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Neoliberalism, "globalization," unemployment, inequalities, and the welfare state.

This analysis of "neoliberalism" and its economic and social consequences is presented in six sections. Section I begins by describing the impact of neoliberal public policies on economic growth and inflation, on business profits and business investments, on productivity, on business credit, on unemployment and social inequalities, on social expenditures, and on poverty and family debt. The author shows that, except in the area of business profits and control of inflation, neoliberal policies have not proved superior to those they replaced. Section II deals with unemployment and social polarization in the developed capitalist countries. The author criticizes some of the theories put forward to explain these social problems, such as the introduction of new technologies and globalization of the economy, and suggests that a primary reason for these problems is the implementation of neoliberal policies. Section III challenges the widely held neoliberal perception that the U.S. economy is highly efficient and the E.U. economies are "sclerotic" due to their "excessive" welfare states and "rigid" labor markets. The author shows that the U.S. economy is not so dynamic, nor the E.U. economies so sclerotic. Some developed countries with greater social protection and more regulated labor markets are shown to be more successful than the United States in producing jobs and lowering unemployment. The reasons for the growing polarization in developed capitalist countries, rooted in political rather than economic causes, are discussed in section IV--especially the enormous power of the financial markets and their influence on international agencies and national governments, and the weakness of the labor movements, both nationally and internationally. Section V questions the major theses of globalization. The author shows that rather than globalization of commerce and investments, we are witnessing a regionalization of economic relations stimulated by political considerations. He also analyzes the globalization of capital finance, criticizing the thesis that capital markets are determining public policies. The economic determinism that underlies the globalization position is questioned, uncovering the importance of political explanations for understanding major social problems such as unemployment. Finally, section VI shows that neoliberal public policies on the deregulation of labor markets are creating enormous instability in the labor force, worsening the living conditions of the majority of the populations.

Developed Countries↗

[Practitioner's freedom to prescribe in relation to the requirements of the AMM, the medical references and the socioeconomic constraints].

The freedom of prescription is registered in texts which have a legislative value: le Health Code, the social security code, the medical deontology code. The control of prescription conditions for certain classes of medicines meets some economic and Health targets. The authorization to put products on the market concerns the medicines produced industrially. The instructions and opposing medical references are tools that could allow "the medicalized control of Health cost evolution" mandated by the National Convention which links the liberal doctors and the organisms of social protection. Their non-respect can involve sanctions for the doctors who have signed the convention but do not constitute at the very outset a fault in the words of civil liability. The freedom of prescription, information and consent of the patient are undissociable. In the name of freedom the responsibility of the practitioner is involved. The faults are classified in two categories: breach of medical humanism, breach of rules of medical art. The aim of the regulation consists in the optimum prescription. Freedom and regulation go together with professionalism and good citizenship.

Drug Prescriptions↗

[25 years rehabilitation. Questions--answers, unanswered questions--retrospective answers].

Starting out from the 10th World Congress of the International Society for Rehabilitation of the Disabled, held 1966 in Wiesbaden on the subject of "Industrial Society and Rehabilitation", social-legislational developments are out-lined, among them the 1971 accident insurance coverage for pupils, the 1974 rehabilitation harmonization act, and the 1975 extension of social insurance coverage to disabled persons working in workshops for the disabled; problems yet unsolved in the structured system of social protection are pointed out. The problem of "early rehabilitation", still to a very great extent unresolved, is dealt with in the context of the present distinction between "acute medicine" und "rehabilitation" facilities. In rehabilitation of persons with chronic mental illness, numerous models have been developed; a generally accepted, and available approach however has not emerged so far. For ensuring care quality and continuity, the urgent need for community-based availability of the "rehabilitation team" is underlined, and interdisciplinary further education efforts are demanded for all professions in the team, both in facility- and community-based service delivery.

Disability Evaluation↗

[Cancer and demographic transition].

