal access to health care services for equal need. However, it has often been argued on a theoretical level that this concept may actually exacerbate health inequalities, and that in order to narrow avoidable health inequalities, greater positive discrimination towards those with relatively poor expected health is required. It is less clear how this can be achieved in practice; hence, the results of the capitation review are eagerly anticipated. Moreover, a host of other measures introduced by the government, such as the national minimum wage, may directly or indirectly serve to narrow the health differentials. Clearly, the government does appear to be paying some attention to health inequality, but what is the extent of this problem?

Ideas, institutions, and resources.

�� Simply put, the goals of any health care system in an advanced industrial democracy are threefold and manifest: (1) provide good care to (2) pretty much the whole population (3) without breaking the bank to do so. The corners of this triangle are quality, equity, and cost. While these combined goals may be manifest, they are also manifestly tricky —p erhaps virtually intractable —i n all the societies under investigation here in this issue. As Jean-Pierre Poullier and Simone Sandier summarize for the French case: “health policy objectives are straightforward and widely shared. . . . [But] mismatches between intent and outcomes have been observed throughout; the future holds more unknowns. Broadly speaking, we can identify two general approaches to the seeking of these health care system goals. The first approach, especially evident in the United States, emphasizes the role of private forces, which may or may not be market ones. These forces interact in a fairly free manner over time to end up resulting in a system—de facto rather than by any overarching design. In this system, the role of the government, or state, is relegated to the margins, a minor referee guarding against some but not all outrageous inequities, perhaps ineffectually coaxing some parties along. Ideologically, in this system, health care is not a “right” or a “due,” but rather a private good, to be obtained according to the individual’s means. The goals-oriented result of such a system has been to (1) provide lots of extremely top-quality care (“rescue medicine”) to (2) only segments of the population, leaving behind other large swathes, while (3) spending

Scandinavia's lessons to the world of public health

The Scandinavian Journal of Public Health embarks on a new phase, under the editorship of Professor Stig Wall. It is timely, then, to consider what unique contributions might be made by the journal. Certainly, the Nordic countries, with their highly regarded universities and well-developed research centers, have much to share with the rest of the world across the broad spectrum of basic science, clinical medicine, and population research. However, much of this excellent research is not unique to this part of the world and it is the thesis of this editorial that, in the area of public health, Scandinavia can play a leading role in shaping contemporary thought. The Scandinavian Journal of Public Health should therefore provide a forum for description and discussion of public health issues in the Nordic context, not only for the bene®t of the Nordic community but also to help those of us from other parts of the world who wish to better understand the theory and practice of public health. Epidemiology and public health have recently been criticized for taking an increasingly smaller role in shaping health policy. Reliance by contemporary epidemiology on ``the black box'' (1), ``the web of causation'' (2), ``risk factorology'' (3), and other paradigms has, according to some thinkers, limited the ®eld's ability to meet new challenges to population health. The increasingly individualistic approach within a medical model causes public health in some countries, such as the US, to be subsumed as another medical speciality, rather than as a primary goal of public policy and social values (3). Others worry about the future of epidemiology (4) and believe that public health is in transition (5). If so, then where will we ®nd the science and experience to choose the best course? This increasing insinuation that public health may be irrelevant raises the need for model systems to examine more collectivist and holistic approaches as alternatives to the individualistic, medical approaches. It is possibly safe to say that the Nordic countries have traditionally taken a much more comprehensive and societal approach to health in general, and public health in particular. To illustrate this, let us contrast two recent policy documents outlining national health strategies for the next decade ± one for a Nordic country (Sweden) (6) and the other for the United States (7) (Table I). The ``Green Paper'' describes the public health strategy for Sweden and sets down, possibly for the ®rst time, public health objectives that address the actual determinants of health and disease at the societal level. Objectives 1 ± 4 and 6 ± 13 deal with broad issues of economic disparity and poverty, homelessness, unemployment, non-participation in political decision-making, personal development, workplace environment, segregation, education, and care of the elderly. Only seven objectives deal with speci®c diseases and health-risk behaviors. Nonetheless, all 19 objectives have quanti®able indicators for ful®llment of each objective. In stark contrast are the Healthy People 2010: Health Objectives for the Nation, released in January 2000 by the Department of Health and Human Services of the United States (7). These objectives also have two overall goals: (i) to eliminate health disparities (between groups de®ned by gender, race/ ethnicity, income and education, rural location, disability, and sexual orientation), and (ii) to improve the quality and years of healthy life. While the goals suggest broad societal changes and determinants of health, the focus areas of Healthy People 2010 largely address a biomedical model. Of the 28 objectives, 23 describe health issues that deal with speci®c diseases or risk behaviors, with de®nable indicators, usually entailing reduction in speci®c mortality or prevalence estimates. These two sets of health policy objectives for the ®rst decade of the 21st century suggest a fundamentally different approach to public health operating at different levels of social integration and organization. According to the biopsychosocial model of Engel, health is determined by a series of levels of process (8). According to this model, the Swedish Public Health Plan is operating at the level of society and culture, whereas the American plan is generally operating at

