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PubMed2000

Consumer empowerment as a solution to health system financing.

The health system of the welfare state has basic design flaws. First, it treats citizens as recipients of entitlements that are bestowed on them rather than as sovereign customers who otherwise can choose among an array of goods and services; with uniform health plans, there are no incentives to economise. Second, benefits are provided by government through monopoly schemes; their performance has been dismal when compared with other sectors of the economy that, under competition, have yielded continuous efficiency improvements. Ceaselessly rising costs for healthcare are the consequence. Applying the principles of the market economy to healthcare--and to social security in general--would unleash a vast potential of efficiency gains. The issue in such a reform is equity. Healthcare must be affordable for all. In reconciling efficiency and equity, the cornerstones of this proposal are financial empowerment and individual responsibility; to hand the individual the money required to purchase the current level of benefits--nobody loses--and to leave it to the individual, within bounds, whether to do so. While guaranteeing that everybody can buy the current benefits, the savings from restraint will be the individual's to keep. The reform steps would be as follows: (i) empowerment, (ii) fairness and finance, (iii) safeguard and choice, and (iv) savings to keep. This is a 'consumer model' of healthcare. Efficiency is achieved by privatisation, individual responsibility and freedom of choice on the demand side and by competition on the supply side. Equity is guaranteed by financial empowerment of the individual and a no-loss rule; mandatory minimum insurance would preserve the safety net.

Community Participation↗
PubMed1997

A question of community: at not-for-profit hospitals health is a local affair.

For-profit hospitals' entrepreneurial status, big business climate, and adherence to market discipline mandate that their services be considered akin to any other market commodity, to be bought and sold at the highest margin to the largest audience. Investor owned healthcare's primary allegiance must be a reasonable return to its stockholders and as a result it must avoid unprofitable services and unprofitable patients, by displacing their costly burdens onto the rest of the healthcare system.

Capital Financing↗
PubMed1960

Community mental health services. Operation in San Jose.

Recent attempts to cope with the growing and costly problem of mental illness are progressively emphasizing prophylaxis and early detection and treatment. California has joined this trend forcefully since the passage of the Short-Doyle Act in 1957.San Jose is one of the communities with a Community Mental Health program, financed 50 per cent by the local government and 50 per cent by the State of California. It implements its program by offering consultative services to the city's public health nurses, police officers, teachers, social workers, ministers, sanitarians and members of staffs of a number of public and private agencies.RESULTS OF THE PROGRAM HAVE BEEN: (1) Increased demand for education in mental health; (2) growing number of requests for case consultation in lieu of patient-referral to already overburdened psychiatric facilities, and (3) growing recognition by consultees of the importance of their own self-awareness.

California↗
PubMed1978

Political-economic and professionalistic barriers to community control of mental health services: a commentary on Nassi.

Nassi (1978) described the limits of community control in community mental health centers. This problem can be further understood by exploring the growth of professional dominance and psychiatric expansionism in the 1960s. One consequence was a 'social movement' ideology which psychologized political and economic phenomena, while actually opposing any effective mobilization for community control. Professionals have largely remained unaware and/or unresponsive to these tendencies. Likewise, they have failed to grasp the system of chaos which characterizes mental health policy in the U. S. Mental health care is increasingly falling under professional medical control, State-sponsored rationalization and efficiency planning, and private-profit concerns such as insurance companies and nursing homes. In this way, professionalism and capitalism coincide in their efforts to further their own efforts, while stemming community control in favor of social control.

Community Mental Health Services↗
PubMed2005

Technology and managed care: patient benefits of telemedicine in a rural health care network.

Rural health providers have looked to telemedicine as a technology to reduce costs. However, virtual access to physicians and specialists may alter patients' demand for face-to-face physician access. We develop a model of service demand under managed care, and apply the model to a telemedicine application in rural Alaska. Provider-imposed delays and patient costs were highly significant predictors of patient contingent choices in a survey of ENT clinic patients. The results suggest that telemedicine increased estimated patient benefits by about $40 per visit, and reduced patients' loss from rationing of access to physicians by about 20%.

Adolescent↗
PubMed1981

Reaction of a harassed administrator.

CMHC's do not currently have the capacity to deal successfully with the complex issues of citizen participation in governance, service delivery and evaluation. The primary obstacle is the continuous financial crisis in which the CMHC finds itself, and the associated disparity between special CMHC funding and the funding of mainstream health services. Until the financial dilemmas of CMHC's are solved, citizen participation in their operations will remain problematic.

Attitude of Health Personnel↗
PubMed1987

Health expenditure by area in Finland--an indicator of equity.

