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PubMed2001

The national financial adjustment policy and the equalisation of health levels among prefectures.

STUDY OBJECTIVES: The objectives of this study were to examine (1) trends concerning financial assistance from the national government to local governments, (2) trends regarding death rates and life expectancies among prefectures, and (3) the effect of the national financial adjustment policy in equalising both the revenues of local governments and variations in the health levels among prefectures in terms of death rates and life expectancies. DESIGN: The study analysed prefectural income, the amount of national taxes collected, financial assistance from the national government to local governments, and age adjusted death rates and life expectancies of all of the prefectures in Japan during the period from 1965 through 1995. MAIN RESULTS: (1) Under the financial adjustment policy, financial assistance from the national government to the local governments, which consists of the sum of the local allocation tax and treasury disbursements, increased from 1831 billion yen in 1965 to 31 116 billion yen in 1995. (2) During the same period, the age adjusted death rate per 100 000 people decreased from 1168.9 (1965) to 545.3 (1995). The range of variation in the age adjusted death rate among prefectures diminished as the coefficient of variation of the death rate declined from 0.060 in 1965 to 0.043 in 1995. (3) There was a significant statistical correlation between higher prefectural incomes and lower mortality rates during from 1965 until 1975 (p < 0.05), whereas this correlation was indistinct in the 1980s and has not been observed since 1990. (4) The relative health level of Tokyo has declined in terms of its ranking among all the prefectures with regard to life expectancy, from being the best in 1965 to below average in 1995. CONCLUSIONS: The national financial adjustment policy to balance the revenues of local governments has increased the health levels of rural prefectures. It is probable that the policy reduced the disparity in death rates and life expectancies among prefectures throughout the country. However, the policy has precluded the nation's capital city from applying its economic resources as local government expenditures to deal with the megacity issues affecting health.

Financial Support↗
PubMed2001

Joint working, reality or rhetoric?

The UK Government has put the elimination of health inequalities and social exclusion at the heart of its agenda. Partnership working is clearly needed to tackle these issues and has been identified as the way forward in a series of policy initiatives. This paper explores whether, despite the rhetoric, joint working happens in reality. Using the example of the Social Exclusion Unit, a 'cross-cutting' unit developed to work across organizational boundaries, it suggests that centrally joint working is not working effectively. As a result, public health programmes are not being well co-ordinated with wider government initiatives and public health appears to be excluded from much of the work around social exclusion. Two potential reasons are identified: (1) poor co-ordination between the Department of Health and the Cabinet Office; (2) a lack of understanding in the wider community of public health and the role it can play in tackling inequalities and social exclusion. A House of Commons Health Committee is currently examining co-ordination between central government, local government and health authorities in delivering public health. Meanwhile, the public health community must attempt to clarify and, if necessary, market its role and strengths in this sphere. Unless directives from central government are better co-ordinated, local efforts to work in partnership could be undermined.

Community Health Planning↗
PubMed1980

Early detection and treatment of mental and physical disabilities: from the standpoints of maternal and child health care.

Japanese maternal and child health policies and measures have implemental health examinations, health guidances, health educations and medical aids program and so on which aim at the following items: 1) Protection and promotion of pregnant women's and infants' health, i.e. the reduction of mortalities; 2) Prevention of the occurrence of mental and physical disabilities; and 3) Sound development of children. In this paper, our administrative structure, the mass screening program for congenital metabolic abnormalities followed by the medical aids program were mentioned. These activities have been carried out in order to detect mental and physical disabilities in their early stage and to prevent to occurrence and further aggravations of the disabilities through providing good medical care services. First of all, our MCH activities are characterized by smooth relationship and close unity of central government, local governments and voluntary bodies. Concerning the congenital metabolic abnormalities, the screening program was started in 1977. Since then 266 patients were found under this program and along with the medical aids program the screening program has proved effective of the early treatments. Finally, it was briefly stated that establishment of a monitoring system of congenital defects, including establishment of a monitoring center, is seriously considering as an important future project of our MCH policies.

Child Health Services↗
PubMed1997

Community partnerships work.

This adult care program epitomizes the values most recently espoused in debates on health care reform. Public/private partnerships are strengthened by emphasizing unique contributions of all resources of health care: private physicians, private pharmacists, local government, local health departments, community hospitals, business leaders, volunteer free clinics and a private medical school. The success of this program is also contingent on a high degree of patient responsibility. Patients must demonstrate a willingness to share in their care through improved capabilities of self-management. They must share in the cost of their medications, and if there is a propensity to abuse the services (unnecessary ER usage, doctor hopping), they run the risk of termination of services. Expectations are high and patients are being taught how to meet them. The next step is an intensive evaluation of outcome measures. It is felt that this evaluation must extend over a minimum of 5 years in order to be valid and demonstrate trends. We are currently pursuing funding for such an evaluation.

