Health policy and education最新文献

This paper reports on the status of the implementation of the national health planning program mandated by Congress in the National Health Planning and Resources Development Act of 1974 (P.L. 93-641). The law created and financed a two-tiered planning network of more than 260 local and state planning agencies. The paper gives a very brief history of previous efforts in health planning and describes some of the environmental factors — rampant cost inflation and proliferation and redundancy of high cost technology and facilities — which triggered interest in controlling capital investment in the health sector.

The major structural features of the statute and the progress made by 1977 in constructing the program are described. The rationale and the requirements related to particular Plan documents are explained, as are the Certificate of Need law provisions and Appropriateness Review.

The authors argue that this program is different from previous planning efforts in several fundamental respects including who the major actors are, the importance given to an empirical, population-based, systems approach to planning, the availability of technical assistance and the emphasis on plan implementation.

While there is evidence of progress in health planning, some persistent policy problems such as unrealistically high expectations, the inadequacy of the knowledge base, insufficient time and patience to allow for agency maturation, conflicts in governance, assuring public accountability, and the desirability of further regulation of the health industry still remain unresolved. The authors conclude that, compared to the apparent alternatives, this health planning program is the best way to go and should succeed.

This brief article discusses implications of the recent findings of the United States Supreme Court in Southeastern Community College vs. Francis B. Davis which was concerned with rights of handicapped persons. At issue in the case was whether or not federal law in Section 504 of the Rehabilitation Act of 1973 forbids a federally funded professional school from considering a disabling handicap of a program applicant in the admissions process; thus no “otherwise qualified handicapped individual” could be excluded from a program on the basis of the handicap even though such a student would not be able to successfully complete the educational program, nor to enter practice. In Davis, a deaf person sued to seek admittance to a community junior college registered nurse program, for which normal or near normal hearing ability is required. Ultimately the Court ruled for the college and held that “otherwise qualified” means a person who meets all program requirements “in spite of his handicap”. This ruling provides protection to both society and the individual.

In the first section of this paper, it is argued that although education is often offered as the most important remedy for the poor quality of health services, its role may have been exaggerated and that educational attempts to improve the quality of health services may be unilateral. Education cannot solve such problems as organizational and environmental barriers to the use of knowledge and available technology which may be far more important causes of deficient quality than lack of knowledge. Educational remedies may also overemphasize the cognitive elements of care, neglect the expectations of the consumers, and lead to unnecessarily expensive care by stressing the highest attainable quality at the expense of optimal and logical quality. In spite of these limitations, education does have a useful role to play in quality assurance. The labor intensiveness of health care and the “knowledge explosion” particularly enhance the role of education as a partial guarantee of high quality. In the second section of the paper, the contributions of basic and continuing education to the quality of health services are profiled. Special attention is paid to the curriculum development process, the credentialing of health personnel, and the establishment of priorities for and educational principles in continuing education. The last two sections deal with the training of health professionals to accept, perform, and use quality assurance and the education of the public in quality related matters.

The physician's role has a dualism inherent within it: a concern for society's health problems and generic solutions to them and a need to find specific remedies for the conditions of individual patients. This paper asserts that a recognition of this dualism and of the difficulties encountered nationally and internationally in distributing medical care on an equitable basis has created a favorable climate for evaluating the problems of providing and assessing the quality of health care. Suggestions for solving the problems are discussed and include those of Ivan Illich. The author's suggestions are given in contrast to Illich's non-medical suggested solutions. Among them are improvement in the teaching of population-based medicine in the undergraduate curriculum; training of physicians, which includes special focus on the disciplines involved in population-based medicine; alteration of clinical training; development and promotion of self-care programs; more emphasis on epidemiology and bio-statistics; and the establishment of institutes of law and ethics to deal with health-related problems.

Unlike other countries which have established some form of national health insurance, the United States is debating this profound social program in facing all problems of financing and managing personal health services simultaneously: elimination of cost at time of service, sharing this cost equitably through the tax system, distributing the services equitably geographically, controlling rapidly rising costs and managing the organizational structure of services. Originally in other countries the primary objectives were to free citizens of the burden of costly illnesses, improve access across income groups, and share the costs more or less equally. Now other countries are expressing the problems found simultaneously by the United States. It is argued that universal and comprehensive national health insurance spreads money and resources so thinly that specific and important problems such as pockets of high infant mortality or curable diseases are obscured and ignored. The United States should set up a health program which targets specific problems and mitigates high cost episodes rather than indulge itself in a comprehensive and universal national health insurance. This proposal is not politically feasibis, however, and predictions are made as to what will happen in the United States within the politically and culturally determined range of debatable options.

