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PubMed2003

Death, taxes, public opinion, and the Midas touch of Mary Tyler Moore: accounting for promises by politicians to help avert and control diabetes.

Anthropologists have begun to publish ethnographic accounts of policy-making, but few have studied medical or health matters, despite broad acceptance in anthropology that "biopower" permeates contemporary societies. This article presents some findings from an ethnographic study of how diabetes gained recognition as a pressing public health problem in Canada. It underlines the importance of statistics for constituting power within and across nation states. Statistics imbricate people and things distributed across vast distances, but they still need to be generated and invoked by individuals to engender effects--as illustrated in this article by the contributions of researchers, aboriginal leaders, and an American actress, Mary Tyler Moore--in this case, the development of Canadian government policies justified in the name of averting and controlling diabetes. To make sense of these findings, subtle differences between two concepts coined by Michel Foucault, "biopower" and "governmentality," seem significant.

Anthropology, Cultural↗
PubMed2000

The anatomy and relations of evidence-based medicine.

Current tensions between evidence-based medicine (EBM) and some clinicians are counterproductive and unnecessary. The most contentious issues concern (a) the limitations of efficacy data from randomised trials as evidence; (b) differences in attitudes to medical diagnosis and clinical judgement; and (c) political concerns about the use of the concept of clinical evidence and guidelines to restrict physician autonomy. Health services research has evolved in response to a bureaucratic need to study health care, including clinical practice, in order to improve its effectiveness (defined mainly in terms of technological interventions), and to contain costs. Its perspective is from the top-down representing the interests of bureaucracy and managed care, and articulates with political demands for professional accountability and cost-containment. EBM has established its place as an important contributor to the methodological toolbox for health services research. There is a need for a corresponding coherent programme of clinical practice research which would locate EBM in the clinical environment beside quality assurance, the study of the appropriateness and effectiveness of interventions, and multidisciplinary research related to the art of medicine and supportive aspects of clinical care. EBM would then be seen as one organ in relation to many others making their contribution to the body of knowledge needed for clinical decisions and policy making. A 'centre for the study of clinical practice' would be an appropriate structure to support such a comprehensive programme of clinical practice research in a tertiary hospital. The bottom-up perspective of clinical practice research would complement the current top-down perspective of most health services research, providing information to doctors, patients and administrators concerning local quality of care and health outcomes, information which could also be aggregated for guidance of health policy makers. It would also represent the voice of the clinician in policy debates. Such a programme, located in the practice environment, would also foster mutual understanding, respect and cooperation between workers from different backgrounds.

Clinical Competence↗
PubMed2003

The SAZA study: implementing health financing reform in South Africa and Zambia.

This paper explores the policy-making process in the 1990s in two countries, South Africa and Zambia, in relation to health care financing reforms. While much of the analysis of health reform programmes has looked at design issues, assuming that a technically sound design is the primary requirement of effective policy change, this paper explores the political and bureaucratic realities shaping the pattern of policy change and its impacts. Through a case study approach, it provides a picture of the policy environment and processes in the two countries, specifically considering the extent to which technical analysts and technical knowledge were able to shape policy change. The two countries' experiences indicate the strong influence of political factors and actors over which health care financing policies were implemented, and which not, as well as over the details of policy design. Moments of political transition in both countries provided political leaders, specifically Ministers of Health, with windows of opportunity in which to introduce new policies. However, these transitions, and the changes in administrative structures introduced with them, also created environments that constrained the processes of reform design and implementation and limited the equity and sustainability gains achieved by the policies. Technical analysts, working either inside or outside government, had varying and often limited influence. In part, this reflected the limits of their own capacity as well as weaknesses in the way they were used in policy development. In addition, the analysts were constrained by the fact that their preferred policies often received only weak political support. Focusing almost exclusively on designing policy reforms, these analysts gave little attention to generating adequate support for the policy options they proposed. Finally, the country experiences showed that front-line health workers, middle level managers and the public had important influences over policy implementation and its impacts. The limited attention given to communicating policy changes to, or consulting with, these actors only heightened the potential for reforms to result in unanticipated and unwanted impacts. The strength of the paper lies in its 'thick description' of the policy process in each country, an empirical case study approach to policy that is under-represented in the literature. While such an approach allows only a cautious drawing of general conclusions, it suggests a number of ways in which to strengthen the implementation of financing policies in each country.