Community Health Services↗
PubMed1997

Washington State reorganization: more of the story.

The creation of a new Department of Health in Washington State in 1989 provided an opportunity for analysis of the many forces beyond the pressure of interest groups leading to such a change. Interviews with key actors from executive and legislative branches of state government, local government, and interested health organizations were conducted to uncover the full scope considered for the new department, and the interactions that led to the final, narrower entity. A process model based on these findings is presented as a useful tool for those seeking to improve public health at the state level through changes in the organizational units responsible for health activities.

Decision Making, Organizational↗
PubMed2000

The National Public Health Performance Standards Program: will it strengthen governance of local public health?

Governing bodies such as local boards of health are the government authority ultimately accountable for public health at the local level. The National Public Health Performance Standards Program (NPHPSP) provides governing bodies guidance in their oversight of the public health system and the provision of essential public health services. Using the NPHPSP's standard guidelines and criteria, local public health governing boards can identify assets and needs for public health improvements, coordinate existing services and programs, and target their advocacy for public health resources. The NPHPSP provides governing boards a means for ensuring that local public health systems coordinate their efforts to improve accountability, quality, and evidence for community health.

Health Policy↗
PubMed2000

Japanese occupational therapy in community mental health and telehealth.

Help for people with mental health problems in Japan has traditionally centred on inpatient medical care. In a revision of the Mental Health Welfare Law planned for 2001, responsibility for the support of people with mental health problems will be transferred from central government to local government. Furthermore, local government will, in turn, delegate administrative tasks to a 'community life support centre'. We believe that such a centre could be linked to a university with a telehealth network. Connection to the network could benefit people with mental health problems living at home. We also believe that occupational therapists are ideally positioned to play a significant role in community life support centres. With the expected sustained growth in Japanese occupational therapy, it could become a key profession in the rehabilitation of people with mental health problems.

Community Mental Health Centers↗
PubMed1987

What governs the decision to contract out for local hospital services?

Increasing hospital costs coupled with increasing numbers of individuals dependent on local governments for health care, at a time of reduced abilities to finance these expenditures, are causing local governments to reexamine their role in the delivery of hospital services. A potentially cost-reducing option for governments is to contract out for service delivery. In this paper we examine the decision of local governments to contract out for hospital services. Factors believed to influence this production choice decision are the cost savings that can be expected from economies of scale or increased competition, the willingness of local officials to trade control for such cost savings, and the political incentives and obstacles to contracting out. Our empirical analysis indicates that the pivotal factors in the contracting-out decision are the availability of external suppliers and the potential for scale economies.

Contract Services↗
PubMed1980

Government attitudes to health education: a crucial factor in effective action.

The author argues that health education, which he defines as dealing responsibly with information about health, cannot effectively cover large groups of population without government support. Community action, both through individuals and groups, and social action of a more organized nature are among the key forces that have an impact on improving health: it is the government's responsibility to provide an administrative and legislative framework that is supportive of such action. Other government responsibilities include: (a) recognition of the role of voluntary agencies and facilitating their participation; (b) sharing information about health and the health consequences of certain practices and behaviours with the entire population, and (c) financial responsibility in developing a policy for health promotion. For the author, the most important form of government is local government which calls for effective participation from within through political elections and administrative processes. Current trends indicate that decentralization, in many countries, is more than lip-service. Such a process has important health implications and is also a major aspect of government support of health education and health promotion. Non-involvement of government in health education is impossible today and a health oriented policy can provide an essential and even crucial framework for community and social action for health.

Attitude↗
PubMed2005

The Environmental Protection Agency's brownfields pilot program.

OBJECTIVE: We studied the diffusion of the US Environmental Protection Agency's national brownfields pilot innovation to more than 300 local governments between 1993 through 2002 to determine why some local governments received grants very early in the process while other awardees received funding later. METHODS: We did an ordinal regression analysis of the characteristics of all local government award recipients, and we conducted interviews with early-award recipients. RESULTS: The first set of local government awardees had lost much of their manufacturing base, had large concentrations of economically disadvantaged minority residents, and had local capacity to compete for funding. Federal and state officials catalyzed the diffusion of the innovation by working with local governments. CONCLUSIONS: The widely praised program was diffused selectively at first and then more widely later on the basis of local need, local capacity to compete, and networks of contacts among entrepreneurs and local governments. The economic, social, political, and public health impacts must be monitored and reviewed.

