Delivering the 'new' Canadian midwifery: the impact on midwifery of integration into the Ontario health care system

This paper addresses the impact on midwifery of its recent integration into the provincial health care system in Ontario, Canada. Data are derived from participant-observation, primary and secondary source documents, and key informant interviews. Based on these data, I argue that midwifery has changed throughout the integration process but it has also successfully resisted change. Specifically, the organisation of the midwifery community evolved from an amorphous social movement to a more bureaucratically organised profession. The regulation of midwifery also shifted from direct-regulation by clients to professional self-regulation. The educational model of midwifery also changed from an eclectic apprentice-based approach to a more standardised baccalaureate degree programme. The midwifery model of practice, however, was sustained. Although these changes occurred at the hands of key members of the midwifery community, they were made in response to the structural context of the health care system into which they were attempting to become integrated.     

A comparison study of access to health care under a Medicaid managed care program.

This article investigates the health care and insurance status of a low-income urban area in East Tennessee. The article reviews the background of TennCare, a compulsory Medicaid managed care program initiated in Tennessee in 1994. The study compared TennCare recipients with other insurance groups on key demographic and access variables. Possible explanations for how TennCare recipients rate their care also were examined. Qualitative analysis revealed accounts of long waiting periods, out-of-town specialist care, problems with obtaining pharmaceuticals, and general confusion about the new system. Implications of these findings for social work policy practitioners are discussed, and suggestions for alleviating the burden on patients are offered.     

Decentralization/regionalization in health care: the Quebec experience

The decentralization policy in Canada was initially aimed at decentralizing the management of services by creating regional bodies within which interested parties would participate in establishing priorities, elaborating programs, allocating resources and assessing program efficiency and effectiveness. A look at the Quebec experience provides insight into the difficulties and implications of decentralization.     

Connections between fiscal federalism and the funding of the Brazilian health care policy

In the Brazilian society's context of meager financial resources for health care, associated with structural features of fiscal federalism and with the current model of funding transfers for the Unified Health System's (SUS), important inequities directly impact political negotiations and the deployment of federal financing alternatives which are not directly linked to the supply and production of health care activities and services by states and municipalities. We observed that health policies, since the second half of the nineties, have developed their own mechanisms that, in the above mentioned context, tend to accommodate different interests and federative conflicts generated by structural factors and by institutional rules. However, the absence of an integrated planning program between the criteria to establish resource redistribution for financing the Unified Health System and the Brazilian Federation's fiscal sharing system, end up reinforcing certain asymmetric patterns and generating new imbalances, making the compensation of inequities difficult in public health spending at the sub-national domain.     

Evaluation of a community health representative program among the Cree of northern Quebec

The James Bay Cree Community Health Representative (CHR) program was implemented in 1984 to train persons from the Cree population of northern Quebec to act as health care advocates and educators, as intermediaries between the Cree population, health services and local organizations, and as participants in assessing health needs. A formative evaluation was initiated which included quantitative analysis of the daily tasks of CHRs and a qualitative component based on documentary research, observation and semi-structured interviews. The evaluation revealed that CHRs actively participated in the ongoing community health programs mainly through health education; the people interviewed showed a high level of satisfaction. However, direct supervision, sufficient continuing education for the CHRs and better integration into health care teams are long-term goals which need to be emphasized in the program.     

How federalism shapes public health financing, policy, and program options

In the United States, fiscal and functional federalism strongly shape public health policy and programs. Federalism has implications for public health practice: it molds financing and disbursement options, including funding formulas, which affect allocations and program goals, and shapes how funding decisions are operationalized in a political context. This article explores how American federalism, both fiscal and functional, structures public health funding, policy, and program options, investigating the effects of intergovernmental transfers on public health finance and programs.     

A preliminary comparison between local public health units in the Canadian Province of Ontario and in the United States.

This comparison between public health departments in the United States and in the Canadian Province of Ontario addresses the funding and staffing and the size and program content of local health departments after Canada''s national health reform provided universal access to personal health services. Ontario''s local health departments are required to provide a uniform set of public health services. In the United States, there is substantial variation among jurisdictions in kinds and amounts of services delivered. Ontario health units have staff sizes and budget levels that increase in proportion to population served, like those in the United States. But in Ontario, per capita expenditures increase with decreasing population, while the reverse is true in the United States. This anomaly may be attributed to lack of critical staff or elimination of key programs in small U.S. departments. Medical care of indigents probably accounts for the increased per capita costs seen in very large U.S. health departments. An estimated price for uniform public health services meeting the Ontario requirements in all U.S. jurisdictions as they were organized in 1989 is $5.8 billion per annum (not adjusted for inflation). If smaller health departments were consolidated, a savings of more than $1 billion could be realized. Even with this reorganization, average expenditures in smaller U.S. health departments would need to be doubled, and staff sizes increased by about 50 percent to meet Ontario''s uniform public health program standards.     

Women and health care: a comparison of theories.

There are three distinct approaches to the analysis of women's position in society, and thus of women's relation to the health care system. Liberal feminists seek equal opportunity "within the system," deman equal opportunity and employment for women in health care, and are critical of the patronizing attitudes of physicians. Radical feminists reject "the system" as one based on the oppression of women and seek to build alternative structures to better fill their needs. They see the division between man and woman as the primary contradiction in society and patriarchy as its fundamental institution. They have initiated self-help groups and women's clinics to extend the base of health care controlled by women in their own interests. Marxist-feminists see the particular oppression of women as generated by contradications within the development of capitalism. Women's unpaid labor at home and underpaid labor in the work force both serve the interests of the owners of capital. The health care system serves these same interests; it maintains and perpetuates the social class structure while becoming increasingly alienated from the health needs of the majority of the population.     

First Nations health care and the Canadian covenant

In this paper I explore the relationship between the Canadian state and Canada’s First Nations, in the context of the Canadian health care system. I argue that Canada’s provision of health care to its citizens can be best understood morally in terms of a covenant, but that the covenant fails to meet the needs of indigenous peoples. I consider three ways of changing the relationship and obligations linking Canada’s First Nations and the Canadian state, with regard to health care- assimilation, accommodation and separation. I argue that all of these options create problems, and at present there is a good argument for working with the status quo, accepting that First Nations are outside the covenant, and securing the state’s commitment to their health care on the basis of their citizenship and the liberal principle of equal treatment of citizens by the state.     

Consumer views of health care: a comparison of hospital and home care

A small interview study (n = 40) is described. Families were generally satisfied with their health care experience although they expressed a clear preference for home care as compared with hospitalization. A significant group of parents identified lack of information as a shortcoming of hospital care.     

Meeting the health care needs of female crack users: a Canadian example

Canada is an egalitarian society committed to accessible and comprehensive health care. Although there has been a tendency to assume that its various social welfare programs have improved health conditions for lower income citizens, Canada's record in ensuring health equality remains poorer than expected (Humphries and van Doorslaer, 2000; Wasylenki, 2001). The Canadian Health Act stipulates that all residents of Canada are to have access to medically necessary hospital and physician services based on need and not the ability to pay. However, for marginalized groups such as drug users and the homeless, structural barriers to better health remain. This paper examines the health care needs and experiences of 30 women who were heavily involved in the street life of crack and prostitution in Toronto. Through their ready access to local drop-in clinics and nearby hospitals, the women reported generally positive experiences with the health care system. The study concludes that the women experienced many of the health problems that typify homeless, poorly housed and economically marginalized groups. Both positive and negative experiences with the health care system, and structural barriers that hamper its full utilization, are identified.