Decision Making, Organizational↗
PubMed1999

Health technology assessment and the regulation of medical devices and procedures in Quebec. Synergy, collusion, or collision?

In this paper, we discuss the complex relationship between health technology assessment (HTA) and the regulation of medical devices and procedures. The relationship is first examined through a conceptual framework describing the itinerary from research to three levels of policy making: micro (standards of medical practice), meso (institutional rules), and macro (health policies). Four reports from the Quebec Health Technology Assessment Council (CETS) are used to illustrate how HTA activities can influence the regulatory mechanisms operating at each decision-making level. We then discuss the skillful balancing act required from HTA agencies to constantly negotiate the right distance from the regulatory process at which to operate. We propose that HTA agencies should not be incorporated into any regulatory, auditing, or monitoring process. Finally, the relationship between health technology assessment and health care reform is discussed. It is suggested that HTA activities will contribute most during the data-driven preparation and consolidation phases of a reform process. The fast pace of events and the political turmoil characteristic of the implementation phase provide a less receptive environment for HTA contributions.

Equipment and Supplies↗
PubMed1978

The acquisition and utilization of technical information by administrative agencies.

Through a review and integration of the heretofore rather distinct literatures dealing with (1) policy making in administrative agencies, (2) the use of scientific and technical information in public policy, and (3) the utilization of policy research, this paper develops preliminary conceptual frameworks of the variables affecting the acquisition and the utilization of technical information by administrative agencies. Although previous research, based largely upon case studies of a few decisions within a single agency, has resulted in numerous bivariate hypotheses, the number of variables involved and recognized problems of generalizing the results suggest that future research be oriented toward a number of strategies capable of simultaneously examining the effect of numerous variables over large numbers of cases.

Decision Making↗
PubMed2006

A novel system for environmental monitoring through a cooperative/synergistic scheme between bioindicators and biosensors.

This paper addresses environmental monitoring through a robust dynamic integration between biomonitor and biosensor systems, a strategy that has not been attempted before. The two systems are conceptually interrelated and methodologically correlated to a cooperative/synergistic scheme (CSS) with a view to minimise uncertainty and monitoring costs and increase reliability of pollution control and abatement. The structures and operations of the biosensor component (in terms of sensitivity, device and method versatility, nature-mimicking physicochemical mechanisms, prospects and technological input) are such that they reinforce or promote the structures and operations of the natural component (in terms of bio-surveillance, impact assessment, environmental quality indexing, stress responses, metabolic pathways, etc.) and vice versa. The bioindicator ontology presented herein, including concepts, relations and controlled vocabulary aiming at establishing an integrated methodology for mapping/assessing negative environmental externalities, provides a useful tool for the design/development/implementation of an environmental network for the monitoring of a variety of pollutants over time and space and the assessment of environmental quality; the collection of the available information and its classification into taxonomic and partonomic relations allows the construction of a database that links pollutants with organisms' response, at a phenomenological and in-depth level, considering ecological parameters, relations and geomorphologic characteristics. As a result, a computer program has been designed/developed as a decision support system and has been successfully tested on a representative population of species indigenous to southern Greece. Significantly, a novel system in the form of a rational framework at the conceptual design level has been developed, that actually contributes towards achieving a cost-effective long-term monitoring program, with the flexibility to counter on-course any (anticipated or not) variations/modifications of the surveillance environment. This novel and pioneering approach will further offer a dynamic system utilised in (a) environmental impact studies and risk assessment (positive/analytic approach), (b) decision-making in the short-run (normative/tactic approach), and (c) policy-making in the long-run (normative/strategic approach). The proposed CSS, based on the integration of multiple data sources, can establish a local area network, incorporated into/expanding to a wide area network, thus offering the potential of better predictive ability and greater lead-time warning at alarm conditions than that provided by separate, stand-alone surveillance modalities.

Biosensing Techniques↗
PubMed2005

The impact of the HIV/AIDS epidemic on hospital nurses in KwaZulu Natal, South Africa: nurses' perspectives and implications for health policy.

