Social and political actors in the formulation of health reform in Spain

An analysis of the participation of social and political actors in the process of formulating health policy allows one to understand the specific characteristics of the organization and operation of a health system. This study analyzes the drafting process for the General Health Act (LGS) in Spain with the purpose of establishing the relationship between social, political, and economic actors in both the formulation of the Act itself and the organization of the Spanish Health System. A case study was carried out from 1982 through 1986. Documentary parliamentary data, the medical press, national magazines and journals, and press reports by political, social, and public health actors were analyzed. The first version of the General Health Act presented by the Spanish Socialist Workers' Party (PSOE) proposed a health system with funding and public administration aimed at achieving universal health coverage, integrated care, community participation, and health education. This proposal was submitted to a complex negotiating process with business groups, unions, and health professionals. The General Health Act as finally approved excludes the principles of equity and incorporates private interests in health: "free choice of doctor and hospital", public funding and private administration of the health system, and the establishment of Social Security as the core of the entire health system.     

Results of a five-year community-based programme for cardiovascular disease prevention: The ATS-Sardegna Campaign

The objective of this study was to evaluate the effects of the ATS-Sardegna Campaign on lifestyle and cardiovascular disease (CVD) risk factors in the Sardinian population. The Campaign was a community-based public health action programme funded by the Sardinian Government with a view to prevent CVD and promote healthy behaviour. It was also part of the Targeted Project FAT.MA. of the Italian National Research Council (CNR), with the main purpose of evaluating the effects of this public health initiative after a five- year intervention. The evaluation was effected with three parallel procedures: individual interviews with 1486 randomly chosen people; assessment of eating patterns through a food-frequency questionnaire; measurement of the mean levels of the major CVD risk factors in 1729 randomly chosen subjects (1044 in the calendar year 1992, and 685 in 1995, two and five years, respectively, after the beginning of the Campaign). Overall, we recorded a favourable trend in eating habits in both sexes; a significant decrease in LDL-cholesterol in males, and in systolic and diastolic blood pressure in both sexes; a non- significant decrease in prevalence of smokers among males and increase among females. The ATS-Sardegna Campaign was the first CVD prevention programme in Italy to have attained reduction in the risk profile of an entire region at the lowest ever borne cost.     

Public Participation in the Process of Local Public Health Policy,Using Policy Network Analysis

Objectives:

To assess the current public participation in-local health policy and its implications through the analysis of policy networks in health center programs.

Methods:

We examined the decision-making process in sub-health center installations and the implementation process in metabolic syndrome management program cases in two districts (‘gu’s) of Seoul. Participants of the policy network were selected by the snowballing method and completed self-administered questionnaires. Actors, the interactions among actors, and the characteristics of the network were analyzed by Netminer.

Results:

The results showed that the public is not yet actively participating in the local public health policy processes of decision-making and implementation. In the decision-making process, most of the network actors were in the public sector, while the private sector was a minor actor and participated in only a limited number of issues after the major decisions were made. In the implementation process, the program was led by the health center, while other actors participated passively.

Conclusions:

Public participation in Korean public health policy is not yet well activated. Preliminary discussions with various stakeholders, including civil society, are needed before making important local public health policy decisions. In addition, efforts to include local institutions and residents in the implementation process with the public officials are necessary to improve the situation.     

Is having private health insurance associated with less support for public healthcare? Evidence from the Norwegian NHS

The purpose of this study was to investigate whether increased uptake of private health insurance (PHI) in a traditionally NHS type system is likely to affect support for the public healthcare system. Using the Norwegian healthcare system as our case, and building on a survey among 7500 citizens, with 2688 respondents, we employed multivariate analysis to uncover whether the preferences for public health services are associated with having PHI, controlling for key predictors such as socio-economic background, self-rated health and perceived health service quality, as well as age and gender. The basis for our analysis was the following two propositions related to the role of public healthcare, which the respondents were asked to score on a 5-point Likert scale (1 = “totally disagree”, 5 = “totally agree”): 1) “the responsibility of providing health services should mainly be public”, and 2) “the activity of private commercial actors should be limited”. The regression analyses showed that the willingness to increase the role of commercial private actors is positively associated with having a PHI. However, we found no relationship between holding a PHI and support for public provision of health services when other factors were controlled for.     

