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PubMed1998

Priorities of the Russian health care reform.

The introduction of health insurance system has been the core of the Russian health care reform. It has coincided with the decentralization of the state administration. The reform has thus been decentralized, and the transition has been fragmentary and incomplete. As a result, the existing health financing system is eclectic and contradictory. Meanwhile, the reform has had a positive stabilizing influence on financing of health care under conditions of continued economic crisis. The new priorities of the reform should be to balance the financial flows and the state's obligations, and to increase the efficiency of the use of resources through encouragement of competition, assurance of transparency of public funding, development of health care planning, and shift from inpatient to outpatient care.

Health Care Reform↗

PubMed1998

Twenty-four-hour change in axial length in the rabbit eye.

PURPOSE: To study the 24-hour changes in axial length, lens thickness, and anterior chamber depth in rabbits and to examine the role of ocular sympathetic activity on these changes. METHODS: Young adult rabbits were entrained to a daily 12-hour light-12-hour dark cycle. Axial length, lens thickness, and anterior chamber depth were measured using ultrasonic techniques. In the first group of 12 rabbits, measurements were taken in the middle light phase and in the early dark phase. In the second group of 12 rabbits, measurements were taken in constant dark every 2 hours for a period of 24 hours. The latter group of rabbits underwent unilateral transection of the cervical sympathetic trunk. Three to four weeks later, axial length, lens thickness, and anterior chamber depth were measured again in constant dark every 2 hours for 24 hours. RESULTS: Under the light- dark condition, axial length and anterior chamber depth were larger in the early dark phase than in the middle light phase. Lens thickness changed in the opposite direction. Under the constant-dark condition, axial length and anterior chamber depth changed gradually during the 24-hour period. The trough appeared in the late subjective light phase, and the peak appeared in the late subjective dark phase. Lens thickness remained relatively constant. In the eyes with decentralized ocular sympathetic nerves, 24-hour changes in axial length and anterior chamber depth occurred. However, magnitudes of nocturnal enlargement were relatively smaller than those in the intact eyes. Although larger in the decentralized eyes, lens thickness appeared unchanged in either eye for 24 hours. CONCLUSIONS: Consistent 24-hour changes in axial length and anterior chamber depth occur in young adult rabbits. These changes are driven endogenously. Significant portions of the nocturnal enlargements of axial length and anterior chamber depth are unrelated to ocular sympathetic activity.

Animals↗

PubMed1998

European food and nutrition policies in action. Finland's food and nutrition policy: progress, problems and recommendations.

Some progress has clearly been made in several aspects of Finland's food and nutrition policy: access to nutrition information and education, improvements in mass catering, increased availability of healthier food products, and pricing and quality requirements favourable to a healthy diet. Finnish eating patterns have improved in relation to some recommended foods and macronutrients. The structural changes in farm and food production are largely the result of new political and economic realities both in Finland and internationally, resulting in the Government focusing on fiscal efficiency, decentralization and a more competitive, consumer-oriented market. This new environment is creating pressures to reduce surplus animal fat production and to expand markets in new foods for Finns and other Europeans who, for reasons of demography, health or working or living arrangements, demand new and sometimes healthier foods. Within this context, some health leaders have been able to make and work for proposals that are consistent both with political and economic imperatives and with health needs. Although the populations health status is improving and in some respects is exemplary, diet-related death and illness rates and risk factors (such as serum cholesterol and obesity) are high and their decline, along with some healthy changes in eating patterns, has slowed since the mid-1980s (ironically, since the adoption of the nutrition policy). The more slowly improvements occur, the higher will be the social and economic costs. Major problems in policy implementation exist. Although much has been done in research and demonstration and in the development of national guidelines (in public catering and labeling, for example) there is an apparent lag in translating such soft technology into action and monitoring its implementation in order to develop corrective measures at the operational level. This problem may increase with decentralized budget control and a less regulated market, where listening to the consumer (whether an individual, retailer or caterer) may not necessarily result in healthier products are more accurate consumer information, especially as foreign products and media continue to attract Finnish young people. The lack of a leading strategic body that can authoritatively assess and anticipate problems in implementation, deal with them and coordinate and monitor the necessary action in fundamental to these issues. Rapid progress in economic and farm policy development and food enterprises can provide conditions supportive of health and nutrition goals if such interests are systematically taken into account and allowed to moderate potential negative changes. If it is to be effective, such accounting will require initiative, clarity of strategic purpose and organization by health and nutrition leaders.

Finland↗

PubMed1998

U.S. suburbanization in the 1980s.