During a stay in South Africa in 2002-2003, we learned that public sector nurses dealt with serious community and workplace impacts from the HIV/AIDS epidemic; and were reluctant to report occupational exposures to HIV or take a short-course of antiretroviral post-exposure prophylaxis to prevent HIV infection. In May 2003, in South Africa's KwaZulu Natal province, we explored perspectives of 34 public hospital nurses in nine group interviews on workplace safety; the impact of HIV/AIDS on nurses' work environments; and, hospital and government policy. The information they provided illustrates that the views of nurses are vitally important to policy-making. We conclude that seeking nurses' views and involving them in policy processes could contribute to worker health, to addressing the dramatic shortage of nurses, recently identified as the largest threat to providing HIV/AIDS treatment in sub-Saharan Africa, and to improving quality of care.

Government Regulation↗
PubMed2005

Vitamin A deficiency and child mortality in Mozambique.

BACKGROUND: In areas where vitamin A deficiency (VAD) is prevalent, vitamin A repletion reduces child mortality by 23% on average. OBJECTIVES: To estimate the potential child survival benefits of policies and programmes aimed at controlling VAD in Mozambique, and to make policy and programme recommendations. METHODS: The potential contribution of VAD to child mortality in Mozambique was estimated by combining the observed VAD prevalence in the under-5s (71.2%), the measured child mortality effects of VAD (risk of death in children with VAD=1.75 times higher than in children without VAD) and the observed under-5 mortality rate in the country (210 per 1000 live births). RESULTS: In Mozambique, an estimated 2.3 million children below the age of 5 years are vitamin-A-deficient. In the absence of appropriate policy and programme action, VAD will be the attributable cause of over 30,000 deaths annually in the under-5s. This represents 34.8% of all-cause mortality in this age group. DISCUSSION: Vitamin A supplementation (VAS) has been adopted as a short- to medium-term strategy to control VAD in children, and is integrated into routine child health services. However, the last VAS coverage survey showed that only 46% of children received a vitamin A supplement in the 6 months preceding the survey. If VAS coverage is to increase significantly in the foreseeable future, four areas appear to be of paramount importance: (1) reduce missed opportunities for VAS such as visits of sick children to child health services and community outreach activities; (2) take advantage of all potential opportunities for accelerating VAS coverage, such as additional vaccination campaigns and emergency response activities; (3) strengthen health workers' training, supervision and monitoring skills; and (4) increase community demand for VAS of children. Biannual VAS, as the primary component of an integrated strategy for VAD control in children, has the promise to be among the most cost-effective/high-impact child survival interventions in Mozambique.

Cause of Death↗
PubMed1998

Florence Nightingale. Passionate statistician.

Nightingale's passionate commitment to statistics was based on her faith in a god of order, who created a world that ran by law. God's laws could be known through research, as a result of which suitable interventions to better the world could be applied. Statistics were a vital component in her holistic approach to health care as a system. They served both to indicate serious problems and to assist in policy making, and then again to monitor the effects of the new policies. She pioneered the use of evaluative statistics and saw reforms achieved as a result of her advocacy. This article explores three key aspects selected from Nightingale's more than 40 years of applied statistical work: her adaptation of Quetelet's methodological foundations, the use of statistics in monitoring public health care systems, and her pioneering study of maternal mortality in childbirth.

Clinical Nursing Research↗
PubMed1995

Balance billing under Medicare: protecting beneficiaries and preserving physician participation.

Medicare's experience with balance billing provides valuable lessons for policy making for national or state health care reform. Medicare developed several policies to encourage physicians to become participating providers who accept Medicare-allowed charges as payment in full. Only nonparticipating physicians are permitted to bill for additional amounts beyond that paid by Medicare, and there are limits on the amount of balance billing per claim. As shown by the analysis of claims presented in this article, Medicare has successfully provided financial protection to beneficiaries. In 1986, more than 60 percent of expenditures for physician services were on assigned claims for which there could be no balance billing; by 1990, 80 percent of expenditures were on assigned claims. Balance billing decreased by about 30 percent during the same period. Although these policies have been successful in reducing total expenditures for balance billing, they may not provide financial protection to the most economically vulnerable beneficiaries. Using survey and claims data, we found that the poor have lower balance billing expenditures for services provided by primary care physicians, but that there is no relationship between poverty status and balance billing expenditures for services of nonprimary care physicians. In addition, most low-income beneficiaries are liable for balance bills. Under health care reform, adoption of Medicare's incentive-based approach with mandatory assignment for the poor would allow for some choice based on price and would provide financial protection for all consumers.