Equity and gender

Gwatkin's paper provides an excellent historical review of the developments in thinking and research with regard to health inequalities and the health of the poor. More importantly, the paper provides a thought-provoking analysis of the impact of those developments on policy and its implications for health inequalities and the health of the poor. I agree entirely with Gwatkin's conclusion that there has been a puzzling disconnection between policy discourse and the setting of health policy objectives and that this disconnection has severely limited the impact of health policies and programmes in reducing health inequalities or solving the health problems of the poor. The central thesis of Gwatkin's paper is that health goals based on societal averages without an effort to incorporate distributional differences in health conditions across the socioeconomic classes do very little to meet the needs of the poor. I would like to add that the setting of health targets based on societal averages also masks gender differentials and thereby fails to deal with the gender-based health inequities that take a great toll on the health of women. In India, for example, using under-five-year-old mortality rates in aggregate form as an indicator of health status would mask the fact that the deaths of girls in this age group exceed those of boys by nearly 330 000 annually (1). Although Gwatkin acknowledges gender inequalities in health status when discussing the dimensions of inequality that matter most, he restricts his recommendation for disaggregated goals to the socioeconomic dimension. It could be argued that because women constitute about 70% of the world's poorest people, disaggregation by socioeconomic status and the pursuit of health goals that specifically target the poor would automatically include the needs of women. But just as Gwatkin argues that using a pro-poor target, such as reducing under-five-year-old mortality by one-third, may not result in any appreciable improvements in the conditions of the poorest, it could be argued that a target to improve the health status of the poor without explicit goals to improve women's health may likewise run the risk of completely missing the health needs of the most vulnerable and the poorest of the poor -- women. Poor women suffer the interactive consequences of two of society's most persistent and damaging inequities, poverty and gender. If the goal of health policy is to reduce health inequalities, it is imperative to set explicit goals for improvements in women's health. Meeting gender-based health goals, however, will only be possible with an approach that addresses the gender-specific sociocultural and economic factors that increase women's vulnerability to illness and infection and restrict their access to health care information and services. For example, women's use of health services has been found to be impeded by sociocultural norms that restrict their mobility or limit their participation in household decision-making (2). Research on human immunodeficiency virus/acquired immunodeficiency syndrome has also shown that economic dependence and income insecurity act as significant constraints for women who want to adopt preventive practices such as the use of a condom, if these go against the wishes of their male partners (3). …

GPs and Contracts: Bringing General Practice into Primary Care

This paper argues that the terms on which GPs entered the NHS, as self‐employed contractors, have proved remarkably resistant to the managerial pressures which have come to dominate other sections of the National Health Service. However, this traditional mode of financing and organizing the delivery of a key element of the National Health Service has become increasingly incompatible with wider health policy objectives—the development of an integrated network of good‐quality, equitable and well‐coordinated primary and community health services which are responsive to local needs. Furthermore, primary health services have themselves come to play a crucially important role in securing other strategic changes in the wider health policy arena, such as securing and sustaining a shift in the traditional balance between hospital and community‐based health services and controlling expenditure in a needs‐led service. The paper argues that, notwithstanding the change of government, the 1997 NHS (Primary Care) Act and the White Paper “The New NHS” are both integral to the achievement of wider strategic health policy objectives, such as improving the quality and coherence of services, and increasing professional accountability for the financial consequences of clinical decisions. However, the greatest significance of these and other related measures is that they shift the emphasis of health policy from commissioning and purchasing by primary care to commissioning and contracting for primary care. They thereby extend the exposure of GP‐based services to managerialist scrutiny and control.

Social movements as catalysts for policy change: the case of smoking and guns.

Social movements organized around perceived threats to health play an important role in American life as advocates for change in health policies and health behaviors. This article employs a framework drawn from social movement and related sociological theories to compare two such movements: the smoking/tobacco control movement and the gun control movement. A major purpose of the article is to identify specific social movement ideologies and actions that are more or less likely to facilitate achievement of the movement's health policy objectives. The article concludes that the success of health-related social movements is associated with (1) the articulation of a socially (as well as scientifically) credible threat to the public's health, (2) the ability to mobilize a diverse organizational constituency, and (3) the convergence of political opportunities with target vulnerabilities.