Two phenomena, one of which relates to the area of human reproduction and the other to the frequency, distribution, and control of disease in a population have emerged in the previous century and continue intensively to develop nowadays. Both these phenomena are directly related to the changes which are occurring in the incidence and prevalence of malignant tumours, as well as to mortality from them and to the opportunities for cancer control. The first of these phenomena has been denominated as the demographic, and the second as the epidemiological transition. The commonly accepted definition of the demographic transition is currently applied to designate a sustainable change in the type of population reproduction, when an initial and abrupt acceleration of population growth is replaced by its rapid deceleration with a subsequent stabilization of a population and a sharp change in its age structure. Demographic transition develops in a brief historical space of time and has the character of a global process. Population ageing and disequilibrium between the younger and older generations are the most important consequences of the demographic transition, and must inevitably influence the strategy and implementation of national cancer control programs. As life expectancy increases, so does the certainty that people will become more and more prone to diseases that are more common among older age groups, i.e. noncommunicable diseases and cancer in particular, rather than being affected by epidemics of infectious diseases. This situation is known as the epidemiological transition and reflects spectacular shifts in the pattern and causes of death and morbidity that have taken place in the vast majority of countries over the previous century. Epidemiological transition results in accession by poor countries to the problems of the rich, and leads to the "double burden" of disease in countries whose economies are undergoing transition, because of the still continuing burden of endemic infectious diseases. Russia is entering the final stages both of the demographic and the epidemiological transition, a period when numerous reasons, increasing demands on the systems of social protection and public health are inevitable. During the years 1992 to 2001, cancer incidence increased from 271.8 up to 313.9 per 100,000 population, i.e. a growth of over 16% and an annual rate of growth of 1.7%. According to the global estimates provided by the International Agency for Research on Cancer the number of new cancer cases in the year 2000 exceeded 10 million, and the number of deaths from cancer reached 6.2 million. The annual growth rate of global cancer incidence during the last 25-30 years was higher than the global population growth rate. Analysis of data available from population based cancer registries in Russia and abroad confirms the conclusion that cancer is mainly the fate of people belonging to the older age groups. Given the levels of exposure to specific carcinogens and genetic predisposition factors, the incidence of cancer should be considered as an exponential function of age. The unfeasibility of attempts to change, in the foreseeable future, the rate and trend of demographic transition and demographic ageing, in particular, is obvious. It would therefore be more feasible to envisage their probable consequences and to adapt the limited resources of national health and social support services to the needs of cancer control, which will significantly increase in the near future.

Age Distribution↗

[Some resolutions in difficulties of postgraduate psychiatric education in Japan].

1. Board Certification System of Psychiatry There was a heated debate about "Postgraduate Psychiatric Education and Board Certification of Psychiatry" in the annual meeting for the Japanese Society of Psychiatry and Neurology held in Nagasaki in 1968 and in Kanazawa in 1969. The oppositions of young psychiatrists were as follows; 1) Issues of low cost of medical expense as government politics, social protect politics from psychiatric patients, and improper management of patients in mental hospitals should be dealt before making Board Certification System of Psychiatry. 2) Management of the Society of Psychiatry and Neurology dissatisfies many psychiatrists. Board Certification Systems started in many medical societies from 1969 to 1987. Main nine departments except psychiatry started the system. In 1987, the Japan Association of Chairmen of Department of Psychiatry of Medical Colleges (JACDPM) proposed a program for a postgraduate course. The Japanese Society of Psychiatry and Neurology (JSPN) formed the Committee on Psychiatric Education in 1987 and Working Group on Accreditation Program (WGAP) in 1991 under the Committee of Psychiatric Education. After intensive discussions on the Board certification, the WGAP reported a summary of their discussions in 1994. The essence of the WGAP recommended model for the Board of Association was as follows: Minimal Requirements Outline Training Period--three years psychiatric training after two years primary care experience by rotation through other departments. Field of Training--WGAP recommended that post-graduate training should be given at different kinds of institutes such as the department of psychiatry in medical schools, mental hospitals, out-patient mental clinics, community experiences in rehabilitation, day care, social clubs and health centers. Assessment--both oral examination and case reports are requested for evaluation and board certification. Re-evaluation every five years is required. However, there have been the following opinions and the Board Certification System has not been realized. 1) Making improvement in mental hospital is more important than starting Post-graduate Training and Organization for Board Certification of Psychiatry System (PTOBCP). 2) Starting PTOBCP makes professors in department of psychiatry in medical colleges give great power to suppress the right of personal management. 3) Financial support for postgraduate trainee and trainer is insufficient. Medical and psychiatric situations have changed from 2001 to 2002. 1) A neutral organization instead of academic societies will make Board Certification System in each department in the future. 2) Postgraduate educational rotation system (two years) will start in 2004. 3) Advertisement of being certificated by the Board has been possible. In recent situation, necessity for making of PTOBCP is increasing and many members of JSPN long to make it. In the 98th annual meeting, 2002 it was decided to make PTOBCP. 2. Post-graduate mandatory education system including psychiatry Recently, it was legally decided that post-graduate education for two years should be mandatory for every medical doctor who has passed a national board from 2004. Furthermore, psychiatric training should be mandatory for every rotating resident. The period of psychiatric training is one, two or three months, which depends upon each teaching hospital. It is epoch-making that every resident should receive psychiatric training, however, in other words, it means that psychiatric education in Japan will be re-evaluated through such a new training system.

