Public Health Care Provision Research Articles

Welfare State and Life Satisfaction: Evidence from Public Health Care

We examine the effect of publicly provided health care on welfare by combining local level data on public health care, and individual level data on life satisfaction. It is shown that relatively high expenditures in health care have a positive effect on individuals' life satisfaction in our data. We further illustrate how life satisfaction data can be used to directly test theoretical hypotheses about how the welfare effect of public provision should vary among different groups in the population. We find some evidence for an ends-against-the-middle equilibrium (Epple and Romano, 1996) in the provision of public health care, where middle-income individuals prefer higher public expenditure at the margin than low-income or high-income individuals. Further, our results indicate that valuation for health care depends on individual political orientation.

Coping with poverty in the health sector: Evidence from public spending in Thailand

This paper examines whether an increase in government expenditure on health has been accompanied by greater equality between the poor and non-poor in Thailand. In the period 1992-2000, real government expenditure grew on average 10 per cent per annum, the number of health services personnel and facilities increased and the rise was far greater than the growth in population or incomes per capita. However, in the distribution of public resources on health the bottom quintile of the population received disproportionately less government spending. The widening inequality between the poor and non-poor could partly be explained by large differences in the mix of health resources used by each province in the country over time and the associated costs involved. These phenomena imply that improving equity in public health care provision needs to be given higher priority in Government spending.

Food-borne botulism in the United Kingdom

Food-borne botulism is a rare but serious disease caused by ingestions of neurotoxin [botulinum neurotoxins (BoNTs)] produced as a result of the growth of the bacterium Clostridium botulinum in foods before consumption. The disease is rare in the United Kingdom, and only 62 cases have been recognized between 1922 and 2005. This report provides a brief review of C. botulinum and food-borne botulism as well as descriptions of the six episodes (33 cases with three deaths) of this disease that occurred in the United Kingdom between 1989 and 2005. The six incidents illustrate the importance of the risk factors of poor processing or storage of commercially prepared foods, improper home preservation of foods and travel to countries where botulism is much more common than in the United Kingdom. Even small outbreaks of food-borne botulism can precipitate a national emergency and inundate public health and acute care provision. This report provides a reminder to public health professions of the occurrence, diagnosis, treatment and control of this rare but serious food-borne disease.

Freedom-Costs of Canonical Individualism: Enforced Euthanasia Tolerance in Belgium and the Problem of European Liberalism

Belgium's policy of not permitting Catholic hospitals to refuse euthanasia services rests on ethical presuppositions concerning the secular justification of political power which reveal the paradoxical character of European liberalism: In endorsing freedom as a value (rather than as a side constraint), liberalism prioritizes first-order intentions, thus discouraging lasting moral commitments and the authority of moral communities in supporting such commitments. The state itself is thus transformed into a moral community of its own. Alternative policies (such as an explicit moral diversification of public healthcare or the greater tolerance for Christian institutions in the Netherlands) are shown to be incompatible with Europe's liberal concern with securing social and material freedom resources, as well as the concern with equality of opportunity, as embodied in the European Union's anti-discrimination labor law. The essay's argument for the preferability of a libertarian solution closes with the challenge that only if the provision of public healthcare can be shown to be rationally indispensable for a morally justified polity, could the exposed incoherence of modern European liberalism be generously discounted.

Ethische Konflikte im Gesundheitswesen

AbstractThe public good provided by public health care is not the maintenance of citizens’ health but rather the maintenance of the legal order and the citizens’ support for it. Several policy proposals for achieving the aim of supporting the rule of law by minimal means of public health care provision are explored. A system of assigning limited amounts of guaranteed health care that are provided in competitive processes below market clearing prices is suggested. We are seeking for minimum public health care under the constraint of maintaining the legal order rather than solving a maximization problem.

Public Health Care with Waiting Time Revisited

In this model we use delay as a tool to improve income redistribution. Delay makes people with the highest opportunity cost of waiting leave the public health care market. If these, as we assume, are the ones at the higher end of the income distribution, they are made to pay twice for health care: they contribute through income tax, but they address their demand to the private health care system and pay for the care they receive. In this way public and private provision of health care is made mutually consistent within a utility-based approach. Our model extends the results obtained by Hoel and Saeter (2003) to a more general approach and shows that delay may be an optimal tool in the presence of distortionary taxation. However, delay might not always be welfare-improving, even when utility is linear and taxation non-distortionary. We show that this statement applies to the model proposed by HS as well, unless the specific normalisation proposed by the authors is used.