"This paper measures and analyzes differences in rates of suburbanization during the 1980s among U.S. metropolitan areas which fit a monocentric urban model. Three findings are of interest: (1) the average rate of suburbanization for U.S. metropolitan areas was the same in the 1980s and the 1970s; (2) the monocentric urban model provides a good description of population distribution for a diminishing number of urban areas; and (3) variables that characterize the entire metropolitan area as well as those that measure disparities between the central city and its suburban ring are important in explaining differences in rates of decentralization."

Americas↗

PubMed1986

Multi-sectoral urban growth in space and time: an empirical approach.

"This paper compares the distribution of growth of several economic sectors in an attempt to trace and analyse their spatiotemporal sequence of decentralization. The paper applies a polynomial regression model capable of dealing with detailed spatiotemporal series. The application of the model to the urban field of Philadelphia [Pennsylvania] shows population to be the farthest spread followed by manufacturing industries. Despite, or probably because of, their extensive spread, both sectors display low levels of growth." In addition to population and manufacturing, the patterns of growth in retail and wholesale trade, services, and the provision of financial, insurance, and real estate services are examined for the period 1960-1980. (summary in FRE, GER)

Americas↗

PubMed1996

Strengthening health management: experience of district teams in The Gambia.

The lack of basic management skills of district-level health teams is often described as a major constraint to implementation of primary health care in developing countries. To improve district-level management in The Gambia, a 'management strengthening' project was implemented in two out of the three health regions. Against a background of health sector decentralization policy the project had two main objectives: to improve health team management skills and to improve resources management under specially-trained administrators. The project used a problem-solving and participatory strategy for planning and implementing activities. The project resulted in some improvements in the management of district-level health services, particularly in the quality of team planning and coordination, and the management of the limited available resources. However, the project demonstrated that though health teams had better management skills and systems, their effectiveness was often limited by the policy and practice of the national level government and donor agencies. In particular, they were limited by the degree to which decision making was centralized on issues of staffing, budgeting, and planning, and by the extent to which national level managers have lacked skills and motivation for management change. They were also limited by the extent to which donor-supported programmes were still based on standardized models which did not allow for varying and complex environments at district level. These are common problems despite growing advocacy for more devolution of decision making to the local level.

Administrative Personnel↗

PubMed1999

Reforming health service delivery at district level in Ghana: the perspective of a district medical officer.

Many countries in sub-Saharan Africa face the problem of organizing health service delivery in a manner that provides adequate quality and coverage of health care to their populations against a background of economic recession and limited resources. In response to these challenges, different governments, including that of Ghana, have been considering or are in the process of implementing varying degrees of reform in the health sector. This paper examines aspects of health services delivery, and trends in utilization and coverage, using routine data over time in the Dangme West district of the Greater Accra region of Ghana, from the perspective of a district health manager. Specific interventions through which health services delivery and utilization at district level could be improved are suggested. Suggestions include raising awareness among care providers and health managers that increased resource availability is only a success in so far as it leads to improvements in coverage, utilization and quality; and developing indicators of performance which assess and reward use of resources at the local level to improve coverage, utilization and quality. Also needed are more flexibility in Central Government regulations for resource allocation and use; integration of service delivery at district level with more decentralized planning to make services better responsive to local needs; changes in basic and inservice training strategies; and exploration of how the public and private sectors can effectively collaborate to achieve maximum coverage and quality of care within available resources.

Developing Countries↗

PubMed1992

Surveillance for equity in primary health care: policy implications from international experience.

Experience around the world shows that health agencies can promote community-based surveillance for equity to focus low-cost interventions on priority needs. Social inequities which have seemed intractable can be resolved if care responds directly to demonstrated need. The concept of promoting equity as a basic principle of primary health care has an interesting psychological twist. The ethical imperative of equity can strengthen services when linked with the practical management tool of surveillance. Moral conviction in applying this social justice norm can facilitate action which is made efficient by the realism of statistically based methods of surveillance. If international agencies condition their aid on surveillance for equity their assistance will more likely go to those in greatest need. This is a more efficient and effective way of tracking their money than the previous tendency to set up vertical programmes which generally have poor sustainability. Surveillance helps mobilize political will and community participation by providing practical data for local, district and national decision-makers. The many field demonstrations of successful surveillance for equity tend to have been brushed off by development experts who say they are difficult to replicate nationally. The Model County Project in China shows how a systematic extension process can test procedures in experimental areas and adapt them for general implementation. Surveillance can help bureaucracies maintain capacity for flexible and prompt response as decentralization promotes decision-making by local units which are held responsible for meeting equity targets. Surveillance for equity provides a mechanism to ensure such accountability.

