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The following document describes the process President Clinton's Health Care Reform Task Force will use to develop his reform plan by the May 7 deadline--and sheds light where it may come down on some issues. This information is disclosed in a memo by Ira Magaziner, senior White House adviser for policy development, and obtained by HCR Week.
Health systems in developing countries are facing major challenges in the 1990s and beyond because of a growing epidemiological diversity as a consequence of rapid economic development and declining fertility. The infectious and parasitic diseases of childhood must remain a priority at the same time the chronic diseases among adults are emerging as a serious problem. Health policymakers must engage in undertaking an epidemiological and economic analysis of the major disease problems, evaluating the cost-effectiveness of alternative intervention strategies; designing health care delivery systems; and, choosing what governments can do through persuasion, taxation, regulation, and provision of services. The World Bank has commissioned studies of over two dozen diseases in developing countries which have confirmed the priority of child survival interventions and revealed that interventions for many neglected and emerging adult health problems have comparable cost-effectiveness. Most developing countries lack information about most major diseases among adults, reflecting lack of national capacities in epidemiological and economic analyses, health technology assessment, and environmental monitoring and control. There is a critical need for national and international investment in capacity building and essential national health research to build the base for health policies.
These guidelines provide scientific information for policy development by state health departments considering appropriate use of newborn screening specimens after screening tests are finished. Information was collected, debated, and formulated into a policy statement by the Newborn Screening Committee of the Council of Regional Networks for Genetic Services (CORN), a federally funded national consortium of representatives from 10 regional genetics networks. Newborn screening programs vary widely in approaches and policies concerning residual dried blood spot samples (DBS) collected for newborn screening. Recognition of the epidemiological utility of DBS samples for HIV seroprevalence surveys and a growing interest in DBSs for DNA analysis has intensified consideration of issues regarding retention, storage, and use of residual DBS samples. Potentially these samples provide a genetic material "bank" for all newborns nationwide. Their values as a resource for other uses has already been recognized by scientists, administrators, and judicial officials. Programs should promulgate rules for retention and use of residual newborn screening DBS samples based on scientifically valid information. Banking of newborn samples as sources of genetic material should be considered in light of potential benefit or harm to society.
This paper presents a case study of the Abanico Medicinal Plant and Organic Agriculture Microenterprise Project in the Arenal Conservation Area, Costa Rica. Microenterprise is the Sustainable Development and the Women in Development model for gender equity and environment of the World Bank, International Monetary Fund and large non-government organizations, like the World Wildlife Fund-Canada. The authors of this paper argue that debt-for-nature investment in microenterprise and ecological economic models are not distinct from neoclassical economic and development models that created the environmental, social and cultural crises in the first place. This case study shows that the world market accommodates only one model of development: unsustainable export-oriented production based on flexible labour markets, low wages, indebtedness and low cost production. Working standards in those micro-enterprises are eroded due to many factors,including indebtedness. What happened at a national level in non-industrial countries with the international debt crisis is now mirrored in individual indebtedness through microenterprise. Is current development policy creating a new form of indentured servitude? Medicinal plants, prior to commodification, were a source of women's power and upon commodification in international development projects, are the source of their exploitation.
This study was designed to explore the factors that differentiate sexually experienced teenagers who become pregnant from those who do not. The study examined the differences between pregnant and never-pregnant female adolescents in personal background characteristics, family characteristics, substance use, contraceptive attitude, contraceptive knowledge, contraceptive self-efficacy, sexual history, and effective contraceptive use. Sexually experienced but never-pregnant female adolescents were selected from two vocational high schools. Pregnant adolescents were recruited by convenience sampling from obstetric clinics and health stations in Tainan City, Taiwan. Multiple logistic regression analysis identified six factors associated with pregnancy: poor contraceptive knowledge, poor contraceptive self-efficacy, low socioeconomic status, low effective contraceptive use scores, more frequent sexual intercourse, and older age. The results of this study provide health professionals with information to develop more-effective prevention and intervention programs to reduce adolescent pregnancy. The results also could be used as a reference for related research and policy development in other countries.