Public participation in health planning and priority setting at the district level in Uganda

OBJECTIVE: To explore the experiences of the public and leaders with participatory planning and priority setting in health, in a decentralized district in Uganda. METHODOLOGY: An exploratory qualitative approach, involving in-depth interviews with health planners at the national, district and community levels (n = 12), and five group discussions at community level with women (two groups), men, youths and adolescents (n = 51). The analysis adapted some principles from grounded theory. The five levels of the participation framework by Rifkin (1991) were used to assess the actual level of participation in the study population. RESULTS: Uganda has established structures for participatory planning. Within this context, district level respondents reported to have gained decision-making powers, but were concerned about the degree of financial independence they had. The national level respondents were concerned about the capacity of the districts to absorb their new roles. Actual involvement of the public in priority setting and poor communication between the different levels of the decentralization system, despite the existing structures, were additional concerns. Public participation is mainly through representatives. Majority participation is mainly at health benefits and programme activity levels. Decision-making, monitoring and evaluation, and implementation are still dominated by the locally elected leaders due to reported economic, social and cultural barriers that hinder the participation of the rest of the public.     

Process evaluation of a Dutch community intervention to improve health related behaviour in deprived neighbourhoods

OBJECTIVES: To assess whether a community intervention on health related behaviour in deprived neighbourhoods was delivered as planned and the extent of exposure to the intervention programme. METHODS: Data were gathered throughout the intervention period using minutes of meetings, registration forms and a postal questionnaire among residents in intervention and comparison neighbourhoods. RESULTS: Overall, the intervention was delivered according to the key principles of a "community approach", although community participation could have been improved. Neighbourhood coalitions organized more than 50 health related activities in the neighbourhoods over a two-year period. Most activities were directed at attracting attention, providing information, and increasing awareness and knowledge, and at changing behaviours. Programme awareness and programme participation were 24% respectively 3% among residents in the intervention neighbourhoods. CONCLUSIONS: The process evaluation indicated that it was feasible to implement a community intervention according to the key principles of the "community approach" in deprived neighbourhoods. However, it is unlikely that the total package of intervention activities had enough strength and sufficient exposure to attain community-wide health behaviour change.     

Privatizing indigent health services in Los Angeles County: understanding the effects on community-based providers.

Faced with imminent financial collapse of its public healthcare system, the Los Angeles County Department of Health Services solicited community-based providers to supply primary care health services to the medically indigent. This study highlights the effects that participation in the programme has had on these community providers. While strongly committed to the programme's objectives, community providers tended to overextend themselves financially, putting their organizations at substantial risk of failure should contractual expectations or patient demand forecasts not be met. Because of this risk, policymakers involved in public-private partnerships with community-based providers must exercise extreme caution owing to the unique status many of these providers hold as centrally positioned actors in their communities. On the positive side, we found evidence of increased levels of co-operation and innovation between community providers outside their formal roles in the county-sponsored public-private partnership programme.     

The mental health users’ movement in Argentina from the perspective of Latin American Collective Health

ABSTRACT

The mental health users’ movement is a worldwide phenomenon that seeks to resist disempowerment and marginalisation of people living with mental illness. The Latin American Collective Health movement sees the mental health users’ movement as an opportunity for power redistribution and for autonomous participation. The present paper aims to analyze the users’ movement in Argentina from a Collective Health perspective, by tracing the history of users’ movement in the Country. A heterogeneous research team used a qualitative approach to study mental health users’ associations in Argentina. The local impact of the Convention on the Rights of Persons with Disabilities and the regulations of Argentina’s National Mental Health Law are taken as fundamental milestones. A strong tradition of social activism in Argentina ensured that the mental health care reforms included users’ involvement. However, the resulting growth of users’ associations after 2006, mainly to promote their participation through institutional channels, has not been followed by a more radical power distribution. Associations dedicated to the self-advocacy include a combination of actors with different motives. Despite the need for users to form alliances with other actors to gain ground, professional power struggles and the historical disempowerment of ‘patients’ stand as obstacles for users’ autonomous participation.     