This paper examines the available evidence on the impact of economic factors on the specialty and locational choices of physicians. Economic variables which influence the “rate of return” to the physician (profitability in relation to training costs) to alternative specialties and locational decisions include average yearly income, hours of work, price for each health service and training costs.

The findings of the review indicate that the rate of return to specialty training varies substantially among specialties. Rates of return to training in surgery and radiology are nearly three times that of other medical specialties. These rates of return differences are shown to have a small, albeit significant, effect on a physician's specialty as well as location choices. Furthermore, there is a positive relationship between the mean fees of physicians and the physician population ratio in an area, i.e., areas with more physicians have higher fees. Confounding the relationship between economic variables and specialty and locational choice is the fact that physicians may have substantial amounts of market power and can themselves influence the price of their services. Thus, the influence of reimbursement policies to alter the distribution of physicians may be less effective because physicians may have the ability to influence and alter the level of income and rate of return to training.

This article gives a review of the hospice concept of care. The importance of caring for the patient and family as one unit for the purpose of addressing specific needs of each, and the specific needs of the dying patient and of his/her family are discussed.

The alleviation of symptoms and control of pain are of primary importance in terminal cases. Throughout the dying process the patient should be treated as a unique individual and his fear of isolation and abandonment must be overcome by the availability of personal attention. Although the patient receives a great deal of attention it is of vital importance to him/her that he/she is just as involved in giving as receiving.

The family is both an agency and a recipient of care. It is the task of hospice care to allow the family to go on living. Feelings of anticipatory grief — of which a definition is given — have to be reduced; the most difficult time for the family is however when the patient is very close to death. It is stressed that real exchange of feelings between family and the dying person is of utmost importance for both, and should be encouraged by hospice care.

The hospice staff should maintain contact with the family and close friends after the death of their loved one, to allow them ventilation of their feelings.

After World War II, a new socio-economic policy stimulated development of industry and the socio-economic reconstruction of Poland. One of the main objectives of the new social policy was to develop the national health service so that it was available to the whole population. The most important decisions made for the health services and health manpower development in Poland were the following:

• 1945

  Ministry of Health appointed as superior body responsible for organization and administration of national health services;

• 1951

  Medical and Pharmaceutical Faculties become Medical Academies under the administration of the Minister of Health. Medical schools for nurses, midwives, sanitary instructors, and allied health personnel placed under supervision of the Ministry of Health;

• 1954

  Sanitary epidemiological services organized and State Sanitary Inspection Act passed;

• 1956

  Industrial health service organized;

• 1960

  Minister of Health and Social Welfare appointed and charged with the administration of social welfare as well as rehabilitation and employment of invalids;

• 1971

  Medical care and medical aid made available free of charge for the entire population, including the rural popualtion previously not covered by health insurance system.

In the years 1946–1960, a tendency towards vertical centralization prevailed in the organization and administration of the health services. Subsequently, decentralization has dominated, with a tendency to integrate health services with the social services, especially at the provincial and county levels and, more recently, in the form of the Integrated Health Service Institutions at the local level.

In Southern Israel, rapid development and industrialization have generated strains affecting both the population (ca. 0.5 million immigrants and ca. 50,000 Bedouin) and the medical care agencies (of the General Labour Federation and other Sick funds, the Health and other Ministries, etc.). In Beer-Sheva, the Center of Health Sciences (CHS) of the Ben-Gurion University of the Negev (BGUN) is the scene of a concerted effort to change the orientation of health care. The direction of change is away from the impersonal (the hospital and the disease) and towards that demanded by the public (the community and the person). It is being accomplished by fundamentally changing the education of health personnel. Change is being implemented and mediated by a coordinating consortium of in-region and BGUN care and/or welfare agencies, that plans and evaluates the process and progress of change for which each agency is responsible. Infrastructural innovation, somewhat hampered by the inertias of tradition, consists of making the university hospital effectively serve the regional network of hospital-affiliated, community-oriented primary care clinics. Curricular innovation, enthusiastically accepted and flourishing, uses the concept of “the natural history of disease” in basic-science and clinical teaching. Teaching takes place not only in the wards, but also in outpatient and primary care clinics, and in the facilities for occupational health, rehabilitation and public health.