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International journal of health services [journal]
- Making the most of open windows: establishing health in all policies in South Australia. [Journal Article]
- Int J Health Serv 2014; 44(1):185-94.
Significant improvements in population health are likely to arise when the social determinants ofhealth are addressed. This creates a challenge for health systems, as the policy levers to influence the determinants largely lie outside of their direct control. Health agencies have been attempting to develop responses that affect these policy levers with mixed success. Success often requires particular conditions or "windows of opportunity" to be present before even small systemic change can be made. The government of South Australia has developed a practical, policy-oriented response to address the determinants of health--Health in All Policies--and has been successfully working across government for the past five years, using a policy learning process to implement this approach. This article will focus on how the South Australian Health in All Policies initiative started and the conditions that enabled South Australia to establish a centralized governance structure, harness a group of cross-sector policy entrepreneurs, and conduct health lens projects across a range of policy issues. The authors will comment on the nature of these conditions and their relevance for other governments struggling to reduce the burden of chronic disease and growing health budgets by addressing the social determinants of health.
- Horizontal inequality in rationing by waiting lists. [Journal Article]
- Int J Health Serv 2014; 44(1):169-84.
The objective of this article was to investigate the existence of horizontal inequality in access to care for six categories of elective surgery in a publicly funded system, when care is rationed through waiting lists. Administrative waiting time data on all elective surgeries (n = 4,634) performed in Ostergötland, Sweden, in 2007 were linked to national registers containing variables on socioeconomic indicators. Using multiple regression, we tested five hypotheses reflecting that more resourceful groups receive priority when rationing by waiting lists. Low disposable household income predicted longer waiting times for orthopedic surgery (27%, p < 0.01) and general surgery (34%, p < 0.05). However, no significant differences on the basis of ethnicity and gender were detected. A particularly noteworthy finding was that disposable household income appeared to be an increasingly influential factor when the waiting times were longer. Our findings reveal horizontal inequalities in access to elective surgeries, but only to a limited extent. Whether this is good or bad depends on one's moral inclination. From a policymaker's perspective, it is nevertheless important to recognize that horizontal inequalities arise even though care is not rationed through ability to pay.
- Social differentials in non-employment following hospital admission for musculoskeletal disorders in Sweden, 2001-2006. [Journal Article, Research Support, Non-U.S. Gov't]
- Int J Health Serv 2014; 44(1):155-68.
The article studies social differentials in non-employment among individuals who had been employed in 2001 following hospital admission for musculoskeletal disorders, by gender, educational level, and country of birth, in Stockholm County during 2001-2006. Individually linked population registers on health service use and sociodemographic characteristics were used. Individuals ages 25 to 59, living in Stockholm County and having employment in 2001, were followed until 2006. Annual age-standardized employment rates were calculated for people admitted to the hospital and diagnosed with a musculoskeletal disorder (n = 1,888) and compared to a reference group of others in employment. Multivariate Cox regression analysis was used to calculate the hazard risks of non-employment in 2006. Both women and men admitted to the hospital had lower age-standardized employment rates compared to the reference group and were at higher risk of non-employment. The hazard risk of non-employment was significantly higher among women and men with short education and among foreign-born individuals. Employment consequences of musculoskeletal disorders seem to be unequally distributed between different social groups, with women, people with short education, and people born outside Sweden more likely to be non-employed.
- Limits to neoliberal reforms in the health sector: the case of pharmaceutical management in New Zealand. [Journal Article, Research Support, Non-U.S. Gov't]
- Int J Health Serv 2014; 44(1):137-53.
In New Zealand in 1993, a pharmaceutical management agency (PHARMAC) was established during the height of neoliberal reforms in the health sector. The agency's relationship with pharmaceutical companies, patient lobby groups, and health professionals has been hostile at times, but despite this hostility, PHARMAC has remained substantially independent from political interference. This article draws on critical theory and Durkheimian perspectives to explain how such a strong regulatory organization was established during a time when attempts were made to reshape the health sector to conform to a neoliberal agenda. An analysis of historical and contemporary issues demonstrates the contradictory position of the state in relation to the regulation and subsidization of pharmaceuticals, with conflicting demands to retain popular support, restrain state expenditure, and respond to expectations to provide pharmaceuticals to its citizens. This article demonstrates how the establishment of PHARMAC reconciles these contradictory demands, arguing that it removes decision making from political control and has been able to sustain its place by appealing to objective assessment criteria. This case signals limits of the neoliberal agenda.
- Work, health, and welfare: the association between working conditions, welfare states, and self-reported general health in Europe. [Journal Article, Research Support, Non-U.S. Gov't]
- Int J Health Serv 2014; 44(1):113-36.
This article is the first to examine the association between self-reported general health and a wide range of working conditions at the European level and by type of welfare state regime. Data for 21,705 men and women ages 16 to 60 from 27 European countries were obtained from the 2010 European Working Conditions Survey. The influence of individual-level sociodemographic, physical, and psychosocial working conditions and of the organization of work were assessed in multilevel logistic regression analyses, with additional stratification by welfare state regime type (Anglo-Saxon, Bismarckian, Eastern European, Scandinavian, and Southern). At the European level, we found that "not good" general health was more likely to be reported by workers more exposed to hazardous working conditions. Most notably, tiring working positions, job strain, and temporary job contracts were strongly associated with a higher likelihood of reporting "not good" health. Analysis by welfare state regime found that only tiring or painful working conditions were consistently associated with worse self-reported health in all regimes. There was no evidence that the Scandinavian welfare regime protected against the adverse health effects of poor working conditions. The article concludes by examining the implications for comparative occupational health research.