Recent Developments in German Health Law

Health law provides the regulatory constitution for the medical and healthcare system. It covers individual medical treatment as well as public healthcare provision and is insofar medical law as well as social security law (statutory health insurance law). The medical and health sciences (public health sciences) are the main complementary disciplines of health law. This article gives an account of some representative developments in both fields which have taken place in the last three years.

Welfare, environment and changing US-Chinese relations: 21st century challenges in China

Welfare, Environment and Changing US-Chinese Relations: 21st Century Challenges in China, edited by Maria Weber. Cheltenham: Edward Elgar, 2004. xxxii + 181 pp. £55.00/US$90.00 (hardcover). This book explores major domestic social-economic issues as well as external challenges confronted by China. It is divided into two parts: the first includes such outstanding challenges for China as the likelihood of high growth in the coming decade, control of environmental damage during periods of high growth, increasing inter-regional and urban-rural disparities in the reform era, and conflict and cooperation in US-China relations. The second part focuses on issues related to the welfare system, including the size of urban unemployment in the wake of the reform of state-owned enterprises (SOEs), the aging population and the pension system, building an inclusive health care system, and liberalization of insurance services after China's accession to the WTO. Some of the main arguments by individual contributors are quite sensible. For example, Andrea Boltho argues that, given the rise of the US between 1870 and 1913 and the rapid growth of East Asian economies in the post-WWII era, it is possible that China may continue its high growth until 2020 and become the world's largest economy in purchasing power parity (PPP) terms. Giacomo Boati suggests that the statistics on registered urban unemployment in China severely underestimate the real unemployment in China's cities. Given the limited space of this review, I will limit my attention to selected chapters dealing with three key issues - environment, welfare and US-China relations. In Chapter 2, Nicoletta Marigo explores environmental protection and economic growth in China, providing a good overview of the major aspects of environmental degradation in China. She identifies the main causes of these environmental problems and some mechanisms of improvement, including ownership structure, urbanization and heavy consumption of coal for energy. She advances a reasonable argument that China could improve its environment at the current level of income, but the process could be complex and challenging; development of appropriate technology is critical for the success of a cleaner development strategy and active measures are needed to foster the adoption of the right technology options and to support clean development in key sectors. Nevertheless, the chapter relies too heavily on secondhand data and insufficiently utilizes primary data from the Chinese sources, and Marigo's discussion of the economic or opportunity costs for a cleaner path of development is inadequate. In Chapter 7, Maria Weber and Anna Stenbeck offer a useful overview of the evolution of the Chinese public health system in the reform era. This chapter offers a snapshot of the progress of and challenges for China's public health in the past two to three decades. Basically, as the Maoist public provision of preventive and primary health care has given way to an increasingly marketized health care system, patients have had to rely primarily on out-of-pocket payment, instead of social payment and insurance, to cover their health expenses. Weber and Stenbeck also identify major problems in health care in today's China, including soaring medical expenses, growing inequality in health services and over-prescription of drugs and services. …

The role of the military in post-conflict situations

This article considers the possible role of the military in relation to 'post-conflict situations' and helping to improve the health of affected civilian populations. The opinions expressed are personal reflections which draw upon the author's recent military medical experience in southern Iraq in 2004. The perspective of humanitarian aid agencies that have strong reservations about any involvement with the military is recognised, as they seek to maintain neutrality and the safety of their staff. The environment itself, however, may represent an unacceptable level of threat to humanitarian aid agencies, if their personnel are at risk of serious intimidation, e.g. kidnap or murder. Where terrorist and insurgent para-military groups emerge in a post-war fighting phase, it may be that the military is best placed to help co-ordinate efforts to ensure public health and health care provision until a satisfactory level of security is attained and humanitarian aid agencies are able to operate with confidence.

Public health care under pressure in sub-Saharan Africa

Taking as point of departure the need for a strong public health care sector in developing countries the article firstly outlines how in sub-Saharan Africa enhanced scarcity has characterized the content and quality of health care in the public sector. This has eroded the trust among the public in the government as provider of health care and guardian of public health. Secondly, it describes how workers in the public health domain have dealt with the implications of scarcity by etching out a “puvate” zone in health care provision and how these informal activities need to be interpreted as “muddling through”. It also points out what are reactions of clients to a decline in public health care provision. Thirdly, it discusses the changing relation between the state as provider of health care and private sector health care provision at a time of emerging public–private partnerships. The article emphasizes the need for strong health services at basic health centre level. It is at that level that the state has to address problems of scarcity and regain public trust. It also is at that level where major long-term health policies like the imminent large-scale delivery of antiretrovirals (3by5) have to be accomplished.

