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Project 2000: a new preparation for practice--has policy been realized? Part I.

Project 2000 was established in the UK in 1984. The project report, published 2 years later, embraced the whole of the educational system for nursing, midwifery and health visiting. It is useful, 10 years on, to note what actually happened in what became an enormous undertaking and the biggest ever change in nursing, midwifery and health visiting training. But how well were policy formulation and implementation planned? Has the policy process been successful? What are the outcomes to date? This policy review chronicles policy initiation and formulation, decisions within the political system and policy outputs, implementation and outcomes in the context of the environment, using a combination of two policy models as the guiding framework. The focus is on implementation in England. The extent to which the original proposals in the project report have been realized is identified, together with policy changes and additions which occurred during the policy process. This macro-review of the whole of the policy process avoids the common faults of separating policy initiation from its implementation, or policy content from policy process. The record will enable past actions and events to be taken into account in the context of future plans for the 21st century.

Decision Making, Organizational↗

Populism and health policy: the case of community health volunteers in India.

The Indian Community Health Volunteer (CHV) Scheme is a major large scale experiment in people's participation into primary health care. This study intended to elicit the origins, the formulation and decision making process and the implementation of this programme. The evolution of the CHV programme is a particularly striking example of the contradictions of participation policies in a populist regime. Political awakening of the rural masses makes it absolutely necessary to take action so as to re-direct a portion of state interventions for their benefit. But the determining influence of the dominant classes, in both political and intermediate level bureaucracy of the state apparatus, tends to divert most of the resources made available by the State from their initial object, while inevitable reforms are constantly delayed. Thus the development of a popular participation policy would seem to be the necessary complement to the centre's reform policies. Yet the implementation of this participation policy can be realized only through the intermediary apparatus which must be verified and reoriented. Participation policy is thus distorted in order to reinforce the patronage capacities of existing political apparatus. In its present configuration, the CHV programme would appear first as an effort to constitute a poor-people's medicine circuit, answering the aspirations awakened by a populist political system, and much less the springboard for collective mobilization of communities in order to master their own development. As a whole, the order of priorities has been deeply altered in the course of implementation. The curative action took precedence over preventive action; individual action over collective action. This distortion could be explained both by the nature of people's demand and by the prevalence of clientelism and patronage as mode of political control.

Community Health Services↗

Debates, divisions, and decisions: recombinant DNA advisory committee (RAC) authorization of the first human gene transfer experiments.

Possibly the most far-reaching, controversial research currently being conducted in the international biological science community involves human gene therapy experimentation. In this paper, I report the dynamics of the political process which ultimately found the Recombinant DNA Advisory Committee (RAC) of the National Institutes of Health approving for the first time protocols of this genre. A full appreciation of the policy-making dialogue shows that significant participants perceived the process from very different vantage points regarding the way in which the American political system works and the way in which it ought to work. I argue that, if we are to understand how the RAC should proceed in orchestrating a human gene therapy policy agenda, then we must flesh out and critically analyze these competing vantage points. To that end, I postulate seven possible "action models" for characterizing how protocol assessments of the type at issue might be developed given the nature of our politics, reaching the conclusion that one of these models holds out the most promise for synthesizing efficaciously the key factors involved. In conclusion, I discuss how the RAC might profitably employ this preferred strategy in these and other cases.

Advisory Committees↗

Political and economic determinants of insurance regulation in mental health.

This article studies determinants of two important sets of laws regulating insurance coverage for mental health care: mandated inclusion of minimum coverage for psychotherapy, and mandated coverage for psychologist services, the so-called freedom of choice (FOC) laws. Political market models are developed and estimated to examine the passage of mandates and FOC laws among all fifty states from 1968 through 1983. Findings indicate that a number of groups influence whether these laws are passed, including psychologists and the state, which acts both in its own interests as a direct provider of services and to protect the public's interest. A state's political system and socioeconomic environment also influence the likelihood of passage of these regulations. Our findings run counter to the assumption often made by policymakers and researchers that regulations exclusively serve the interests of providers.