Certification↗

[The sociomedical problems in the work of flight instructors].

Study of medicosocial problems of pilot instructors revealed their sufficiently good health status which, however, was liable to decrease because of augmenting stress due to poor social protection and difficulties in the training of young pilots. Early professional aging of this group is obvious; it is caused by deterioration of the health status and by destruction of motivation coupled with the pension policy pursued with regard to military pilots. Pilots engaged in the training of young specialists are in need of sociopsychological monitoring and regular and comprehensive measures aimed at health maintenance and rehabilitation. We consider that at present these problems can hardly be solved because of insufficient attention of the state organizations and governmental structures to the present-day situation in aviation. The authors propose measures for regulating the labor of pilot instructors and prophylactic, therapeutic, and rehabilitation measures aimed at reducing the impact of psychogenic occupational factors.

Adult↗

Access to physician services: does supplemental insurance matter? evidence from France.

In France, public health insurance is universal but incomplete, with private payments accounting for roughly 25% of all spending. As a result, most people have supplemental private health insurance. We investigate the effects of such insurance on the utilization of physician services using data from the 1998 Enquête sur la santé et la protection sociale, a nationally representative survey of the non-institutionalized French population. Our results indicate that insurance has a strong and significant effect on the utilization of physician services. Individuals with supplemental coverage have substantially more physician visits than those without. While French patients have greater freedom than patients in other countries to choose to see a specialist rather than a general practitioner, we find no evidence that supplemental insurance affects this decision.

Adult↗

Decentralization and health care in the former Yugoslav Republic of Macedonia.

Since its independence in 1991, the Republic of Macedonia became a highly centralized state, with most relevant decisions taken at the central level in Skopje, resembling the highly centralized system, which once characterized Former Yugoslavia. As agreed in the Framework Agreement, which ended six months of internal conflict, the Macedonian Government will decentralize public services delivery, including social protection, health, education, and infrastructure over the course of the next few years. Within health care, it is argued that by placing policy-making authority and operating control closer to the client, decentralization will reduce some of the inequities in service provision and inefficiencies present within the current centrally controlled system. In principle, local voters will have more information on the price and quality of services, thereby increasing competition in the sector and strengthening the private sector. The emphasis on market incentives resulting in greater efficiency and better management of health care institutions is viewed as one of the benefits of privatization. Critics of decentralization and the subsequent privatization of public services fear it may result in an erosion of quality and consistency across regions, leaving some regions, cities, villages and potentially vulnerable groups worse off than others. The paper argues that if the institutional weaknesses in Macedonia have not been addressed, decentralisation could result in further excluding the rural population from health care provision. Similarly, the need for a clear delineation of responsibilities and functions among different levels and institutions is outlined.

Delivery of Health Care↗

[Obese children and adolescents in Germany. A call for action].

Obesity in children and adolescents has become a major public health issue in our country. Until now this issue has not been sufficiently recognized in our health system. Compared to reference values from the 1970s every fifth school child and every third adolescent in Germany is overweight today. Obesity as a disease is found in 4-8% of all school children. The prevalence of obesity in children and adolescents seems to still be increasing steadily in Germany. Overweight children have a high risk to become overweight adults with a high risk for the occurrence of type 2 diabetes, cardiovascular, orthopedic, and other diseases. Due to the steady increase of the prevalence of obesity in children and adolescents and the consequences, it is expected that the German health system and society as a whole will be confronted with considerable costs. The German Ministry for Health and Social Protection as well as the German Ministry for Consumer Protection, Nutrition and Agriculture have established working groups who will propose straightforward activities in the field of prevention and treatment. Hopefully these working groups will have enough political and financial support that they will be able to establish activities which are effective in counteracting this important health problem.