Medical Photography: a Trinidad Experience

In 1991, the creation of the Media Unit at the St. Augustine Campus, University of West Indies, first established medical illustration as an organized profession within the public healthcare provision of Trinidad and Tobago. Since then the Unit has overcome many difficulties, some of them unusual for medical illustrators in the developed world, not least in obtaining equipment unavailable in the country, in finding suitable working facilities, and in developing practices for veterinary work. Today the Media Unit services a wide range of the University's schools, clinics and media services, and has been instrumental in educating a new generation of healthcare professionals.

Wealth, Health, and Health Services in Rural Rajasthan

What are the determinants of health and of well-being? Income and wealth are clearly part of the story, but does access to health care have a large independent effect, as the advocates of more investment in health care, such as the World Health Organization’s Commission on Macroeconomics and Health (Commission on Macroeconomics and Health, 2001), have argued? This paper reports on a recent survey in a poor rural area of the state of Rajasthan in India intended to shed some light on this issue, where there was an attempt to use a set of interlocking surveys to collect data on health and economic status, as well as the public and private provision of health care.

Public Sector Unions Shaping Hospital Privatization: The Creation of Boston Medical Center

In this paper the author examines, through a case study of a hospital merger in Boston, MA, the ways in which a locally scaled union strategy can shape privatization. She first examines recent economic changes in the US hospital industry, which have resulted in a record number of mergers, closures, and conversions. A case study of the merger between a public hospital, Boston City Hospital, and a private hospital, Boston University Hospital, into the private, nonprofit, Boston Medical Center is presented to demonstrate the ways in which unions can participate in setting the terms of such mergers. The strategy of one labor union local in particular, the Service Employees International Union (SEIU) Local 285, is examined in regard to protecting both the provision of public healthcare and the conditions of employment during and after the process of privatization. By utilizing a local strategy and waging a highly public campaign, leaders of SEIU Local 285 were able to build coalitions with other labor unions and public healthcare advocates and played an instrumental role in setting the terms of the merger. As a result, the final merger agreement contained significant protection for quality public healthcare and labor practices favorable for workers. Unions that previously represented public sector workers now represent private sector workers, and wages for all employees moved upward as part of the agreement. In addition, the new private sector entity was charged with what had formerly been a public sector mission. In effect, although the public hospital was ultimately privatized, the private sector was restructured by local level, public sector union activism.

Do budget-holding physicians respond to price? the case of fundholding in the UK.

In an effort to improve the efficiency of the healthcare sector, some countries have experimented with various forms of 'internal market' in public healthcare provision. In some models, policymakers have assumed that actors will behave, as in a retail market, by responding to price in the course of seeking the best 'value for money' from healthcare providers. In the study reported here we examined the responsiveness of general practitioners to price during the British experiment in general practice (GP) fundholding. The study analysed routine data on 29 423 referrals for elective care made by 129 practices in one city to two competing providers of secondary care. Indices of price responsiveness were calculated for each practice from their manifest referral behaviour. These were then used to compare fundholding and non-fundholding practices. The results showed no difference between these groups in their propensity to respond to published procedure prices, even when potential savings were very large. Our findings are consistent with the reported views of fundholding GPs that price was a secondary consideration in their referral behaviour, and provides further evidence that healthcare markets cannot be understood in simplistic terms.

Women's Reproductive Health & Population Policy: Tanzania

Population policies have rarely been linked to economic policy, although the promoters of economic liberalisation also support the embrace of population policy as important to the economic wellbeing of African states. Using a case study from Tanzania, I argue that population policies with a limited focus on fertility reduction may continue to be successful in the context of post-adjustment African health care systems, but policies that aim for the larger goals of improving women's reproductive health will be severely limited. Tanzania's donors and lenders promoted Neo-Malthusian types of population policies aimed primarily at reducing childbearing as a partial solution to the country's economic crisis. However, in the mid-1990s, the international discourse on population shifted toward a new dependent variable of ‘women's reproductive’ health. The notion of reproductive health reunites population and development issues in the context of basic health care provision. Improvements in the reproductive health of Tanzanian women will require more than simply the effective provision of contraceptives. This article argues that the challenges of improving reproductive health are unlikely to be met without a revitalisation of public health care provision in African countries.

Inequalities in public health care provision in Chile

From 1997 to 1999, the Chilean Ministry of Health conducted studies on the health care networks in each of the country's 13 regions in order to help plan regional health sector development and define investment projects. Health insurance coverage displayed major geographic, age, and gender variations. Out-patient and in-patient medical care in the public sector showed substantial geographic variations. According to patient discharge records from national referral hospitals, only some 20% of total health care capability is used to treat 60% of the Chilean population living in regions outside the Greater Metropolitan area. Analysis of primary care funding shows that municipalities allocating the highest per capita funds are not the ones with the greatest health care needs. New reform proposals must address the issue of complementarity between the public and private health sectors and strengthen the Ministry of Health's leadership role in order for the health system to improve its overall response to the population's health care needs.