Adult↗

PubMed1987

Nicaragua: a health system developing under conditions of war.

Since its inception in 1979, the Nicaraguan National Health System has dramatically improved health care in Nicaragua through the provision of universal coverage, emphasis on preventive community-based primary care, and community participation in health activities. Of major importance in the development of the health system has been the decentralization of the administration, planning, and implementation of health programs. The war in Nicaragua has had a major impact on the development of the health system. Nicaraguan health personnel and facilities have been the objects of attack by the contras and scarce resources have been diverted from the development of social programs to military activities. A large refugee population has been created which further strains existing resources. Community-based preventive health programs have been adversely affected, particularly in rural areas where military activity is the most intense. Because of the war, efforts to optimize regionalization of the health system have been retarded. Economic pressures both within Nicaragua resulting from the war and within the entire Latin American area have further hampered efforts for development. Continued major improvements in health care in Nicaragua will depend on a settlement of the present military conflict which is draining resources in all sectors of development, including health.

Economics↗

PubMedDate not supplied

[Population-territory: 100 years of evolution, 1895-1990].

The authors "describe population distribution trends [in Mexico] from 1895 to 1990 as they relate to a division of political and administrative factors. The study provides an estimate of population dispersion throughout time by analyzing the behavior of state populations with respect to the distance between state capitals and the Federal District. It also provides 100-year curves describing time variations of population dispersion and explaining the process of decentralization of displacement from the country's main population center to its peripheral areas." (SUMMARY IN ENG)

Americas↗

PubMed1994

[Demographic statistics after the GBA Law is passed].

"The Dutch Ministry of Internal Affairs plans to replace the old written population systems on paper with a new system of decentralized automated population registers (in Dutch this system is called: GBA) on 1 October 1994.... In the summer of 1993 Statistics Netherlands carried out a test to find out whether the GBA messages are appropriate for making population statistics. To do this such messages were forwarded to Statistics Netherlands by five municipalities for three months. The conclusion of the test results was that the GBA system is technically adequate for making population statistics." (SUMMARY IN ENG)

Data Collection↗

PubMed1990

Urban ties of rural Thais.

This article analyzes interpersonal linkages between villagers and urban dwellers and the effect on circular migration in Thailand. "Using data from Northeast Thailand, it examines the prevalence of urban social contacts, selectivities involved in such linkages, the characteristics of the urban contacts themselves, the salience of the interpersonal relationships, and the potential for the urban contact to act as a sponsor for the villagers. Furthermore, using a prospective research design, the impact of social contacts on subsequent rural-urban mobility of villagers is examined." A distinction is made between Bangkok and Northeastern Thai urban centers in order to illustrate some of the obstacles to the decentralized urbanization program in Thailand.

Asia↗

PubMed1988

Counterurbanization: spatial division of labour and regional life-cycles in Canada.

"After a discussion of major concepts of counterurbanization, a narrow definition is proposed. Various demographic and socio-economic dimensions are analysed at different scales with special regard to the Canadian heartland. The basic hypothesis suggests a temporary weakening of urban growth dynamics: decentralization, thus, is a result of locational adjustment strategies, emerging during revolutions in basic technology. The corresponding 'filtering down' processes create a selective, interregional spread of labour. However, shift analytical time series indicate that the development capacity of core regions oscillates in a life-cyclical rhythm. Counterurbanization is expected to fade out with regional adjustment to basic technological transformation."

Americas↗

PubMed1992

Smaller health areas for a better service.

An analysis of Sudan's health system revealed a lack of sound leadership for village-level providers. The district-based peripheral health system was failing to meet an increased demand for leadership and management support. Some of the principal factors explaining this state of affairs were population growth, increased numbers of health units, long distances and transport difficulties. With a view to solving these problems, the country was divided into smaller health areas around rural hospitals and similar physician-led facilities. A decentralized system based on the principles of primary care was established in these areas under health area management teams. Setbacks encountered in giving effect to the policy have led to proposals for a new implementation strategy.

Catchment Area, Health↗

PubMed1998

Commentary: malaria control in the 1990s.