Environmental Health↗
PubMed2004

Public funding of US syringe exchange programs.

Although there has been no federal government funding of syringe exchange, there is substantial state and local government funding. We report here on program characteristics associated with receiving state and local government funding. Annual telephone surveys were made of program directors of syringe exchange programs known to the North American Syringe Exchange Network. The number of syringe exchange programs known to this network has increased from 63 in 1994-1995 to 127 in 2000. Approximately 80% of programs participated in each of the surveys. Approximately 50% of programs receive state and local government funding, and this has remained constant from 1994 to 2000. Receiving state and local government funding was associated with larger numbers of syringes exchanged per year and providing more on-site services. Among programs that received state or local government funding, this funding accounted for a mean of 87% of the budget for syringe exchange services. In the absence of federal funding, state and local government support is associated with better syringe exchange performance.

Financing, Government↗
PubMed2004

[Factors related to municipality expectations of retaining physicians in public medical facilties].

OBJECTIVES: This study was conducted to investigate the association between municipality expectations of retaining physicians in public medical facilities and their evaluation of the physicians from key aspects considered important for practicing community medicine. METHODS: A cross-sectional study using a self-reported postal questionnaire survey was conducted with all 3,152 local governments in Japan from July to September, 2000. Three thousand and fifty-nine (94%) local governments responded. Of the responders, 1,315 (42%) operated public medical facilities. These local governments evaluated their expectations of retaining physicians in medical facilities and the physicians themselves focusing on the following aspects considered important for practicing community medicine: degree of government satisfaction with the physician's involvement in public health and welfare services; primary care for emergency patients; human relationships between the physician and the population, staff of the facility or the municipal officials; public estimation of the facility; income and expenditure of the facility; understanding of the local government's system. RESULTS: The subjects were 1,092 local governments (83.0%) that responded to all of the questions. The proportion of municipalities expecting to retain physicians was 56% overall, 61% in rural areas and 44% in urban areas (P<0.001). The proportion of governments satisfied with the physicians' human relationships was higher than the other factors and the proportion satisfied about income and expenditure of facilities was the lowest. Multiple logistic regression analysis revealed that the degree of local government expectation of retaining physicians was significantly associated with the physicians' involvement in public health and welfare services (Odds ratio (OR) 1.8; 95% confidential interval (95%CI) 1.3-2.5), their human relationship with the population and public estimation of facilities (OR 1.6; 95%CI 1.1-2.2), and income and expenditure (OR 1.3; 95%CI 1.01-1.8 in all, OR 1.7; 95%CI 1.7-2.4 in rural areas). Primary care for emergency patients demonstrated a significant association in rural areas (OR 1.6; 95%CI 1.1-2.3). CONCLUSIONS: Municipal expectation of retaining physicians in public medical facilities was significantly associated with factors related to the integration of medical, public health and welfare systems, human relationship with the population, public estimation and income and expenditure of the facilities overall. In rural areas, there was a closer association with income and expenditure and a significant association with emergency care. These findings suggest that the local governments' thought related with the expectation of retaining physicians are influenced by their different needs for medical services in community healthcare.

Community Health Services↗
PubMed2006

Encouraging fruit consumption in primary schoolchildren: a pilot study in North Wales, UK.

OBJECTIVE: To explore the feasibility and cost of promoting fruit consumption among primary schoolchildren across Anglesey, a region in North Wales, UK. DESIGN, SETTING AND SUBJECTS: A postal survey of the head teachers of all 51 primary schools across Anglesey to ascertain their attitudes to promoting fruit consumption and current initiatives in place was conducted. This was followed by a 1-week pilot study in a single primary school to assess parents' support and willingness to bear or share costs, to determine children's fruit preferences, and to calculate fruit waste. Finally, the cost to local government of providing a piece of fruit to each primary schoolchild daily was calculated. RESULTS: A 53% response rate was obtained in the postal survey of primary school head teachers. All respondents expressed an interest in participating in future fruit promotion programmes. Of 27 primary schools, 26 that responded (96.3%) had programmes in place in which 18 had adopted specific food policies. In the pilot study at the single Anglesey primary school, a response rate of 97% from parents who expressed support for fruit promotion in school was obtained. Parents expressed their willingness to pay at least 15 pence per day towards fruit provision at break time for their children if such a service was not provided by local government. If local government was to invest in this initiative, the total cost of providing one piece of fruit per day to all primary school children in Anglesey would be 211,000 pounds per annum (2004 prices; 19 pence per child per day). CONCLUSION: This pilot study shows support by teachers and parents for initiatives to encourage primary schoolchildren to eat more fruit. Waste can be minimized by choosing fruit that children prefer, in this study, grapes, apples and oranges. The decision as to whether local government or parents are asked to pay for fruit provision is political, depending on local socioeconomic circumstances, local government priorities, national education and nutrition policies.

