Planning for primary health care in Nicaragua: a study in revolutionary process

Recent changes in the political economy of Nicaragua have resulted in significant advances in public health. The improvements are due to changes in the health system which include comprehensive health planning, regionalization of health services and popular participation in health education and mass drug administration programs. Traditional structural approaches to the study of national health systems can benefit from an analysis of the process of change. The research reported herein focuses upon struggles between instructional actors who would professionalize primary health care and those who promote popular participation in the planning and execution of primary care programs. An analysis of decision-making within the Sistema Nacional Unico de Salud illustrates the process whereby a health system undergoes structural change from within. The Nicaraguan case suggests that the changing configuration of health systems is a dynamic process and the result of negotiation among several constituencies amid changing conditions in the world system. The role of a government seeking to democratize health delivery within a socialist political economy is to create and promote constituencies for the popular model and thereby institutionalize the debate.     

The merger of rural primary care and home health services.

The merger of rural primary care and home health services offers the potential for increasing the administrative efficiency of health care, and thereby enhancing the quality of care and increasing access to services, particularly health promotion. However, the proposed benefits of any merger can only be realized if the merger process is successfully completed. An analysis of the factors that were important in a case study of successful and unsuccessful mergers of rural health centers and home health care agencies in northeastern Vermont is presented. Three components were found to be necessary to start the merger process: complementary needs, opportunity, and common philosophy. The involvement and support of key individuals was crucial to sustaining merger interest. Good communication throughout the process contributed substantially to the maintenance of both community and staff support. Others considering similar mergers should recognize that the process of consolidating organizations and satisfying regulations takes some time to complete.     

Perceptions of community leaders and the merger of rural health services

The merger of rural primary care and home health services offers the potential of increasing the administrative efficiency of health care, and thereby enhancing quality of care and increasing access to services, particularly health promotion. In a merger of rural health services in Northeastern Vermont, a survey of key community leaders revealed that improved organization of services, improved health status and greater accessibility of services were benefits expected and to some extent realized as a result of the merger process. The desire to preserve community-based services and having a common philosophy were important factors which served to initiate the merger. The actions of a few key individuals and the support of involved organizations were instrumental in continuing the process.Dr. Smith is an Assistant Professor, Department of Health Services Management and Policy, The University of Michigan School of Public Health.Dr. Zuckerman is an Associate Professor, Department of Health Services Management and Policy, The University of Michigan School of Public Health.This study was supported by a grant from the W.K. Kellogg Foundation (UHG0001L/RAD).     

Case study of a failed merger of hospital systems

The failed merger between Geisinger Health System and Hershey Medical Center is an instructive case study. The advantages of merging include: 1) support of financially threatened academic health centers, 2) access to greater capital, and 3) integration of managed care principles in the delivery system. Nevertheless, if the leadership of the new organization fails to deal effectively with the inevitable winners and losers, underestimates the role of cultural differences, does not have the management skills necessary to achieve cost savings and address the operational inefficiencies resulting from a larger clinical enterprise, does not anticipate the distrust of other local health care providers, and fails to anticipate the market forces that determine the success or failure of a managed health care system, mergers can fail. Lessons to be learned include: mergers involving health care systems with competing programs need to plan aggressively and execute carefully their clinical consolidation; cultural differences and the impediments they cause can be easily underestimated; health system mergers do not automatically result in economies of scale; and not all stakeholders in the surrounding community necessarily will welcome a merger.     

Building a consensus for expanding health coverage

Despite a flourishing economy and recent growth in employment-based health coverage, forty-three million Americans remain uninsured. Extending coverage to the uninsured is not an intractable public policy problem but could be addressed if the various health care stakeholders could only find common ground. We argue that to win broad-based support from across the ideological and political spectra, a meaningful proposal should achieve a balance between public- and private-sector approaches, focus attention on those who are most in need of assistance (low-income workers), and build on systems that work today. With the aim of pulling together a political coalition, we present a proposal specific enough to attract support but whose details will arise later, in the context of the legislative process.     