Implementation of public policy on alcohol and other drugs in Brazilian municipalities: comparative studies

One of the challenges with respect to public health and the abuse of alcohol and other drugs is to implement policies in support of greater co‐ordination among various levels of government. In Brazil, policies are formulated by the Secretaria Nacional de Políticas sobre Drogas (SENAD – State Department for Policies on Drugs) and the Ministério da Saúde (MS – Ministry of Health). This study aims to compare implementation of policies adopted by SENAD and MS at the municipal level. Three municipalities were intentionally selected: Juiz de Fora having a larger network of treatment services for alcohol and drug users; Lima Duarte, a small municipality, which promotes the political participation of local actors (COMAD – Municipal Council on Alcohol and Drugs); and São João Nepomuceno, also a small municipality, chosen because it has neither public services specialised to assist alcohol and other drugs users, nor COMAD. Data collection was conducted through interviews with key informants (n = 19) and a review of key documents concerned with municipal policies. Data analysis was performed using content analysis. In Juiz de Fora, there are obstacles regarding the integration of the service network for alcohol and other drug users and also the articulation of local actors, who are predominant in the mental health sector. In Lima Duarte, while there is a link between local actors through COMAD, their actions within the local service network have not been effective. In São João Nepomuceno, there were no public actions in the area of alcohol and drugs, and consequently insufficient local debate. However, some voluntary, non‐governmental work has been undertaken. There were weaknesses in the implementation of national‐level policies by SENAD and the MS, due to the limited supply of available treatment, assistance and the lack of integration among local actors.     

A template for improved prevention and control of cardiovascular disease in sub-Saharan Africa.

Cardiovascular disease (CVD) is rapidly becoming an important public health problem in sub-Saharan Africa, yet the response so far is often minimal and inadequate. While there is, undoubtedly, a 'double burden of disease' (persisting infectious diseases co-existing with emerging non-communicable disease), this is hardly reflected in current health planning, possibly due to a limited appreciation of the changing pattern of CVD and CVD risk factor exposure. In a situation where there are also considerable budget constraints and well-established infectious disease priorities, it is difficult to implement effective interventions for prevention or treatment of CVD. Yet such planning is urgently needed and a template for a comprehensive programme, adaptable to local situations, is presented here. The first step is to raise awareness and create evidence-based commitment among policy-makers, which could lead to the establishment of a multi-sectoral CVD unit at national level. Programmes need to focus on prevention of modifiable risk factors at population level, involving a wide range of institutions and individuals. Recommended strategies include decentralizing the design and implementation of programmes, with appropriate standardized surveillance of major risk factors, all complemented by operational, epidemiological and basic research.     

Cardiovascular Health Outcomes of Latinos in the Affordable Housing as an Obesity Mediating Environment (AHOME) Study: A Study of Rental Assistance Use

Studies have shown that households subsidized with vouchers live in higher quality units and exhibit fewer physical, mental, and social problems than do their peers living in public housing. However, none of these studies have included cardiovascular outcomes. The objective of this study was to assess if use/type of rental assistance is independently associated with poor cardiovascular health among Latino adults (ages ≥18) who are eligible for federal low-income rental assistance and living in the Bronx, NY. Data from the cross-sectional, Affordable Housing as an Obesity Mediating Environment study, collected over 18 months (January 2011 to August 2012) were used. The prevalence of cardiovascular disease (CVD) outcomes was determined by measured high blood pressure and self-reported heart attack and/or stroke. Type of housing status was defined as: public housing units, units subsidized by section 8 vouchers, and units unassisted by either federal program. Statistical techniques used were analysis of variance and multivariate logistic regression. The prevalence of CVD was significantly higher among public housing residents than unassisted participants even in the presence of all individual level covariates. Public housing residents also have higher levels of CVD than do section 8 participants. The prevalence of CVD was similar for unassisted and section 8 participants. These findings point to the potential for health benefits arising from housing voucher use even within a fairly delimited geographic area.     

Influence of an Interdisciplinary Re-employment Programme Among Unemployed Persons with Mental Health Problems on Health,Social Participation and Paid Employment