Child↗
PubMed1995

The geographical distribution of physicians in Oyo State, Nigeria.

The distribution of physicians in the different States of Nigeria is unknown. Recently, data about physicians and their practice location in Oyo State became available. The overall physician:population ratio was 1:7,858, with a ratio of 1:3,877 in Ibadan local government areas and 1:27,439 in other local government areas in the state (z = 9.32, p < 0.001). Similarly, specialists are more likely to locate in Ibadan local government areas. With increasing supply of physicians, this pattern of distribution may possibly persist and widen the differences in the availability of physicians between the Ibadan and other local government areas in the state. Our findings have important implications for policy review by the government to plan the future supply of physician manpower and alleviate physician maldistribution.

Nigeria↗
PubMed2002

Exemptions and waivers from cost sharing: ineffective safety nets in decentralized districts in Uganda.

The introduction of user-payment for health services is frequently followed by concern about the impact on equity of access for poor people. Decentralizing governments often try to remedy the created inequities by putting in place safety nets in the form of exemptions and waivers in the user-fee systems. However, where user payments merely operate as local government strategies for health financing, without national policy they are likely to be self-defeating, as local governments are frequently more interested in raising revenue to meet recurrent costs of devolved services than in promoting equity. Thus guidelines put in place by the central government to operationalize safety nets are seen by local governments as being contradictory to this goal, and are thus ignored or altered to suit the district revenue aims. This study was carried out to investigate the context and the constraints in implementing exemption schemes. Data were collected in two selected administrative districts of Uganda (Mbarara and Mukono). Qualitative approaches to data collection were adopted, namely focus group discussions and key informant interviews with policy-makers, health administrators, service providers and community members. These methods were combined with document review. We found little evidence of safety-net guidelines initiated by decentralized/local governments, since district local governments had little motivation to extend exemptions, waivers or credits. The conclusion is that safety nets such as waivers and exemptions will only be effective if they are backed by a national health financing policy, they reconcile the often competing demands of local government revenue needs, and are strictly enforced and supervised by both the local and central governments. The implications of the findings for remedying the tension between the needs for cost recovery and for attainment of equity goals through exemption policies for the poor and indigent are discussed.

Cost Sharing↗
PubMed2004

[Community healthcare activities of physicians in public medical facilities and their evaluation by municipalities].

OBJECTIVES: In order to practice appropriate community healthcare activities, it is essential for healthcare providers to integrate medical, public health, and welfare systems into one comprehensive healthcare body. In Japan, local governments are obliged to provide their entire population with public health and welfare services And physicians who work as government employees at public medical facilities play an important role in combining the three systems. It has been reported that the level of subjective evaluation by the municipality of the degree of involvement by physicians in the region's public health activities and welfare services is associated with the standardized mortality rates for strokes in the area's population. However, little is known about which specific public health and welfare services are more important as factors contributing to the level of evaluation of physicians by the people or municipality. The present study was therefore conducted to determine associations between levels of participation by community physicians in each specific public health or welfare service and the respective levels of evaluation by their municipalities. METHODS: A cross-sectional study design using a self-reported postal questionnaire survey was conducted with all 3,152 local governments in Japan from July to September, 2000. A total of 3,059 local governments (94%) responded, and 1,315 (42%) that operated a public medical facility were analyzed. The aspects from which local governments evaluated the physicians working for their public medical facilities were: the frequency of involvement in each of 13 services related to public health and welfare; the degree of satisfaction of governments with the physicians' involvement in each of the services; and the relationship between the physicians and the municipal healthcare officials. RESULTS: The services in which the local governments responded that they 'always' appreciated the physicians involved was significantly associated with the degree of municipal satisfaction. In the multiple logistic regression analysis, the degree of municipal satisfaction was significantly associated with their perception of consistent involvement by the physicians in case conferences on homecare management, health counseling, health education, life style instruction after basic health screening (odds ratio > 2.0 respectively), and school healthcare, vaccination, school health screening, and basic health screening (0 < odds ratio < 1.5 respectively). There was no significant difference in the level of satisfaction between large and small municipalities. CONCLUSIONS: The findings showed that high levels of municipal appreciation of consistent participation by physicians in certain public health and welfare services is associated with a higher degree of local government satisfaction with the physicians. It is noteworthy that services found to be highly associated with municipal satisfaction were concerned with individual affairs or education, and with activities that do not entail any legal obligation.

Cities↗