Management and Quality Control

The economic approach of the industrial and commercial sector cannot be transferred to the medical one without proper measures. The final objective of the health service is not to gain profits but rather to achieve results in terms of health. Professional quality and, therefore, appropriateness becomes the foundation for proper management. In turn, appropriateness means to do the right things when they are useful regarding both the organisational, administrative, educational and training aspects and the medical ones. Management control is the right answer to this challenge to know and monitor consumption, strategies and results in relation to preestablished administration health policy objectives. Its purpose is to allow the organisation to carry out its objectives with the highest effectiveness and efficiency possible and it is joined with technical-professional elements which orient and support management in a logic of total quality. The adoption of the process of management control does not mean to turn doctors into managers. It must be hoped that doctors will understand the economic implications of the decisions made at clinical level as well as the technical-organisational ones. A medical action becomes effective if it is part of a system in which each person involved carries out his duties in an integrated logic where relationships are clearly defined. To decide what is appropriate, one refers to what is known and proven. It is clear that the problem of quality must be faced firmly and systematically. The activation of a quality program is not only based on the definition of "good practice", in terms of procedures, protocols, pathways and reference parameters for measuring quality but rather on the introduction of clinical methods that can guarantee a series of highly important opportunities.

Public health, private genes: The social context of genetic biotechnologies

The last decade has seen rapid discoveries in the genetic basis of disease associated with the Human Genome Project (HGP). Understanding the social (including legal, ethical and political) impact of these findings, however, lags far behind. This paper addresses the social context of biotechnologies arising out of this project as well as the tension between the individual and collective uses of these technologies. The danger is that, in the context of a global trend towards conservatism, the ideology of genetic reductionism is legitimizing the abandonment of collectivist responses to social problems in favour of the promotion of individualist ones. In seeking to pursue health policy objectives of reducing premature morbidity and mortality more traditional public health concerns are in danger of being marginalized.

The need for longer term psychiatric care in medium or low security

AbstractThe provision of long‐term inpatient care for some mentally disordered patients is one objective of mental health policy. Because medium‐secure units were established in England with the objective of patients staying between 18 and 24 months, longer term care in secure conditions in England and Wales has mainly been provided by the high‐security (special) hospitals. There has been very limited provision specifically designed for patients needing longer term psychiatric care in security below the levels of the high‐security hospitals. This has led to patients being detained in inappropriate levels of security or in acute wards when rehabilitative care is more appropriate. A survey of all patients in all high‐ or medium‐secure units in England and Wales in December 1994 by questionnaire to their consultants showed that of some 1500 patients in the high‐security special hospitals, 490 would be more appropriately placed in longer term medium security and 150 in longer term low security. Of some 1250 patients in the current shorter stay medium‐secure units, 183 were considered to need longer term medium security and 278 longer term low security. To these must be added those in the general psychiatric service who need local/low secure care, perhaps 1300 in England. Overall there appears to be a need for some 750 beds in England and Wales offering long‐term medium security and 2000 beds offering longer term low security. Copyright © 1997 Whurr Publishers Ltd.

Health policy versus industrial policy in the pharmaceutical sector: the case of Canada

This paper analyses the trade-off between health policy and industrial policy objectives in the field of pharmaceuticals in the Canadian policy setting. In Canada pharmaceutical regulation is organised in two tiers. The federal government is responsible for the conduct of industrial policy for the pharmaceutical sector, including the patenting of new molecular entities, the registration and approval of pharmaceutical products, and the pricing of new products. At the province level, policy-makers are responsible for the reimbursement of the cost of medicines; the methodologies implemented for this purpose may be greared towards meeting the objective of cost containment within tight health budgets rather than addressing industrial policy objectives and, thereby, supporting the pharmaceutical industry. The reimbursement methodologies implemented may also be related with the strength of pharmaceutical presence in each province. The paper provides evidence from two such provinces, British Columbia and Ontario, and contrasts pharmaceutical policy-making at the provincial level with that at the federal level.

Avoidable morbidity in infants. A classification based on diagnoses in administrative databases.