- "Trade creep" and implications of the Transatlantic Trade and Investment Partnership Agreement for the United Kingdom National Health Service. [Journal Article]
- Int J Health Serv 2014; 44(1):93-111.
The ambitious and comprehensive Transatlantic Trade and Investment Partnership Agreement (TTIP/TAFTA) agreement between the European Union and United States is now being negotiated and may have far-reaching consequences for health services. The agreement extends to government procurement, investment, and further regulatory cooperation. In this article, we focus on the United Kingdom National Health Service and how these negotiations can limit policy space to change policies and to regulate in relation to health services, pharmaceuticals, medical devices, and health industries. The negotiation of TTIP/TAFTA has the potential to "harmonize" more corporate-friendly regulation, resulting in higher costs and loss of policy space, an example of "trade creep" that potentially compromises health equity, public health, and safety concerns across the Atlantic.
- Does autonomization of public hospitals and exposure to market pressure complement or debilitate social health insurance systems? Evidence from a low-income country. [Journal Article]
- Int J Health Serv 2014; 44(1):73-92.
Granting public hospitals greater autonomy and creating organizational arrangements that mimic the private sector and encourage competition is often promoted as a way to increase efficiency and public accountability and to improve quality of care at these facilities. The existence of good-quality health infrastructure, in turn, encourages the population to join and support the social health insurance system and achieve universal coverage. This article provides a critical review of hospital autonomization, using Vietnam's experience to assess the influence of hospital autonomy on the sustainability of Vietnam's social health insurance. The evidence suggests that a reform process based on greater autonomy of resource mobilization and on the retention and use of own-source revenues can create perverse incentives among managers and health care providers, leading to the development of a two-tiered provision of clinical care, provider-induced supply of an inefficient service mix, a high degree of duplication, wasteful investment, and cost escalation. Rather than complementing social health insurance and helping the country to achieve universal coverage, granting public hospitals greater autonomy that mimics the private sector may indeed undermine the legitimacy and sustainability of social health insurance as health care costs escalate and higher quality of care remains elusive.
- The impact of Thatcherism on health and well-being in Britain. [Journal Article]
- Int J Health Serv 2014; 44(1):53-71.
Margaret Thatcher (1925-2013) was the United Kingdom's prime minister from 1979 to 1990. Her informal transatlantic alliance with U.S. President Ronald Reagan from 1981 to 1989 played an important role in the promotion of an international neoliberal policy agenda that remains influential today. Her critique of UK social democracy during the 1970s and her adoption of key neoliberal strategies, such as financial deregulation, trade liberalization, and the privatization of public goods and services, were popularly labeled Thatcherism. In this article, we consider the nature of Thatcherism and its impact on health and well-being during her period as prime minister and, to a lesser extent, in the years that follow; we focus mainly on Great Britain (England, Scotland, and Wales). Thatcher's policies were associated with substantial increases in socioeconomic and health inequalities: these issues were actively marginalized and ignored by her governments. In addition, her public-sector reforms applied business principles to the welfare state and prepared the National Health Service for subsequent privatization.
- The painful effects of the financial crisis on Spanish health care. [Journal Article]
- Int J Health Serv 2014; 44(1):25-51.
Spain has an advanced, integrated health care system that has achieved remarkable results, including substantially improved health outcomes, over a relatively short time. Measures introduced by central and regional governments to combat the financial crisis may be severely affecting the health sector, with proposed changes potentially threatening the principles of equity and social cohesion underlying the welfare state. This article examines recent developments in Spanish health care, focusing on the austerity measures introduced since 2010. In Spain, as in other countries, evaluation of health care changes is difficult due to the paucity of data and because the effects of measures often lag well behind their introduction, meaning the full effects of changes on access to care or health outcomes only become apparent years later. However, some effects are already clear. With exceptions, Spain has not used the crisis as an opportunity to increase efficiency and quality, rationalize and reorganize health services, increase productivity, and regain public trust. We argue that immediate health care cuts may not be the best long-term answer and suggest evidence-driven interventions that involve the portfolio of free services and the private sector, while ensuring that the most vulnerable are protected.
- Health issues and health care expenses in Canadian bankruptcies and insolvencies. [Journal Article, Research Support, Non-U.S. Gov't]
- Int J Health Serv 2014; 44(1):7-23.
Illness can contribute to financial problems directly, through high medical bills, and indirectly, through lost income. No previous in-depth studies have documented the role of medical problems among Canadian bankruptcy filers. We obtained the bankruptcy filings from a random sample of 5,000 debtors across Canada and mailed surveys to them seeking information about the medical antecedents of their bankruptcy. A total of 521 debtors responded (response rate of 10.4%), of whom 40.1 percent reported losing at least two weeks of work-related income because of illness or injury in the two years before their filing; 8.3 percent reported a similar income loss because of caregiving responsibilities for someone else who was ill. Although 60.1 percent of respondents reported being responsible for a medical bill within the previous two years, only 6.9 percent had bills over $5,000 (all amounts in Canadian Dollars). Prescription drugs were cited as the costliest medical expense by two-thirds of debtors reporting bills > $5,000, with dental bills cited by 22.2 percent. Universal health insurance affords Canadians protection against ruinous doctor and hospital bills. Inadequate coverage for prescription drugs and dental care, however, leaves some with unaffordable out-of-pocket costs. In addition, illness is a frequent indirect cause of bankruptcy through loss of work-related income.