Purpose To evaluate the influence of an interdisciplinary re-employment programme on labour force participation and perceived health among unemployed persons with common mental health problems. In addition, the influence of entering paid employment on self-rated physical health and mental health was investigated. Methods In this quasi-experimental study with 2 years follow up, 869 persons were enrolled after referral to an interdisciplinary re-employment programme (n?=?380) or regular re-employment programme (n?=?489). The propensity score technique was used to account for observed differences between the intervention and control group. The intervention programme was provided by an interdisciplinary team, consisting of mental health care professionals as well as employment specialists. Mental health problems were addressed through cognitive counselling and individual tailored job-search support was provided by an employment professional. Primary outcome measures were paid employment and voluntary work. Secondary outcome measures were self-rated mental and physical health, measured by the Short Form 12 Health Survey, and anxiety and depressive symptoms, measured by the Kessler Psychological Distress Scale. Changes in labour force participation and health were examined with repeated-measures logistic regression analyses by the generalized estimating equations method. Results The interdisciplinary re-employment programme did not have a positive influence on entering employment or physical or mental health among unemployed persons with mental health problems. After 2 years, 10% of the participants of the intervention programme worked fulltime, compared to 4% of the participants of the usual programmes (adjusted OR 1.65). The observed differences in labour force participation were not statistically significant. However, among persons who entered paid employment, physical health improved (+16%) and anxiety and depressive symptoms decreased (?15%), whereas health remained unchanged among persons who continued to be unemployed. Conclusions Policies to improve population health should take into account that promoting paid employment may be an effective intervention to improve health. It is recommended to invest in interdisciplinary re-employment programmes with a first place and train approach.     

Understanding community participation: a health programme in the Philippines

The principle of community participation is so well recognizedin international health circles that no declaration about primaryhealth care is made without it.1 Yet in actually planning andimplementing programmes it is very difficult to find clear waysof following this principle. This paper analyses the concreteaspects of community participation in the Munoz-community basedhealth programme, a small nongovernment health programme fundedby Missionary Medical Actions (MEMISA - the Netherlands) andestablished in Munoz, Nueva Ecija, the Philippines. The programme started as a parish based charity clinic witha policy of free consultations and medicines but underwent agradual evolution towards a mother and child health (MCH) programme,with a growing emphasis on the participation of the (pregnant)mothers and community health workers (CHWs) in the villages.The sponsoring agency, staff members and CHWs agreed to strivefor financial independence by the year 1990-91. This would requirea better cooperation with the Rural Health Unit (the governmentpublic health sector) at the programme level, and a higher degreeof community participation at the level of the community ifthe MCH-programme was to be maintained after the discontinuationof external financial support. An intensive debate among staff members and CHWs revealed alack of clear understanding of the concept of community participation.Specifically, the absence of an instrument to assess the processof community participation resulted in a vague and unsatisfactoryanalysis of the situation. Recently, an analytical frameworkfor such an analysis has been developed2 which focuses on participationas a process, enabling an assessment of participation to gobeyond the limits of a merely quantitative analysis. It appearsto be a useful instrument for analysing community participation,describing what has been achieved and identifying some of theelements that influenced this process. We have applied thisframework retrospectively to our programme as described here.     

Knowledge, attitudes and cardiovascular risk factors in Danish adults.

A community cardiovascular disease (CVD) prevention programme was undertaken in 1989 in a Danish County (Vejle). A random sample of 5192 adults were asked to complete a mailed questionnaire on knowledge, attitudes, and behaviour in relation to CVD risk factors. The response rate was 56%. The questionnaire produced baseline data for programme planning and measuring the success of on-going interventions. Smoking, overweight, and unhealthy food habits were the most prevalent CVD risk factors. A CVD risk score was calculated from the data on smoking, food habits, exercise, stress, overweight, self-reported presence of hypertension, diabetes, and gender. A high score was commoner in men, in the least educated, in groups who judged their own risk as high, and in groups with negative health beliefs. The level of knowledge about CVD risk factors was high in general. Low knowledge was commonest in the youngest age group, in the least educated, in unskilled workers, and in groups with negative health beliefs. As social position and personality factors seem to play an important role in actions people may take in prevention of CVD, they should be considered in the planning of the health promotion activities in Vejle.     

Promoting social inclusion for young people affected by psycho-social disability in India – a realist evaluation of a pilot intervention

ABSTRACT

India has 600 million young people, more than any other country in the world. Mental illness is the leading burden of disease for young people, and those affected experience restrictions in social participation that compromise recovery. The aim of this study was to assess the impact of a peer-led, community-based, participatory group intervention on social inclusion and mental health among 142 young people affected by psycho-social disability (PSD) in Dehradun district, Uttarakhand. Qualitative data were obtained via in-depth interviews and focus-group discussions. A realist evaluation identified contextual factors, mechanisms and outcomes to develop the programme theory. Group participants described intermediate outcomes including establishment of new peer friendship networks, increased community participation, greater self-efficacy (for young women particularly), and improved public image (for young men) that are likely to have contributed to the primary outcomes of greater (self-perceived) social inclusion and improved mental health (as assessed quantitatively). Mechanisms were identified that explain the link between intervention and outcomes. These findings demonstrate the effectiveness of a brief intervention to improve mental health and social inclusion for young people with PSD and are potentially relevant to programme implementers and policy-makers working with young people and promoting social inclusion, in other low- and middle-income settings.     