Aged↗
PubMed1993

A measure of growth. A system's corporate ethics committee assesses its accomplishments and future direction.

In 1992 the Sisters of Mercy Health System (SMHS) Corporate Ethics Committee (CEC) developed a three-step evaluative process of the system's ethics programs. The evaluation consisted of a retrospective review of the minutes of CEC meetings since the committee's inception, an oral evaluation with current CEC members, and a written assessment of the committee's performance by current and former members. In the open discussion, 86 percent of participants indicated that the system needs the CEC because it facilitates in-depth examination of ethical issues and provides important research and consulting services to the system executive. Respondents completing the written evaluation indicated that the CEC's dominant strength is the diversity of its membership, which includes trustees, physicians, ethicists, nurses, administrators, managers, and chaplains. More than 57 percent of respondents reported the CEC has achieved all six of its goals, which included education, articulation, decision making, policy development, program development, and evaluation. A review of the CEC evaluation suggests that the committee has moved beyond the development stage and entered a period of active growth. CEC members have made great strides in educating themselves, and the committee must now consider whether to broaden its focus by developing its knowledge base and skills for bioethical education and policy recommendations. The CEC is currently testing an ethical decision-making model it recently developed.

Bioethical Issues↗
PubMed1991

The relation between policy and research planning.

The crucial role of total exposure assessment (TEA) in environmental epidemiology, risk assessment, risk management, and disease diagnosis and treatment has been appreciated only in recent years, and then by a relatively small number of policy makers and scientists. Thus TEA is a relatively new research field with a limited data base. As a result, research needs cover a broad range. However, setting research priorities with limited resources is a problem. Agencies usually develop criteria to set priorities. The criteria often have at least one element in common, namely, that the research be compatible with policy goals. However, policies are developed, at least in part, using research data, thus making policy and research planning an iterative process. TEA, by definition, is related to multi-media and multiple routes of exposure. Because of this, research planning can be hampered by differences in policies of programs dealing with different media and routes of exposure. Thus it is important to develop better ways to facilitate communication among policy makers, research planners, and researchers. This paper will argue that one such way is the proper use of the basic scientific tenet of hypothesis testing in planning, executing, and evaluating research. The paper will discuss this tenet, and recommend that exposure researchers use it, not only to improve the quality of their individual research but also to provide a better mechanism for setting priorities for research projects.

Air Pollutants↗
PubMed1968

Developing of methodologic tools for planning and managing library services: 3. Standardized inventories of library services.

A standardized procedure was developed for eliciting those details of a library's service policies that are important to its users and for recording the data by checking appropriate categories on a form. This inventory procedure covers the entire spectrum of user services and accommodates a wide range of policies. The inventory was originally designed for use by trained interviewers in largescale surveys of academic medical libraries. However, it is also suitable for other kinds of libraries, and the Interview Guide and Checklist can be used for a self-survey by library staff. In addition to survey use, the inventory has a variety of educational, administrative, managerial, and research applications. A method for weighting the categorical inventory data to reflect the relative desirability of different policies makes it possible to calculate scores indicating how a library's policies compare with those of an "optimal" library. An analogous inventory of the services a library provides to other libraries was developed for surveying major backup resources in the medical library system.

Consumer Behavior↗
PubMedDate not supplied

Health care reform in Germany: patchwork change within established governance structures.

Under the pressure of health care reform in the 1990s, interactions among the state, sickness funds, and providers in Germany are said to have entered a new era. We examine this new era by assessing both long-term developments connected to German statutory health insurance (SHI) and related short-term developments of the 1990s. Highly institutionalized rules and practices provide little opportunity for abandoning the historical path of two primary factors: the self-governance of SHI and a strong tradition of a semisovereign state. Some opportunities exist for introducing new ideas, rearranging priorities, softening rules, and adding new complex rules and procedures in a fairly fragmented policy-making system, perhaps even because of fragmentation. Yet reforms that depart from the status quo are severely limited by strong legal and administrative traditions and established rules of the game. These restrictions tend to reinforce state intervention, prevent the emergence of consistent and coherent visions of future health policy, and stifle policy innovation and implementation. In sum, reform measures tend to remain well within the priorities established within state and corporatist governance structures.

Cost Control↗
PubMed2003

Risk modeling, assessment, and management of lahar flow threat.