A hierarchical classification for avoidable morbidity in infants was developed based on a conceptual model for causes of morbidity. Experts rated the impact of risk factors and health services on diseases coded according to the International Classification of Diseases, 9th Revision, Classification Modification (ICD-9-CM). An etiologic framework was chosen for the classification because knowledge of etiology often suggests strategies for prevention. Causes of morbidity that cluster on the basis of similar risk factors might be avoided using similar strategies. Diseases (346 different diagnoses) were rated by 16 general pediatricians; 12 attributes were considered, including the impact on disease occurrence and on severity of five risk factors, preventive health services, and medical treatment. Raters evaluated the impact of health services, constitutional risk factors, and environmental risk factors without regard for service site (eg, inpatient, emergency department, primary care office). Environmental risk factors categories, including family, social, and physical environments, were rated separately. The impact of health services was rated on prevention, treatment, and complications of care. Only ratings indicating that the impact of a risk factor category was substantial were used for the final classification of 275 diagnoses. Consistent with the multifactorial etiology of many diseases, many diagnoses had ratings indicating substantial impact of multiple risk factors. Five mutually exclusive clusters were derived from the 12 ratings based on factor analysis and recognized strategies for prevention. Ordered by level of avoidability, these clusters were termed vaccine-preventable, health-care quality indicators, environmental, environmental/constitutional, and constitutional. The usefulness of this classification for policy-oriented epidemiologic and health services research is grounded in the premise that prevention is the cardinal objective of child health policy. Cluster-specific hospitalization rates, ie, rates aggregated for all diagnoses falling in a cluster, might be used for allocating resources to interventions directed at environmental or health service determinants of morbidity. Widespread use of ICD-9-CM codes in hospital discharge and ambulatory databases suggests many potential applications for this classification of morbidity burden in population groups.

Health care cost containment

The prime objective of health policy is to improve the health of the population. This must be done with limited resources and at costs that do not impose an unsustainable burden on the economy and its international competitiveness. This is the crucial question to answer: Is the performance of the economy sufficient to allow further development of health services? If the answer is, no', then the affordability of health care has to be maintained through cost containment. The aim of cost containment (or cost control) is to contain the escalation of health care cost in real terms, or in relative terms as opposed to economic growth. Cost containment is a response to the imbalance between the resources generated by the economy end the health system needs (thus not necessarily health needs). This imbalance proves, inter alia, by growing health care expenditures as a percentage of GDP.

A pay-for-performance system for civil service doctors: the Indonesian experiment.

In 1980 the Government of Indonesia proposed the introduction of a pay-for-performance system, the Functional Position System (FPS), for certain occupational categories of civil servants to provide a career development path and stimulate productivity (Government of Indonesia. Government Ordinance No. 3, 1980 Concerning Appointment to Civil Service Rank. Jakarta, 1980). The FPS, a bold pay concept in the civil service, links pay to skills and performance. In 1987, instructions were issued for doctors to be included in the system (Government of Indonesia, Credit Scores for Doctors. Circular Issued by the Ministry of Health and the Agency for Administration of the Civil Service No. 614/MENKES/E/VIII/1987 and No. 16/SE/1987). In this paper we evaluate how well the system-which in principle could be applicable to both developed and developing economies--can meet its stated objectives for Indonesian doctors working in the community, and for Indonesian health policy objectives as stated in the country's last five-year development plan "Repelita V" (Government of Indonesia. The Fifth Five-year Development Plan (Repelita V) 1989-1994. Jakarta, Indonesia, 1989). The FPS is particularly innovative in the Indonesian environment where wages are low and comparatively uniform, reflecting a philosophy of 'shared poverty', and vary primarily by seniority. The FPS has, however, several conceptual and practical shortcomings. The design of the reward system disregards effort or time inputs, as well as other inputs needed per unit of reward. Consequently, the FPS can not be used as an effective incentive system promoting professional excellence and health policy objectives. Practically, the system hardly provides an effective alternative for career development among community physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

Care of the Chronically and Severely Ill: Comparative Social Policies.

Because most severely and chronically ill people will receive care outside of hospitals or nursing homes, there is increasing recognition that the integration of community-based care, including home care, must be an objective of health policy. Contributors explore the structure of community-based and home care, along with the ways in which services are provided at one or all of the following levels: central government, state or provincial government, local government, and the private sector.

Forming the system of health insurance in the Russian Federation

A radical reform is being prepared in the Russian Federation health care. Its major point is a transition from tax-financed national health system to social health insurance. The paper highlights the issues of forming the system of health insurance. First, the arguments for a transition to a new model of finance are discussed. Secondly, the concept of the new model and its implementation in the context of the regional experiment are addressed. A discussion of current and expected developments focuses on two major issues: monopsony or pluralistic model of third-party purchasing? What is important for forming the market of health care provision? The major argument is that a transition from a highly integrated to a contractual model may start with regional monopsony or some version of it. A pluralistic model of third-party purchasing needs a refined regulation and may not meet health policy objectives. It is also argued that on the first stage of reform implementation forming the market of health care provision is more dependent on its regulation and management than on the market structure of health care purchasing.