District health systems in a neoliberal world: a review of five key policy areas

District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a 'second generation' reform--to be superseded by third generation reforms with a market orientation--flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass campaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor.     

'The public is too subjective': public involvement at different levels of health-care decision making

There are a number of impulses towards public participation in health care decision making including instrumentalist, communitarian, educative and expressive impulses and the desire for increased accountability. There has, however, been little research looking systematically at the public's preferences for being involved in particular types of rationing decisions, nor indeed, has there been a critical examination of the degree of involvement desired by the public. The research reported here uses findings from focus groups and in-depth interviews to explore these questions. Eight focus groups were conducted with a total of 57 informants, four amongst randomly selected members of the public and four with informants from health and non-health related organisations. Nineteen interviews were conducted to allow the elaboration of focus group comments, to probe views more deeply and to pursue emerging themes. The findings show variations in the willingness of members of the public to be involved in health care decisions and consistency across the different forms of the public as represented by the focus groups with randomly selected citizens and pre-existing organisations. There was a strong desire in all the groups for the public to be involved both at the system and programme levels, with much less willingness to be involved at the individual level. At the system and programme levels informants generally favoured consultation, without responsibility for decisions, but with the guarantee that their contribution would be heard and that decisions taken following consultation would be explained. At the patient level informants felt that the public should participate only by setting criteria for deciding between potential beneficiaries of treatment. The public has much to contribute, particularly at the system and programme levels, to supplement the inputs of health care professionals.     

School health education and gender: an interactive effect?

Post-primary school students (n = 2407) and young adults (n = 477) participated in a cross-sectional evaluation of a health education programme for schools. The Lifeskills programme is based on a philosophy of student empowerment, and aims to teach knowledge and skills relevant to health promoting behaviour. School students were recruited in schools, while young adults were opportunistically recruited in workplaces, training centres and on public transport. Those who attended schools where Lifeskills had been taught and who remembered such lessons were conservatively classified as the intervention group, while those who attended other schools and did not remember such lessons were classified as the comparison group. Participants completed questionnaires designed to collect data on health-related behaviours, indicators, knowledge and psychological health. School-level factors were employed as covariates in subsequent analyses of covariance. Amongst younger pupils, females reported more positive health behaviours but lower levels of psychological well-being and more symptoms. The impact of the programme became evident at ages 13-15. Those involved drank less and reported more positive adjustment to school. However, sex differences remained, with females reporting more health-promoting behaviour and more symptoms, and lagging behind males in self-esteem and general well-being. An interaction between gender and the intervention was identified among senior pupils. Exposure was especially beneficial for females. However, as young adults, the two main effects of gender and programme participation re-emerged as the most important independent variables, and the interaction between them was not significant. This pattern has implications for the interpretation of evaluations conducted on short-term interventions as well as for short-term impact evaluations.     

Social capital and leisure time physical activity: a population based multilevel analysis in Malmö, Sweden

Objective: To investigate the influence of social capital and individual factors on the level of leisure time physical inactivity in the neighbourhoods. Methods: The public health survey in Malmö 1994 is a cross sectional study. A total of 5600 people aged 20–80 years were invited to answer a postal questionnaire. The participation rate was 71%. A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second, was performed. The effect (intra-area correlation, cross level modification, and odds ratios) was analysed of individual and neighbourhood (the 1993 migration out of an area as a proxy for social capital) factors on leisure time physical inactivity after adjustment for individual factors. Results: Neighbourhood factors accounted for 5.0% of the crude total variance in physical inactivity. This effect was significantly reduced when the individual factors, especially country of origin, education, and social participation, were included in the model. In contrast, it was not reduced by the introduction of the contextual social capital variable. Conclusion: This study suggests that in the neighbourhoods of Malmö leisure time physical inactivity is mainly affected by individual factors.