Drug overdose mortality data for narcotics and cocaine for Texas for 1976-87 reveal a cyclic pattern of narcotics mortality falling from 0.92 per 100,000 population in 1976 to a low of 0.13 in 1979, and rising to 0.62 in 1986. The data also show a sharp increase in cocaine mortality from 0.07 per 100,000 in 1983 to 0.38 in 1987. The data indicate that men consistently are at higher risk than women for overdose from both categories of drugs. Hispanics in the El Paso and San Antonio areas were found to have much higher risk of mortality from narcotics than expected, while blacks in the Houston and Dallas areas were at higher risk of cocaine mortality. The evidence suggests that narcotics and cocaine mortality is highest among the blue collar categories of the work force. The cyclical pattern of drug overdose mortality suggests the need for more examination of the historical interplay of public policies and social factors against the magnitude of the drug problems. The differences in mortality patterns by sex, ethnicity, and location indicate the need to develop policies and programs that address the unique characteristics of different at-risk populations.
Initiatives in the Neponset, Ipswich, and Sudbury-Assabet-Concord watersheds highlight how watershed-scale innovation in engaging nongovernment participants is influenced, but not dominated, by the statewide program, the Massachusetts Watershed Initiative. The presence or absence of three elements--external support, process, and issue--and the order in which they occur, shape the viability of collaborative watershed-scale management initiatives. External support includes providing personnel or funding from outside an initiative. Process is the interaction among individuals undertaking watershed-wide policy development and/or implementation. An issue is an attention-requiring concern, vital to a watershed, that can most effectively be addressed by a coordinated strategy among different parties. A process generated by an issue is sustainable and amenable to enhancement through external support. The contribution of external support is most apparent when outside assistance is provided after an issue has crystallized into clear problem needs that can be addressed through specific research projects or implementation activities. Process is central in shaping issues, utilizing external support, and generating management results. The outcomes of voluntary processes in the three watershed initiatives highlight how the evolution of the Massachusetts Watershed Initiative leads to, and depends upon, the development of watershed-scale initiatives.
Since its formation in 1947, the World Medical Association (WMA) has been a leading voice in international medical ethics. The WMA's principal ethics activity over the years has been policy development on a wide variety of issues in medical research, medical practice and health care delivery. With the establishment of a dedicated Ethics Unit in 2003, the WMA's ethics activities have intensified in the areas of liaison, outreach and product development. Initial priorities for the Ethics Unit have been the review of paragraph 30 of the Declaration of Helsinki, the expansion of the Ethics Unit section of the WMA website and the development of an ethics manual for medical students everywhere.
International comparisons of health care expenditures and their determinants have attracted considerable attention since the early 1960s and have since been used widely to compare countries. The impetus for this has been two-fold: firstly, to assess the macroeconomic efficiency of health systems by determining whether different methods of financing and delivering health care have contributed to the control of overall spending levels; and, secondly, to investigate the determinants of the level of health care expenditure. Empirical research has suggested that there is a causal and statistically significant relationship between growth in health spending and growth in gross domestic product (GDP), and that an increase in the latter brings about a proportionately larger increase in the former. This relationship holds even when other potential determinants, such as urbanisation and age structure of the population, are included in the analysis, leading to the conclusion that health care is a luxury good. This paper examines the extent to which this finding is valid from a methodological perspective and how far it assists policy analysis. We argue that there are significant problems in the measurement of health spending and GDP, discuss the methodological problems in the analysis and suggest that the observed relationship between GDP and health spending is unhelpful and almost certainly misleading for health policy development.