Factors affecting the implementation of health legislation and its impact on the rural poor in China: a case study of implementation of the maternal and infant health care law in two poor counties

This paper presents and discusses a case study of health legislation in China. In the transition to a market economy, legislation has been developed to offset the weakening in the central planning mechanism and political control that have historically influenced the behaviour of institutions and individuals in the Ministry of Health. There has been relatively little empirical examination of the implementation and impact of legislation as a tool for influencing health service provision in low-income countries. The study aimed to contribute towards filling this gap by exploring the factors affecting the implementation and impact of the Maternal and Infant Health Care Law, through a case study of two poor, rural counties in Chongqing municipality, China. The study found that key local actors perceive health legislation to be an important tool for safeguarding access to essential health care. However, the implementation of health legislation is inevitably a political process. The study illustrates the difficulties involved in efforts to influence provider behaviour through a national level legislative framework in a situation of decentralization of control over those providers, due to extreme regional variation in economic situations and limited resource inputs from the centre. Lessons are drawn for Chinese and international policy makers.     

Health inequities: evaluation of two paradigms

Social work practice in health is shaped by underlying paradigms.To effectively target health inequities, practitioners need to consider appropriate paradigms. In this exploration of how six health paradigms shape theory and practice, the two health paradigms that most attended to health inequalities are social determinants of health and political economy. The article undertakes a critical review of the social determinants of health paradigm and the political economy paradigm regarding how they might shape social work theory and practice targeting health inequities.     

Health management guide. Managing mergers

Structural change is everywhere in the health service. Driven by political imperatives, the logic of the market and the frenetic pace of development in medical technology, the impetus on both purchasers and providers is towards merger into fewer, more influential organisations. But as health authorities combine to increase their purchasing power, moving ever closer to family health services authorities, and as trusts rethink patterns of service provision to maintain a competitive edge, are they getting it right? This Health Management Guide surveys the changing health service landscape and puts forward a practical manifesto for successful mergers.     

Changing organisations: a study of the context and processes of mergers of health care providers in England

This paper presents findings from a study of the context and processes of provider mergers in the NHS in England. Mergers are an example of organisational restructuring, a key lever for change in the UK health care sector and elsewhere, although it is only one strategy for organisational change. The framework for the study is key themes from the organisational change literature: the complexity of the effects of change; the importance of context; and the role of organisational culture. The drivers for health care mergers and the evidence for these are analysed. Using documentary analysis and in-depth qualitative interviews with internal and external stakeholders, the first part of the paper reports on stated and unstated drivers in nine mergers. This provides the context for four in-depth case studies of the process of merger in the second and third years post-merger. Our study shows that the contexts of mergers, including drivers of change, are important. Merger is a process without clear boundaries, and this study shows problems persisting into the third year post-merger. Loss of management control and focus led to delays in service developments. Difficulties in the merger process included perceived differences in organisational culture and perceptions of 'takeover' which limited sharing of 'good practice' across newly merged organisations. Merger policy was based on simplistic assumptions about processes of organisational change that do not take into account the dynamic relationship between the organisation and its context and between the organisation and individuals within it. Understanding the process of merger better should lead to a more cautious approach to the likely gains, provide understanding of the problems that are likely in the period of change, and anticipate and avoid harmful consequences.     

Maintaining population health in a period of welfare state decline: political economy as the missing dimension in health promotion theory and practice

There is increasing recognition in the health promotion and population health fields that the primary determinants of health lay outside the health care and behavioural risk arenas. Many of these factors involve public policy decisions made by governments that influence the distribution of income, degree of social security, and quality and availability of education, food, and housing, among others. These non-medical and non-lifestyle factors have come to be known as the social determinants of health. In many nations--and this is especially the case in North America--recent policy decisions are undermining these social determinants of health. A political economy analysis of the forces supporting as well as threatening the welfare state is offered as a means of both understanding these policy decisions and advancing the health promotion and population health agendas. The building blocks of social democracies--the political systems that seem most amenable to securing the social determinants of health--are identified as key to promoting health. Health promoters and population health researchers need to "get political" and recognize the importance of political and social action in support of health.     