The responsibility of organizing and funding health services has in Finland been delegated to small local government units (to 461 communes, average pop. about 11,000), but not to counties or provinces like e.g. in other Nordic countries. PHC is organized by one or few communes and for the specialist level services they have formed 21 Central Hospital Regions (CHR). The central government pays per cent subsidies which are weighted on the basis of income of each community. In 1982 the average share of central government was 44.3% and the communes were responsible for 28.6% of the total expenditure. The national sickness insurance is subventing mainly private services. Its share was in 1982 about 11%. Direct personal costs were about 16%. There are no marked regional differences in the structure of services, e.g. the average share of inpatient care expenditure was 53% and the differences between regions small (z 6%). Total expenditure varied as indexes between regions from 82 tot 119. One reason is the high costs of some university hospitals which do not receive full compensation for services made available to other regions. The expenditure by region did not correlate at all with indicators of ageing. The same can be said of areal differences in income level. Only SMR, a crude indicator of the level of health, correlated positively with expenditure. It is concluded that the areal equity is acceptable if measured with expenditure. The general structure of services does not markedly differ between CHRs. The total health expenditure has been and will remain at the relatively low level of 6.5-7.0% of the GNP. The involvement of small communes is seen as a favourable basis of controlling the expenditure and developing an efficient service system.

Catchment Area, Health↗
PubMed2005

The landscape of community health insurance in India: an overview based on 10 case studies.

The Indian health system is mainly funded by out-of-pocket payments. More than 80% of health care expenditure is borne by individual households. Only about 3% of the population, mostly those in the formal sector, benefit from some form of health insurance. Several Indian Non-Governmental Organisations (NGOs) have initiated Community Health Insurance (CHI) schemes within their existing development programmes. This article describes the principal features of the design and functioning of a selection of 10 CHI schemes and presents a brief overview of the current landscape of CHI in India. The schemes explicitly target the poorest and most vulnerable households in Indian society-scheduled tribes, scheduled castes and poor women. Three CHI management models can be distinguished. The first model consists of local NGOs acting as both insurer and provider. In the second model, the NGO is the insurer but does not itself provide care, which is then purchased from a private provider. In the third model, the NGO neither does provide health care nor acts as an insurer: the NGO, on behalf of a community, links with an insurer and purchases health care from a provider. The benefit packages generally include both primary and secondary care and most of the providers are in the private sector. Most of the schemes require external resources for financial sustainability. There is currently little information on the impact of CHI schemes on the performance of local health systems and more research is warranted in that respect.

Community Networks↗
PubMed2005

Ascribing quantitative value to community participation: a case study of the Roll Back Malaria (RBM) initiative in five African countries.

OBJECTIVES: There are two objectives. The first is to outline the processes involved in the estimation and use of quantitative values to measure community participation. The community participation value (Cp value) is a new concept being introduced in this study. The second is to compare the levels of community participation in the RBM programmes in five African countries, namely, Burkina Faso, Ghana, Nigeria, Tanzania and Uganda. STUDY DESIGN: The study design is based on the Rifkin and Pridmore Spidergram model for assessing the level of community participation in a development programme. METHODS: The methods involved a structured review of web-based and published secondary data. Appropriate indices were used to capture the extent of malaria control in the respective countries. Comparisons were then made between the Cp values and the results obtained for malaria control in order to arrive at a judgement of the significance of community participation to the success of the RBM programmes. RESULTS: The findings from this study showed that community participation was present in varying degrees in the RBM programmes of the different countries. The computed Cp values for the five countries under consideration were as follows: Uganda (12.5), Ghana (10.5), Tanzania (10.0), Nigeria (9.0) and Burkina Faso (8.0). Based on a maximum attainable Cp value of 25, it was observed that the level of community participation in the RBM initiative is still generally low in the countries studied. CONCLUSIONS: Although community participation was present and relevant to the Roll Back Malaria initiative, other factors appeared to have more significant influence on the success, or otherwise, of the initiative. Such factors include the availability of financial resources for malaria control, competent health personnel, and the general health infrastructure available in a given country.

Africa↗
PubMed2003

Community management structures to promote health.

This article describes key requirements of effective health service management that emerge from a review of Australian developments in the respective roles of government and the market. From a public interest perspective, community and industry ownership and management of funds appear superior to market-driven health management approaches. The clear separation of public interest-based policy and administrative functions is vital for effective fund management. Greater transparency, more community input to broadly planned service delivery, casemix funding systems and better outcome data are required to tap the potential benefits of this policy-led model. A pooled funding approach to service provision may assist regional communities achieve their health aims, and the service breadth and flexibility which appear to be necessary to support health and related regional goals.

Australia↗
PubMed1996

Peacekeeping and peacemaking: the conceptual foundations of a plan to reduce violence and improve the quality of life in a midsized community in Jamaica.