The terms 'managed care' and 'disease management' are gaining common usage in the health service but their meaning is not widely understood. Managed care is a generic term describing any health care system that integrates the financing and delivery of medical care. Its growth in the United States has been driven by pressure to control costs, and there is circumstantial evidence that costs are slowing as a result of better management of resources. However, it is not clear how much of this is due to managed care, the selection of more favourable enrollees to health plans or other factors. Research evidence is limited, and that available is constrained by the rapidly changing nature of managed care. In the United States a bewildering variety of managed care arrangements have emerged, although several common characteristics can be identified: limited choice of physician providers; controlled access to secondary care; selective contracting; financial incentives; quality management; and utilization management. All are present in the National Health Service (NHS), which exemplifies a nationalized managed care system. Disease management is an extension of managed care that takes a global approach to patient care by attempting to co-ordinate resources across the entire health care delivery system throughout the life cycle of the disease. This is poorly developed in the NHS, so that the attention of commercial organizations has been attracted. However, concern has been expressed about the implications of commercial involvement: the fragmentation of general medical services; effect of for-profit status; and use of patient-based data. Recent policy developments could allow disease management to develop within the NHS.
The escalating burden of heart disease and stroke in the United States, coupled with the complexity of public health goals to prevent and control chronic diseases, warrant new strategies and partners. The 2.7 million nurses in the United States represent the nation's largest healthcare profession and, through their professional organizations, constitute a strategic partner for the Centers for Disease Control and Prevention (CDC) Heart Disease and Stroke Programs. In addition, because heart disease and stroke rank first and third among leading causes of death in women in the United States, and 95% of nurses are women, nurses represent an important population to target with preventive cardiovascular health approaches. The authors describe a proposed CDC strategic partnership with professional nursing organizations, including goals aimed at improving the capacity of nurses as change agents in the area of heart disease and stroke, as well as promoting change among the change agents to reduce nurses' risk for cardiovascular disease. The primary goals of the partnership between key professional nursing organizations and the CDC Cardiovascular Health (CVH) Programs follow: (1) share information and develop effective communication; (2) link with key professional and community organizations; (3) assess capabilities and expertise that nursing organizations can add to CDC's internal and external partnerships, including the Public Health Action Plan; (4) explore possible linkages with the CDC-funded state-level heart disease and stroke prevention programs and emerging CDC stroke networks; (5) develop, disseminate, and apply evidence-based guidelines to improve outcomes of care; and (6) develop policy and environment strategies in work-site settings to prevent heart disease and stroke in women and among the membership of professional nursing organizations. The development and implementation of a CDC CVH Program Professional Nurse Partnership have strong potential for enhancing collaborative public health efforts to prevent heart disease and stroke, and to improve cardiovascular outcomes for hypertension, high cholesterol, myocardial infarction, stroke, and heart failure.
Hearing aids are crucial for people with hearing loss, especially dementia patients in nursing homes. However, the actual use of hearing aids in this population is very low. A major barrier to use is the cost. This paper examines the issue in terms of current financial coverage available through federal and state systems as well as private insurance. We discuss the applicability of the Americans with Disabilities Act (ADA) and other federal laws to this problem. There is a need for future policy development to improve both the quality of hearing aids and the financial mechanisms that will allow nursing home residents to use them. Plans to move the policy agenda forward are suggested.
The purpose of this paper is to examine the effects of job preference, unpaid overtime, importance of earnings, and stress in retaining nurses in their employing hospitals and in the profession. Data come from our survey of 1396 nurses employed in three teaching hospitals in Southern Ontario, Canada. Data are analyzed first for all nurses, then separately for full-time, part-time, and casual nurses. Results show that the key to understanding the effects of these variables may be to pay attention to the work status of nurses. With regards to retaining nurses in their hospitals, working in their preferred type of job is important, particularly for part-time nurses. Working unpaid and longer than agreed hours is also a factor for increasing the likelihood of part-time nurses to leave the profession. All nurses are less inclined to leave as the importance of their earnings for the family increases, but it is particularly important for part-time nurses. Stress is an ongoing concern for retaining nurses in their hospitals and within the profession. We suggest managers and policy makers pay attention to employing nurses in jobs they prefer, decrease unpaid overtime, and consider the importance of earnings for them and their families in developing policies and programs to retain nurses. More importantly, stress levels should be lowered to retain nurses.