In May 1955 the Eighth World Health Assembly adopted a Global Malaria Eradication Campaign based on the widespread use of DDT against mosquitos and of antimalarial drugs to treat malaria and to eliminate the parasite in humans. As a result of the Campaign, malaria was eradicated by 1967 from all developed countries where the disease was endemic and large areas of tropical Asia and Latin America were freed from the risk of infection. The Malaria Eradication Campaign was only launched in three countries of tropical Africa since it was not considered feasible in the others. Despite these achievements, improvements in the malaria situation could not be maintained indefinitely by time-limited, highly prescriptive and centralized programmes. Also, vector resistance to DDT and of malaria parasites to chloroquine, a safe and affordable drug, began to affect programme activities. A global Malaria Control Strategy was endorsed by a Ministerial Conference on Malaria Control in 1992 and confirmed by the World Health Assembly in 1993. This strategy differs considerably from the approach used in the eradication era. It is rooted in the primary health care approach and calls for flexible, decentralized programmes, based on disease rather than parasite control, using the rational and selective use of tools to combat malaria. The implementation of the Global Strategy is beginning to have an impact in several countries, such as Brazil, China, Solomon Islands, Philippines, Vanuatu, Viet Nam and Thailand. The lesson from these areas is clear: malaria is being controlled using the tools that are currently available. The challenge is now to apply these tools among vulnerable individuals and groups experiencing high levels of morbidity and mortality, particularly in sub-Saharan Africa, for which long-term investments are required.

DDT↗

PubMed1998

Rehabilitation of the expanded programme on immunization in Sudan following a poliomyelitis outbreak.

In 1993 a large outbreak of paralytic poliomyelitis occurred in Sudan as a result of an accumulation of large numbers of susceptible children that was accelerated by faltering immunization services. The extent of the outbreak led to the rapid rehabilitation of Sudan's Expanded Programme on Immunization (EPI); the government began financing vaccine purchase, operational aspects of EPI were decentralized, vaccine delivery was changed from a mobile to a fixed-site strategy, a solar cold chain network was installed, inservice training was resuscitated, and social mobilization was enhanced. National immunization days (NIDs) for poliomyelitis eradication were conducted throughout the country, including the southern states during a cease fire in areas of conflict. Measles immunization coverage was increased by offering measles vaccine during the second round of NIDs and subsequently through routine immunization services. Supplemental tetanus toxoid immunization of women of child-bearing age began in three provinces at high risk for neonatal tetanus. From 1994 to 1996 reported immunization coverage increased and the incidence of all EPI target diseases fell. Trends in coverage, disease incidence, financing, and the implementation of WHO-recommended disease-control strategies suggest that more sustainable immunization services have been re-established in Sudan.

Adult↗

PubMed2005

Analysis of how the health systems context shapes responses to the control of human immunodeficiency virus: case-studies from the Russian Federation.

OBJECTIVE: To develop a methodology and an instrument that allow the simultaneous rapid and systematic examination of the broad public health context, the health care systems, and the features of disease-specific programmes. METHODS: Drawing on methodologies used for rapid situational assessments of vertical programmes for tackling communicable disease, we analysed programmes for the control human of immunodeficiency virus (HIV) and their health systems context in three regions in the Russian Federation. The analysis was conducted in three phases: first, analysis of published literature, documents and routine data from the regions; second, interviews with key informants, and third, further data collection and analysis. Synthesis of findings through exploration of emergent themes, with iteration, resulted in the identification of the key systems issues that influenced programme delivery. FINDINGS: We observed a complex political economy within which efforts to control HIV sit, an intricate legal environment, and a high degree of decentralization of financing and operational responsibility. Although each region displays some commonalities arising from the Soviet traditions of public health control, there are considerable variations in the epidemiological trajectories, cultural responses, the political environment, financing, organization and service delivery, and the extent of multisectoral work in response to HIV epidemics. CONCLUSION: Within a centralized, post-Soviet health system, centrally directed measures to enhance HIV control may have varying degrees of impact at the regional level. Although the central tenets of effective vertical HIV programmes may be present, local imperatives substantially influence their interpretation, operationalization and effectiveness. Systematic analysis of the context within which vertical programmes are embedded is necessary to enhance understanding of how the relevant policies are prioritized and translated to action.

Delivery of Health Care↗

PubMedDate not supplied

The department without walls. Acceptability, cost, and utilization of interactive video technology.

As groups of physicians continue to provide more of their activities in sites remote from the central office, communication among providers and staff and the provision of common educational activities are important priorities. An analysis of a 12-month period of the use of full-motion interactive video technology to accomplish these goals in a decentralized academic department shows this method to be acceptable and cost-effective. Careful attention to room environment and staff support were found to be important. Practical recommendations are provided for those considering the use of this technology.

Academic Medical Centers↗