Community Mental Health Centers↗

Government and mental health policy: a structural analysis.

It is generally recognized that mental health policy is shaped by the interaction of complex social, economic, intellectual, and medical variables. An often neglected, yet significant, factor, however, is the very structure of the American political system that was created by the adoption of the federal Constitution in 1789. The constitutional framework made intergovernmental relations--local, state, federal--important determinants in shaping and transforming social policy in general and mental health policy in particular. The division of power among three levels of government created incentives to shift responsibilities, which in turn changed and distorted coverage patterns, thereby inadvertently transforming both costs and policy goals. It is thus critical to take into account the ways in which America's political structure mediates and recasts the context of mental health policy.

Community Mental Health Services↗

The "new" immigration and the politics of cultural diversity in the United States and Japan.

"Certain parallels between the recent experience of Japan and that of the United States with immigration from Third World countries are increasingly evident. In this discussion, I shall focus on these key similarities rather than the obvious differences between the two countries, in terms of culture, economy, political system, and 'immigration profile'." Aspects considered include the structural nature of the demand for foreign labor, the composition of immigrant stocks and flows, public tolerance, and contradictions in government policies.

Americas↗

Third nature: the co-evolution of human behavior, culture, and technology.

Within a dynamical-systems framework, human behavior is seen as emergent from broad evolutionary processes associated with three basic forms of nature. First nature, matter, emerged from the big bang some 12-15 billion years ago; second nature, life, from the first bacteria up to 4 billion years ago; third nature, ideology and cultural artifacts (e.g., institutions and technology), with a shift to self-reflective, symbolic thought and agrarianism in humans some 8-40 thousand years ago. The co-evolution of these three natures has dramatically altered human behavior and its relationship to the whole planet. Third nature has infused human minds with several powerful ideas, or memes, including the idea of progress. These ideas have fueled the evolution of a complex institutional order (e.g., political systems and technology) and myriad attendant global problems (e.g., wars and environmental degradation). The human brain/mind is seen as the primary medium by which third nature governs human behavior and, therefore, self perpetuates.

Behavior↗

The prevention and mitigation of famine: policy lessons from Botswana and Sudan.

Botswana and Sudan experienced consecutive years of drought in the 1980s. Sudan faced a large decline in food entitlement and nutritional deterioration, which translated into famine in 1984/85. Botswana, on the other hand, nearly compensated income losses and averted nutritional deterioration and famine-related deaths. There are important lessons to learn from the famine prevention experience of Botswana. Its strategy for dealing with drought and famine combines policies of steady economic growth with supplementary poverty alleviation and drought relief programs. To provide continuity and stabilization of market operations in times of distress, the country channels sufficient food through market chains, provides price support to preempt market collapse and augments the income of consumers through public income transfer programs to prevent demand failure. In addition, it maintains a responsive and accountable political system and a decentralized participatory administrative structure. While Sudan should develop policies that are compatible with its own environment, it is crucial that it recognizes the critical role of public action in promoting growth, alleviating poverty, and providing timely relief responses in times of anticipated growth failure.

Botswana↗

Zero-base budgeting in the federal government: a case study.

The implementation of a zero-base budgeting system in Federal government agencies, instituted by President Carter in 1977, yielded quite different results, not only among the agencies but within specific departments as well. The experience of the Public Health Service with this budgeting process is documented and analyzed in this article. Though the individual PHS agencies generally felt that ZBB is a poor budgetary tool, the author's principal claims are that the technique was misused and that its application may well be inappropriate for the entire budget of a large political system. The result, according to Professor Herzlinger, was that those individuals who should have been the prime beneficiaries of the ZBB process were most disappointed by it.

Budgets↗

Land degradation: a challenge to Ethiopia.