Adolescent↗

The HIV transmission gradient: relationship patterns of protection.

We describe a gradient of potential HIV transmission from HIV-infected persons to their partners and thence to uninfected populations. The effect of this newly discovered transmission gradient is to limit the spread of HIV. We roughly estimate a 2% long-term transmission probability for sex and 14% for drug injection for two-step transmission. Then we test theories to account for this pattern on a network sample of 267 inner city drug users and nonusers. Although HIV positive persons engaged in a high level of risk with one another, they engaged in less risk with HIV negative partners, and these partners engaged in even lower levels of risk with other HIV negative persons. Analyses suggest that the primary motivation for sexual risk reduction is partner protection, while emotional closeness is the major barrier. Hypotheses accounting for risk in terms of self protection, social norms, gender power, and drug use were weakly supported or unsupported.

Adolescent↗

Preventive involvement in child abuse and neglect by general pediatrician in a military community.

Thirty-three cases among nineteen troubled families of U.S. Coast Guard personnel with problems of child abuse and neglect in Hawaii were managed by joint U.S. Public Health Service, U.S. Coast Guard, U.S. Army, State and County child protection, social and health staff, and local and area-wide lay volunteers. These cases ranged from inaccurate accusations in an emergency room to abdominal gunshot wounds. The preventive role of primary pediatric involvement in community health areas such as pre-school, day care, prenatal infant care education, parent discussion groups, and lay therapists is stressed. The early intervention therapy of pediatric advocacy for social and psychological services to families in stress is emphasized. Continued pediatric leadership for prevention and early intervention is essential in our times of pervasive family breakdown.

Child↗

The influence of system factors upon the macro-economic efficiency of health care: implications for the health policies of developing and developed countries.

This paper aims to clarify the global association of system factors with the attainment of health policy goals, through economic analyses of cross-country data. In the case of OECD (the Organization for Economic Co-operation and Development) data for 1990, the variation in total expenditure on health among 24 countries can be explained by various factors including Gross Domestic Product (GDP). Among these, the variables representing the level of public sector involvement through social protection or public-private mix within a health care system, such as the Public-to-Total Expenditure Ratio, Coverage Rate and Public Cost Sharing, are significantly negative when factors such as GDP are controlled. This suggests that countries attaining higher equity or accessibility are in a better position to gain higher cost-containment or macro-economic efficiency. The results of this study may be helpful for developing countries searching for a long-term health care system as well as for developed countries facing health care system reforms.

Costs and Cost Analysis↗

Racial and ethnic differences in infant mortality and low birth weight. A psychosocial critique.

Recent studies on differences in infant mortality and low birth weight (LBW) among non-Hispanic whites, African Americans, and Mexican Americans were reviewed. Despite similar socioeconomic profiles, infant mortality among Mexican Americans (8/1000 live births) is less than half that of African Americans (18/1000 live births). In fact, the rate for Mexican Americans is identical to that of non-Hispanic whites. The data for LBW follow a similar pattern. What accounts for this unexpectedly low frequency of poor birth outcomes among Mexican Americans, especially given their economic disadvantages, reduced access to prenatal care, and exposure to discrimination based on ethnicity? Does adherence to a traditional Mexican cultural orientation protect otherwise high-risk Mexican Americans from poor pregnancy outcomes, as has been suggested? What is the "protective" social and psychological content of a traditional Mexican cultural orientation? And what are the implications of this line of reasoning for understanding the excess risk for poor birth outcomes among African Americans? This article explores these and related questions and concludes that new conceptual models are needed to guide research in this area.

Black or African American↗

Health system factors impacting on delivery of mental health services in Russia: multi-methods study.