The 1991 eruption of Mount Pinatubo in the Philippines is considered one of the most violent and destructive volcanic activities in the 20th century. Lahar is the Indonesian term for volcanic ash, and lahar flows resulting from the massive amount of volcanic materials deposited on the mountain's slope posed continued post-eruption threats to the surrounding areas, destroying lives, homes, agricultural products, and infrastructures. Risks of lahar flows were identified immediately after the eruption, with scientific data provided by the Philippine Institute of Volcanology, the U.S. Geological Survey, and other research institutions. However, competing political, economic, and social agendas subordinated the importance of scientific information to policy making. Using systemic risk analysis and management, this article addresses the issues of multiple objectives and the effective integration of scientific techniques into the decision-making process. It provides a modeling framework for identifying, prioritizing, and evaluating policies for managing risk. The major considerations are: (1) applying a holistic approach to risk analysis through hierarchical holographic modeling, (2) applying statistical methods to gain insight into the problem of uncertainty in risk assessment, (3) using multiobjective trade-off analysis to address the issue of multiple decisionmakers and stakeholders in the decision-making process, (4) using the conditional expected value of extreme events to complement and supplement the expected value in quantifying risk, and (5) assessing the impacts of multistage decisions. Numerical examples based on ex post data are formulated to illustrate applications to various problems. The resulting framework from this study can serve as a general baseline model for assessing and managing risks of natural disasters, which the Philippines' lead agency-the National Disaster Coordinating Council (NDCC)-and other related organizations can use for their decision-making processes.

Journal Article↗
PubMed2006

Variant Creutzfeldt-Jakob disease and the Canadian blood system after the tainted blood tragedy.

The transfusion transmission of hepatitis C and HIV to thousands of Canadian blood recipients was one of this country's largest public health catastrophes. In response to this crisis, and in an effort to prevent such a tragedy from occurring again, the Canadian blood system has undergone substantial reform. Variant Creutzfeldt-Jakob (vCJD) disease was the first infectious threat faced by the blood system since undergoing reform. The response at the time to this risk provides insights into the Canadian blood system's new approach to infectious threats. Our analysis of the decision-making concerning vCJD identifies two dominant themes characterizing the new blood system's approach to safety: (1) the adoption of a precautionary approach to new risks which involves taking action in advance of definitive evidence, and (2) risk aversion amongst policy makers, which has contributed to the adoption of safety measures with comparatively high cost-effectiveness ratios. Overall the principles governing the new blood system have contributed to the system both providing protection against emerging infectious risks and regaining the confidence of the public and recipients. However, the current set of policy factors will likely contribute to increasingly risk-averse policy making that will contribute to continued increases in the cost of the blood system. The challenge the blood system now faces is to find the appropriate balance between maximizing safety and ensuring the system remains affordable.

Blood Banks↗
PubMed2002

Employers and policy makers can make a difference to the employment of persons with disabilities.

PURPOSE: The purpose of this article is to discuss what employers and policy makers can do to promote employment success for persons with disabilities. A study carried out in Rehabilitation Science at McMaster University, Ontario, Canada identified a number of themes, definitions of success and recommendations for change. METHOD: This article is a descriptive review of the study outcomes as well as a discussion of how the literature contributes to the position that employers and policy makers can do more to ensure that persons with disabilities achieve success in paid employment. RESULTS: The author proposes strategies that employers and policy makers can use that have been recommended both in the study and other more recent documents. CONCLUSIONS: Despite attempts to move the employment agenda for persons with disabilities forward, the results in both North America and Europe appear to be dismally low. There is evidence to suggest that employer activity in this regard is still minimal and that policy makers are not working together to ensure that there are opportunities for this population to succeed. Professionals working in this field need to be more actively involved with both employers and policy makers in order for the environment to change in a significant way.

Canada↗
PubMed2003

Putting the public back into public health. Part II. How can public health be accountable to the public?

The practice of public health involves the application of evidence to improving population health, and should be accountable to the public. Accountability to the public can be considered either at the individual doctor-patient interface or through population-level policy making. The public, at both patient and population levels, should join the professionals at each stage of the 'population health evidence cycle'-in asking for, collecting, understanding and using evidence. A greater appreciation of the non-professional, public perspective would represent a substantial commitment to transforming our understanding and needs for different kinds of evidence required to improve the health of the population.

Community Participation↗