Maintenance of subjective health during a merger: the role of experienced change and pre-merger social support at work in white- and blue-collar workers

Prospective research on psychosocial effects on employees' health associated with organizational mergers has been scarce. The first aim of this study was to explore the subjective health effects (exhaustion and functional incapacity) of an organizational merger among employees who had experienced a change in their own job position differently (improved, unaltered, and declined). Secondly, the effects of pre-merger social support (organizational, supervisor, and coworkers) at work on the experienced change in job position and on subjective health were examined. The merger took place in 1999 between two multinational firms of equal size. The study is based on two surveys (n=2,225) carried out in 1996 and in 2000 in the Finnish part of the company. The data on age, sex, pre-merger sickness absence (1996-98) and subjective health status (1996) were used as covariates. The results indicate that all sources of social support had a significant effect on the experience of change in one's job position. A decline in job position strongly increased the risk of poor subjective health after the merger. Weak organizational support was associated with impaired subjective health, especially in blue-collar workers, while weak supervisor support impaired functional capacity in white-collar workers. In turn, strong co-workers' support increased the risk of poor subjective health among blue-collar workers when their job position declined. We conclude that negative changes experienced in one's job position and lack of upper-level social support at work create a potential risk for health impairment in different employee groups in merging enterprises.     

Changes of subjective stress and stress-related symptoms after a merger announcement: a longitudinal study in a merger-planning company in Japan

To investigate the influences of a merger on employees in a Japanese company, changes of subjective stress and stress-related symptoms after a merger announcement in a major Japanese financial company were explored using longitudinal study surveys. Seventy-one participants responded to the first and second questionnaires, consisting of stress and symptoms, personal characteristics, lifestyle, medical examination, and work-related factors. After the merger announcement, the prevalence of subjective stress, anxiety, and impatience increased significantly from 46.5% to 78.9%, 18.3% to 40.8%, and 15.9% to 29.0%, respectively. The study suggests that subjective stress and stress-related symptoms may increase after a merger announcement. To reduce the negative impact of mergers, employers are expected to provide mental health-promotion programs in a merger-planning company.     

Beauty salons: a promising health promotion setting for reaching and promoting health among African American women.

African American women suffer disproportionately from a wide range of health disparities. This article clarifies how beauty salons can be mobilized at all levels of the social-ecological framework to address disparities in health among African American women. The North Carolina BEAUTY and Health Project is a randomized, controlled intervention trial that takes into account the unique and multilevel features of the beauty salon setting with interventions that address owners, customers, stylists; interactions between customers and stylists; and the salon environment. The authors make explicit the role of the political economy of health theoretical perspective for understanding important factors (social, political, historical, and economic) that should be considered if the goal is to create successful, beauty-salon-based interventions. Despite some important challenges, the authors contend that beauty salons represent a promising setting for maximizing reach, reinforcement, and the impact of public health interventions aimed at addressing health disparities among African American women.     

The Impact of Poverty,Chronic Illnesses,and Health Insurance Status on Out-of-Pocket Health Care Expenditures in Later Life

This study aims to examine poverty, chronic illnesses, health insurance, and health care expenditures, within the context of a political economy of aging perspective. Subsamples of 1,773 older adults from the Medical Expenditure Panel Survey were selected for analyses. The results showed that chronic illnesses influenced out-of-pocket health care costs. Older persons with more than one health insurance spent less on out-of-pocket health care costs. The results have implications for health care social workers concerned with the growing costs of chronic illnesses, implementing integrated care, and advocating for extending public health insurance coverage especially for our most impoverished older adults.     

浅析并购在医院改制中的实践

医疗市场竞争日趋激烈，医疗机构之间出现兼并与收购，是市场经济发展的必然结果，是资本运作的一个重要组成部分。通过并，色动因推动，医院获得并购的协同效益，完善自己的资本结构。本文同时分析了并购的一般程序．如何正确选择并购对象医院．保证并购的顺利实施，以及医院并购后要实现医院各种资源整合，避免貌合神离的局面．从而使医院在市场经济中发展壮大。     

Environmental justice research and action: a case study in political economy and community-academic collaboration