La política farmacéutica nacional en Colombia y la reforma de la seguridad social: acceso y uso racional de medicamentos

Based on the new social security system in Colombia (1993), which establishes equity and mandatory care as the basis for public health care provision, the authors analyze whether the formulation and implementation of pharmaceutical policy promote accessibility, availability, and rational use of medicines, thereby contributing to equity in health. Two approaches were used: a macro approach centered on the legal framework and various actors in the reform process and a micro approach related to the processes and results in the drug supply system. The authors studied the legal instruments backing the country's pharmaceutical policy and evaluated their application, using indicators and a specific disease (diabetes mellitus) as a marker. Although there is a legal framework providing the people's right to access health care services and essential medicines, the country lacks a comprehensive pharmaceuticals policy. Most of the institutions experience problems in distributing the medicines listed under the Mandatory Health Plan, a low percentage of medicines is dispensed at zero cost, and a major portion of patients purchase medicines through associations of diabetics or rely on alternative medicine. The study unveiled several obstacles to equity in health care coverage and access to essential medicines.

Poverty and single elders in Hong Kong

This paper proposes a methodology for measuring poverty among people aged 60 years or more and living alone in Hong Kong. It uses a lifestyle approach and is based on an index of subjective perceptions of deprivation consisting of 79 indicators. These cover the main expenditure categories of single elders in Hong Kong: housing, food, clothing, durable goods, fuel and water, entertainment and social activities, medical care and transport. We tentatively identify a poverty threshold of HK $7,000 per month in regard to these expenditure categories. With incomes below $6,000, respondents reduce spending on miscellaneous items and, at incomes of $5,000, they reduce spending on clothing, entertainment and social activities and transport. At incomes below $4,000, they cut down on food, durable goods, and fuel and water expenditure. As incomes drop below $4,000, respondents are forced to cut to a significant degree the ‘necessities’ of life, in particular food, to make ends meet. Despite this, levels of transfer payments to Hong Kong's eligible single elders are currently below this amount. It is noteworthy that respondents do not reduce housing, medical care, services and ‘other’ expenses when their incomes are below $7,000 per month. We conclude that Hong Kong's status as a ‘tiger welfare regime’, and in particular its relatively comprehensive provision of public housing and health care, helps to explain this finding.

Public health‐care provision in the Canadian provinces and American states

Abstract: While there are broad differences between the health‐care systems in Canada and the United States, sub‐national variation is significant in both countries (though more notably among American states), both in terms of the role of government in the provision of health‐care as well as outputs of the health‐care system such as access and cost‐control. Although this variation is rarely considered in comparisons of health‐care policy in the two countries, the value of using the United States as a comparative reference in contemporary policy debates in Canada would be considerably greater if such variations were utilized to augment the analytical leverage resulting from such comparisons.Sommaire: Alors que les différences entre les systèmes de soins de santé au Canada et aux États‐Unis sont importantes, l'écart infranational est considérable dans les deux pays (bien que plus notoire parmi les États américains) aussi bien en ce qui concerne le rôle joué par le gouvemement dans la prestation des soins de santé, que les extrants du système de soins de santé comme l'accès et le contrôle des coûts. Même si cet écart est rarement pris en compte dans les comparaisons de la politique de soins de santé des deux pays, le fait de recourir aux États‐Unis comme point de référence comparatif dans les débats aduels sur la politique au Canada aurait beaucoup plus de valeur si un tel écart était utilisé pour accroître le levier analytique résultant de telles comparaisons.

Competitive health policies and community health

Since 1992 there have been fundamental changes in health care policy in Victoria, Australia, as the state government moves to competitive market models of service delivery and the measurement of service provision through output based funding. The introduction of competitive relationships to the public health system has had a major impact in the primary health care sector, particularly on community health centres. Most community health centres in Victoria have traditionally been semi-independent agencies controlled by community based committees of management. Such policies have had huge implications for the management and organisation of these agencies, as they have led to different patterns of service delivery and different models of management practice, often devaluing traditional philosophical perspectives of ‘primary health care practice’. Although many agencies have embraced change as providing opportunities for growth and development and to have more influence in the provision of mainstream public health care, primary health care models of practice should be supported for their intrinsic and increasing value.