Thomas Jefferson noted that social ills breed economic ills and vice versa. An endless regress can occur with violence and mayhem as a chorus: Every community in the world has its own thresholds and patterns of violence, and communities experience varied levels of deterioration of safety with a reciprocal increase in violence. The United States, having undergone 200 years of social evolution as an independent nation, has a spiraling problem with violence. Jamaica, with only recent independence from British sovereignty, is an ideal crucible for the study of evolution of violence in a very young democracy and, hopefully, to identify problems and provide some solutions. Having gained independence from British rule in 1962, Jamaica immediately demonstrated a facile experimentation with forms of government that differed dramatically from what had been previously experienced under the rather rigid, autocratic British administration. In its 33 years of independence, this country has gone through some extraordinary shifts. An initial courtship with Communist theory led to a destructive liaison with Fidel Castro's version of Marxism. During this brief interlude, the intellectual ideals of equality and peace came into direct contrast with facts of a failing Communist regime. During this period, there was a steady exodus of wealthy Jamaican families for whom heavy taxation threatened financial ruin. The prime minister, the Honorable Michael Manley, a highly sophisticated left-wing intellectual liberal, soon realized the political cost of the alliance with his Caribbean neighbor, Fidel Castro, who was then and is now dedicated to old-fashioned, state-controlled Communism. He attempted to return to a free-market democracy with financial foundations that were, by then, very shaky. To succeed in a project to reduce violence and improve the quality of life, the entire community needs to be involved. From our work in countries where community projects were primarily financed by federal and state agencies, we were aware that the participation of private citizens in projects was essential for success. Commitment has an added intensity when personal time and funding is involved. Prime Minister Manley enthusiastically embraced and inspired this project, believing that it embodied the fundamental principles of democratic involvement to which he was committed. When the authors personally presented their plan to him, he accepted it immediately and with an obvious personal sense of urgency. Illness led him to resign the post of Prime Minister in 1993, but his successor, Mr. P.J. Patterson, has continued in the same committed, democratic mode.

Developing Countries↗
PubMed2005

The Human Genome Project: an examination of its challenge to the technological imperative.

Increasingly scientists and governmental policymakers find themselves leaving their laboratories and office cubicles to share information and decision making with the general public. Contributing in large part to the development of science communication via the mass media has been the Human Genome Project (HGP). Examining the development of the HGP in the United States beginning with the early 1970s helps to establish why and how the general public has become a major player in science policy in the United States during the past quarter century, especially in regard to the ethical, legal, and social implications of research on human genetics. Calling into question the technological imperative--the idea that all things scientific must be pursued without question--the general public came to realize that exerting control over research funding is the key to participating in the scientific process.

Attitude↗
PubMed2000

Participants in the Program of All-Inclusive Care for the Elderly (PACE) demonstration: developing disease-impairment-disability profiles.

The Program of All-Inclusive Care for the Elderly (PACE) builds on On Lok's community-based care and financing model for disabled elderly people who are state certified as eligible for nursing home care. Yet PACE's diverse population has not been fully described. We obtained data for a complete cross-section of PACE participants from early 1997 (N = 2,917). Using grade-of-membership analysis, we classified participants on the basis of their specific diseases, impairments, and disabilities. The classification was reviewed by a physician panel to produce clinical profiles, which were then validated against participants' PACE tenure, demographics, supports, and health. Cognitive impairment, incontinence, and activities of daily living disabilities were influential in producing eight types, which correspond predictably to responses in tenure (the more disabled, ill types likely to be in PACE longer), demographics, health, and informal support.

Activities of Daily Living↗
PubMed2001

Collaboration between an internal medicine residency program and a federally qualified health center: Norwalk Hospital and the Norwalk Community Health Center.

In 1999, Norwalk Hospital and an independent, community-based board collaboratively developed the Norwalk Community Health Center (the NCHC). The objectives of the affiliation were to (1) create a new, free-standing, high-quality community health center, (2) optimize grant and clinical revenue, (3) create an ideal venue for ambulatory care training for residents, and (4) replace the traditional and increasingly inefficient hospital-based primary care clinics. The hospital transferred all of its primary care clinical activity to the new community health center and provides an ongoing financial subsidy of the NCHC operations via a forgivable loan. In exchange, the NCHC granted Norwalk Hospital 24% of the seats on its board of directors and purchases all primary care provider services from the hospital. For adult medicine, the contract providers are exclusively Norwalk Hospital internal medicine residents and faculty. Contract charges are based not upon actual staffing but upon a standard formula relating full-time-equivalent providers to patient visits. The new 10,000 square-foot NCHC contains 2,500 square feet of additional integrated space, rented from the NCHC by Norwalk Hospital, which supports the residency education program. The NCHC opened in April 1999 and received FQHC status in November 1999. Adult medicine volume increased 30%, from 36.8 daily visits in the old hospital-based clinics to 48.0 at the NCHC. Resident and patient satisfaction are high. The NCHC now receives cost-based visit reimbursement from Medicaid and has received $1.8 million in state, federal, and local grants.

Adult↗