Land degradation is a great threat for the future and it requires great effort and resources to ameliorate. The major causes of land degradation in Ethiopia are the rapid population increase, severe soil loss, deforestation, low vegetative cover and unbalanced crop and livestock production. Inappropriate land-use systems and land-tenure policies enhance desertification and loss of agrobiodiversity. Utilization of dung and crop residues for fuel and other uses disturbs the sustainability of land resources. The supply of inputs such as fertilizer, farm machinery and credits are very low. The balance between crop, livestock, and forest production is disturbed, and the farmer is forced to put more land into crop production. For environmentally and socially sustainable development, there is an urgent need to promote awareness and understanding of the interdependence of natural, socioeconomic, and political systems at local and national levels. Understanding the current status and causes of land degradation is very important. This paper reveals the important elements of land degradation in Ethiopia and suggests possible solutions that may help to ameliorate the situation.

Agriculture↗

Globalisation, complex humanitarian emergencies and health.

A new political economy of conflict has emerged in the aftermath of colonialism and the Cold War. Complex political emergencies have been simmering in the post-colonial world for more than three decades. Intra-country armed conflict, often combined with natural disasters, at present contributes to the displacement of over 20 million people world-wide. The international community remains profoundly uncomfortable with the complex political emergencies of the new era, torn between the respect for national sovereignty upon which the international political system of the United Nations and other agencies is built, and the growth of concern with human rights and a burgeoning International Humanitarian Law. Globalisation may have brought many benefits to some but there are also many losers. The Word Bank and the International Monetary Fund imposed structural adjustment policies to ensure debt repayment and economic restructuring that have resulted in a net reduction in expenditure on health, education and development. A downward spiral has been created of debt, disease, malnutrition, missed education, economic entrapment, poverty, powerlessness, marginalization, migration and instability. Africa's complex political emergencies are particularly virulent and tenacious. Three examples that are among the most serious humanitarian emergencies to have faced the world in recent times--those in Angola, the Democratic Republic of Congo and Sudan--are reviewed here in detail. The political evolution of these emergencies and their impact on the health of the affected populations are also explored.

Angola↗

A critique of western medical commentary on the People's Republic of China.

The American medical literature generally has given favorable reviews to the Chinese Communist experiment, which has often been credited with astonishing, unprecedented achievements in public health. Improvements are explicitly attributed to the Chinese political system, despite its acknowledged shortcomings from an American perspective. A survey of articles about Chinese medicine discloses numerous scientific flaws, eg, inadequate sampling, biased reporting, inappropriate attribution of causal relationships, lack of suitable controls, and ablation of conflicting data. The promulgation of such errors results in part from imprecise euphemistic language.

China↗

United Nations population conferences: shaping the policy agenda for the twenty-first century.

Population conferences have evolved through three overlapping stages, each stage reflecting a different perspective on the relationship between national policy formulation and the international system. Initially, at Rome in 1954 and in Belgrade in 1965, participants were invited on the basis of their expertise and were not expected to represent their governments. By the time of the Bucharest Conference in 1974, the United Nations, in an attempt to give conferences a greater role in shaping population policy and to inspire member governments to show greater concern for their own population problems, decided that conferences would be intergovernmental gatherings and that national delegations would be selected by governments. The effect of this change was that governments gave less weight to scientific expertise and, conversely, greater weight to political and bureaucratic considerations. At the present time, although conferences remain intergovernmental gatherings, the door has been opened for nongovernmental organizations--civil society--to play a more active role in the conference process and in deliberations. As conferences have become more inclusive, their focus has veered from what has conventionally been regarded as population concerns. The changing composition of participants at UN conferences has had the effect of altering the policy agenda in the international population field and, as some have argued since Cairo, has redefined the meaning of population. Conferences in the twenty-first century likely will be compelled to confront diverse demographic problems in addition to social issues demanding the attention of the political system at every level.

Congresses as Topic↗

The political process and its relationship to the psychotherapy of substance misusers: an historical perspective.