Community-university partnerships increasingly are being created to study and address environmental injustices. This article describes a case study of one such effort and its contributions to a decade-long community struggle to curb the growth of industrial hog operations and their adverse health effects in the United States' rural south. Worldwide transformation of livestock production from family farms to large-scale industrial agricultural complexes has resulted in the degradation of local environments, with negative impacts on public health. In the rural south, the concentration of industrial livestock operations has been most pronounced in low income African-American communities. Using political economy and community-based participatory research (CBPR) as a conceptual framework, this article explores the partnership between a strong community-based organization, Concerned Citizens of Tillery, and researchers at the University of North Carolina, Chapel Hill, School of Public Health to study and address this problem. The political, economic, and historical context of the partnership is examined, as are the challenges faced, and the partnership's contributions to maintaining grassroots community organizing and activism and affecting local policy change. Implications for other CBPR partnerships are discussed.     

Is it better to be big? The reconfiguration of 21st century hospitals: responses to a hospital merger in Sweden

OBJECTIVES: Swedish hospital mergers seem to stem from a conviction among policy makers that bigger hospitals lead to lower average costs and improved clinical outcomes. The effects of mergers in the form of multisited hospitals have not been systematically evaluated. The purpose of this article is to contribute to this area of knowledge by exploring responses to the merger of Blekinge Hospital. METHODS: The evaluation was guided by the philosophy of triangulation. A questionnaire was sent to 597 randomly selected employees, that is 24% of the health care staff. Four hundred ninety-eight employees answered the questionnaire, giving a response rate of 83%. Furthermore, interviews of different groups of stakeholders were conducted. RESULTS: A moderate increase of quality was assessed, which, a low proportion of the employees perceived had decisively or largely to do with the merger. The majority perceives economical incentives as the drivers of change, but, at the same time, only 10% of this group believes this target was reached completely or to a large extent. CONCLUSIONS: The employees believe the merger has neither generated economy of scale advantages nor substantial quality improvement. Instead, it seems more rewarding to promote cross-functional collaboration together with clinical specialisation. Needs for both integration and differentiation could thereby be fulfilled.     

The political and moral economy of aging: not such strange bedfellows.

The authors develop E.P. Thompson's concept of moral economy as a useful complement to contemporary political economic analysis in problem areas involving moral conflict. Defined as the shared assumptions underlying norms of reciprocity in which an economic system is grounded, moral economy is seen as holding particular relevance for the study of aging. The evolution of pension systems, the "senior revolt" against catastrophic coverage in the United States, and debates over the allocation of health resources between generations are used to illustrate the utility of a combined political and moral economy for enriching our understanding in these areas. Marx's concept of a "morality of emancipation" is described as holding particular promise for the development of a new moral economy of old age that would move beyond alienation by giving broad attention to quality of life issues at each stage of the life course.     

Toward a political and moral economy of aging: an alternative perspective.

A conceptual framework for empowerment of the elderly is proposed, using variations on Gramsci's hegemony and Thompson's moral economy to complement recent political economic and social psychological theories. The political economy and social psychology of aging highlight structural constraints and actors' reactions without articulating a model for empowerment. Gramsci's idea of hegemony as new moral and philosophical leadership calls for principles of social and economic organization deserving assent because they maximize people's chances for a decent life at all ages. Hegemony, as normalizing dominance, reveals ways in which the elderly may be disempowered as well as possibilities for intervention. Underlying diverse forms of hegemony are economic arrangements and an array of cultural norms. In contrast to Thompson, the authors argue that norms implicit in moral economy vary with changes in social context. In the process, two ideal types of moral economy are elaborated, grounded in exchange value and use value, respectively. Empowerment may be found through a moral economy grounded in use value appropriate to advanced industrial society that is consonant with Gramsci's new hegemony. Implications for health and income maintenance policies are explored.     

Polychlorinated biphenyls in the electrical machinery industry: an ethnological study of community action and corporate responsibility

Environmental and occupational health problems cannot be understood through purely medical and epidemiological analyses, the social forces affecting biologically adaptive behavior must also be analyzed. Research on the political economy of health needs to generate an ethnology of community action relevant to the analyses of corporate structures for which it is best known. In studying the community of Pittsfield, Mass., where a General Electric plant is located, we encountered environmental and occupational health problems in just this context. This essay is, therefore, an effort to extend the political economy of health into the ethnological domain of community research.