OBJECTIVE: To evaluate how the regulatory environment and health system organisation, financing and provider payment systems influence the delivery of mental health services in the Sverdlovsk region of the Russian Federation. METHODS: A multi-methods study was conducted including analysis of routine data and key informant interviews supplemented by analysis of published literature, legal and regulatory documents, ministerial orders and reports. RESULTS: Mental health care services are still largely provided in hospitals, although the need for more community-based and rehabilitation services is widely recognised. Resource allocation and provider payment systems remain largely unchanged from Soviet times and favour large inpatient institutions, creating incentives for hospitals to maintain a large number of beds and staff. Community-based social services and human resources remain limited, especially in the areas of social work, housing support and vocational rehabilitation, but co-operation across sectors at local level is growing. CONCLUSION: In Russia, the pace of reform in the mental health system will be helped if financial resource allocation mechanisms and provider payment systems are also reformed, so that resources follow individuals regardless of where they are treated. Such major health system shifts can only be achieved through changes at the Federal level and require major political will. Additional transitional funding is also required to help develop the necessary alternative community-based services. The nature of mental health disorders mean that this is not a problem faced within the health system alone, greater attention needs to be placed also on how to maximise the cross sector benefits especially with the social protection and employment sectors.

Delivery of Health Care↗

Complementary health insurance in France. Who pays? Why? Who will suffer from public disengagement?

The study is based on a rare database with information about health status, socioeconomic characteristics and the complementary health insurance choices of the French population. We intend to characterise a two-stage decision process: first, the decision to purchase complementary health insurance, and then the factors related to choice of policy quality. Our econometric study indicates that (i) income level has a strong and significant effect on the decision to purchase complementary insurance, whilst there is no evidence that health risk considerations affect this decision at all; (ii) the individual decision about quality is associated barely if at all with any rational explanatory variables. The population's concrete behaviour, revealed by the study, is consistent with an allocation of low-risk people to private insurance and high-risk people to public insurance. Complementary insurance is not especially relevant to patients with serious diseases, who depend much more on the public system. If the public insurance system were to disengage significantly from coverage of serious illness, a vacuum would be created that would leave people at high risk without full coverage. These results have broad implications for numerous national systems of social protection seeking a new mix between private and public insurance.

Adolescent↗

Fear of crime, mobility and mental health in inner-city London, UK.

This paper examines the relationship between fear of crime and mental health, and assesses the role interventions may have in helping overcome any negative impact arising from this fear. The data were gathered over a 2-year period in the Gospel Oak neighbourhood of North London using in-depth interviews, focus groups and participant observation. The data are analysed primarily by comparing the impact of fear of crime across sub-groups notably divided by gender, age and mental health status. It was found that fear of crime had a disproportionately negative impact on certain sub-groups, most notably low-income mothers, and to a lesser extent the mentally ill. They experienced what we term "time-space inequalities" as a consequence of fear of crime and other related factors. These inequalities describe variation in the ability to access and utilise different times and spaces within both the immediate and the wider environment. These have negative behavioural and affective consequences that appear to impact on overall mental health. They restrict spatial and temporal movement deterring protective social activity, health-promoting community involvement and use of services. Affective consequences include negative mood and low self-esteem. These inequalities were experienced less in other groups such as mentally healthy men or middle-income women. They appeared to be diminished by interventions that encourage spatial and temporal movement. These include comprehensive local transport, government-issued free travel passes for vulnerable populations and neighbourhood community safety measures such as the installation of CCTV. We suggest that experience of time-space inequalities may be damaging to mental health and that interventions which lessen them may help prevent, ameliorate or shorten episodes of mental illness.

Crime↗

Is precarious employment more damaging to women's health than men's?

Current global economic trends in both developed and developing countries, including unregulated labor markets, trade competition and technological change, have greatly expanded a complex labor market situation characterised by many employees working under temporary work status, job insecurity, low social protection and low income level. Although the health of women is disproportionately affected by workplace flexibility, this has been largely ignored. The main purpose of this paper is to draw attention to this relevant but neglected topic.

Economic Competition↗

Evidence-based health policy: three generations of reform in Mexico.

The Mexican health system has evolved through three generations of reform. The creation of the Ministry of Health and the main social security agency in 1943 marked the first generation of health reforms. In the late 1970s, a second generation of reforms was launched around the primary health-care model. Third-generation reforms favour systemic changes to reorganise the system through the horizontal integration of basic functions-stewardship, financing, and provision. The stability of leadership in the health sector is emphasised as a key element that allowed for reform during the past 60 years. Furthermore, there has been a transition in the second generation of reforms to a model that is increasingly based on evidence; this has been intensified and extended in the third generation of reforms. We also examine policy developments that will provide social protection in health for all. These developments could be of interest for countries seeking to provide their citizens with universal access to health care that incorporates equity, quality, and financial protection.

Health Care Reform↗