OBJECTIVE: To describe methods and strategies to advance the science of interventions in pediatric psychology. METHODS: We consider the advantages of various strategies to develop and extend the applications of intervention research in pediatric practice settings. RESULTS: Strategies are needed to enhance application of empirically supported interventions to pediatric settings, including testing the generalizability of empirically supported interventions in clinical samples, developing interventions based on clinical experience and tested in controlled clinical trials, designing program evaluations in the context of practice settings, and conducting case studies and series. Critical next steps in intervention research include documenting the clinical significance of interventions, conducting multisite research concerning interventions, including interventions conducted in clinical settings, and implementing integrated clinical intervention and research. Training in empirically supported treatments and intervention research and developing policy related to intervention research would also promote a clinically relevant scientific agenda concerning intervention research with pediatric populations. CONCLUSIONS: Pediatric psychologists have the opportunity to develop a clinically relevant science of interventions in pediatric settings by using multiple methods and strategies.
This article provides an overview of a newly approved World Health Organization framework and classification system for human functioning. The International Classification of Functioning, Disability, and Health (ICF) identifies dimensions of human functioning and describes a common language for clinical practice, research, and policy development across disciplines and service systems. This presentation highlights the development of a version of the ICF for children and youths (ICF-CY) and its potential utility in developmental and behavioral pediatrics. Clinical, research, and policy dimensions are described. Limitations related to scope and clarity of the framework are also outlined. The article proposes that serious consideration be given the ICF-CY as an integrated system to clarify constructs, improve communication, and encourage coordination of health services for children and youths.
Throughout the world blood services aim to provide a life-saving service by ensuring an adequate supply of safe blood. However, across the world blood services are at very different levels of development. Consequently, the actions taken in one country or region would not be appropriate in another. This paper aims to identify how suitable solutions can be developed to match the different prevailing circumstances of an individual country or region. In trying to do this it is important to look at the whole of the supply chain within a blood service and identify the part where a change could make the biggest impact. Four key areas are identified that are integral to this. These are the donor, testing of blood, hemovigilance, and overall management arrangements. Whilst the first two have largely been addressed in highly developed countries, there is still much work that could be done in these areas in developing countries. In particular, a move to voluntary nonremunerated donors worldwide would significantly improve overall safety. Hemovigilance systems are identified as a powerful tool to influence policy development, yet these are largely under developed throughout the world. In order to make high impact and sustainable changes it is important that those in the blood industry across the world work together to improve education and training, to share experience of best practice, and to move to develop agreed standards in transfusion medicine. It is imperative that developed countries recognize the importance of working with developing countries if the safety of the global blood supply is to be maintained and improved.
OBJECTIVE: To assess the impact of HIV on procedures to control infection in general practices. DESIGN: A postal questionnaire survey. SETTING: General practices throughout Britain. SUBJECTS: 5359 General practitioners, 3429 (63.9%) of whom returned the questionnaire. MAIN OUTCOME MEASURE: Response to questionnaire on knowledge about HIV and policies for controlling infection. RESULTS: Most doctors (2018) had started to wear gloves when taking blood. Almost half (1510) had not resheathed needles previously but a further 776 had adopted this policy because of HIV. Over half of the doctors did not know or were unsure about the risk of infection from needlestick injuries, and 1759 had no practice policy for controlling infection. CONCLUSIONS: Many doctors are uncertain about measures to control infection in general practice. More information and advice are needed to help doctors develop policies to protect patients and staff.
The international population policy agenda has traditionally been dominated by demographically driven population control policies. However, in the population policy development that preceded the International Conference on Population and Development in 1994, people's reproductive needs and rights received more emphasis. The aim of this study was to analyze how the new emphasis in population policies has been interpreted at the country level. In analyzing population policy rhetoric and its practical interpretations in India in 1994, the authors found that the rhetoric was broadening to encompass women's empowerment and reproductive health and that the use of direct method-specific monetary incentives and disincentives for accepting family planning methods was disapproved. However, population policy options were still considered mainly in terms of their ability to reduce fertility. Furthermore, the increased emphasis on the general market agenda was more important than that on reproductive needs and rights in molding population policies, as was evident in the greater stress on cost-recovery systems and nongovernmental actors. The findings suggest that the broader agenda for population policies and reproductive rights has been interpreted so that it can serve the aims of population-growth control and be implemented in the context of more market-oriented social policies and trade liberalization.