There are massive changes underway in the allocation of funds for health care in the United States which will impact upon services provided for users and misusers of intoxicating substances. Recent findings suggest that conditions in the marketplace and the development of professions have effected standards of care rather than a reasoned analysis of need and outcome. Psychologists question to what extent they will be involved in public policy issues including what is clinically and socially relevant. The goal of this paper was to determine if an historical perspective upon federal regulation of intoxicating substances (tobacco/alcohol/drugs) would enlighten the psychotherapy scientist in the pursuit of standards for service. The methodology included a review of the economic and social structure of colonial America which included tobacco plantations, breweries, and distilleries as well as a review of the formation of the federal government and political system in which men, women, and slaves were each assigned different performance standards/roles and economic rewards within the community. The implication is that potential for self-regulation and psychological development is based upon the legacy of our forefathers.

Alcohol Drinking↗

Stakeholder attitudes toward the risks and benefits of agricultural biotechnology in developing countries: a comparison between Mexico and the Philippines.

Public perceptions and political debates regarding the risks and benefits of agricultural biotechnology are well documented in industrialized countries. Yet, hardly any surveys have been conducted in developing countries. The following study aims to contribute to a better understanding of stakeholder attitudes toward agricultural biotechnology in developing countries. For this purpose, stakeholder representatives in the public debates in Mexico and the Philippines were asked to complete two nearly identical questionnaires on the risks and benefits of agricultural biotechnology. A comparison of stakeholder attitudes in the Philippines and Mexico is interesting because it shows how the different political systems, cultural and ecological backgrounds, and the regional context of food and agriculture influence perceptions. In general, the results of the surveys indicate that the participants in both countries consider genetic engineering to be an important tool to address agricultural, nutritional, and environmental problems, and they do not regard transgenic foods as risky for consumers. However, they are concerned about the potential impact of such transgenic crops on their countries' rich biological diversity and do not believe that national biosafety guidelines will be implemented properly. Although the surveys show that stakeholder attitudes in the Philippines and Mexico are quite similar, they also highlight significant differences in perception often related to cultural and political aspects.

Journal Article↗

Collective actors and corporate targets in tobacco control: a cross-national comparison.

Cross-national comparative analysis of tobacco control strategies can alert health advocates to how opportunities for public health action, types of action, and probabilities for success are shaped by political systems and cultures. This article is based on case studies of tobacco control in the United States, Canada, Britain, and France. Two questions are addressed: (a) To whom were the dangers of smoking attributed? and (b) What was the role of collective action--grassroots level organization--in combating these dangers? Activists in Canada, Britain, and France moved earlier than the United States did to target the tobacco industry and the state. Locally based advocacy centered on passive smoking has been far more important in the United States. The author concludes that U.S.-style advocacy has played a major role in this country's smoking decline but is insufficient in and of itself to change the corporate practices of a wealthy and politically powerful industry.

Canada↗

[Increasing life expectancy--what are the promises of demography?].

The prospects for a longer life are improving, for life expectancy is growing continuously. In Germany new-born boys are looking forward to 74.4 years, girls even to 80.6 years of life. But Germany is only mid-range internationally. As there is a linear trend for 160 years, it seems realistic that life expectancy in top countries will be 100 years in 2060. If we look more thoroughly we find that there are important differences in Germany. Whereas the southern parts are in the pole position, the former East Germany is at the bottom of the league. This separation is apparently caused by the different political systems in postwar Germany. There are even more differences if smaller regions are examined. The reasons for these differences are due to many influences, including personal features, conditions of life, lifestyle and, of course, medical treatment. As these factors are partly determined by individual behavior, people are partly responsible for their life and therefore also for the further development of life expectancy.

Aged↗

The challenge ahead: the state agenda for the coming years.

The mid-1990s promise to be extremely challenging years as state leaders and institutions struggle to bring accountability and predictability back into their political systems. Faced with continuing budgets troubles, increasing demands for services and a shift of responsibility from the federal to the state level, the American states will be hard pressed to satisfy constituent needs or improve state services. However, the tough times may result in long-term improvement in state government, as administrators streamline agencies, legislators trim inefficient or redundant programs and state leaders generally seek new and cost effective solutions to social and economic problems.

Education↗