Mapping the Zambian prison health system: An analysis of key structural determinants

Health and health service access in Zambian prisons are in a state of ‘chronic emergency’. This study aimed to identify major structural barriers to strengthening the prison health systems. A case-based analysis drew on key informant interviews (n?=?7), memos generated during workshops (n?=?4) document review and investigator experience. Structural determinants were defined as national or macro-level contextual and material factors directly or indirectly influencing prison health services. The analysis revealed that despite an favourable legal framework, four major and intersecting structural factors undermined the Zambian prison health system. Lack of health financing was a central and underlying challenge. Weak health governance due to an undermanned prisons health directorate impeded planning, inter-sectoral coordination, and recruitment and retention of human resources for health. Outdated prison infrastructure simultaneously contributed to high rates of preventable disease related to overcrowding and lack of basic hygiene. These findings flag the need for policy and administrative reform to establish strong mechanisms for domestic prison health financing and enable proactive prison health governance, planning and coordination.     

The prison setting as a place of enforced residence, its mental health effects, and the mental healthcare implications

The subject of place is salient certainly when deliberating the health of prisoners as a social group. This paper provides an overview and assessment of health and place in relation to mental health and the prison locale. Particular attention is devoted to prison culture, both staff and inmate. The incarceration experience (i.e. the nature of enforced residence in the prison environment) can affect negatively prisoners' mental health. The mental health of the prison population is poor, and mental health services in the prison setting have need of further improvement. However, the provision of mental healthcare and the pursuit of good mental health in the prison milieu are challenging. The prison-based—exceedingly complex—three-way relationship between culture–mental and health–mental healthcare is debated.     

Globalization,austerity and health equity politics: taming the inequality machine,and why it matters

The recognition that globalization has an important role in explaining health inequalities has now moved into the mainstream. Much of that role relates to what has been called ‘[t]he inequality machine [that] is reshaping the planet’. At the same time, more attention must be paid to how the state can tame the inequality machine or compensate for its effects. I argue that governments have more flexibility in this respect than is often acknowledged. With an emphasis on current and recent social policy in Britain, I illustrate the need for researchers and practitioners to focus not only on external constraints associated with globalization but also on domestic political mechanisms and dynamics that may limit the extent to which governments can reduce health inequalities by addressing underlying social determinants.     

How do we move forward on the social determinants of health: the global governance challenges

The final report of the WHO Commission on the Social Determinants of Health is the culmination of a huge analytical effort to review the evidence and produce clear policy measures for achieving health equity. Further consideration needs to be given to an effective political strategy for taking forward these measures. Framing health equity in relation to global health, linking it to other key policy priorities, recognising that normative differences rather than lack of evidence lies at the heart of the problem, creating an appropriate institutional form for taking forward the Commission's recommendations, being prepared to challenge the status quo in global governance, and reflecting on the strengths and limitations of WHO's role in global governance should be part of such a strategy.     

中国参与全球环境与卫生治理:机遇、挑战与对策

中国参与全球环境与卫生治理机遇与挑战并存。主要机遇包括:(1)全球环境与卫生治理的走向与中国在此领域的战略部署高度吻合,为其积极参与全球环境与卫生治理提供了强大的内生动力。(2)全球环境与卫生领域的资源为中国提供了有益的参考和借鉴,有利于加快和完善国内环境与卫生领域的治理。(3)全球环境与卫生问题具有公益性质,是中国展现负责任大国形象的重要领域。(4)当前全球环境与卫生治理的相关制度还有待规范和完善,这为中国争取更多的话语权提供了机遇。主要挑战包括:(1)中国国内环境与卫生问题层出不穷,从而使得中国参与全球环境与卫生治理时精力有限,同时也面临较大的国际压力。(2)中国缺乏全球环境与卫生战略。(3)全球"大卫生观"尚未完全建立,有待进一步拓展和完善。(4)智力支撑不足。(5)在中国国际定位方面,中外存在分歧且呈现扩大趋势。为有效参与全球环境与卫生治理,中国应统筹国内和国际两个层面采取一系列应对措施。     

Advancing health equity in the global marketplace: How human rights can help

The WHO Commission on Social Determinants of Health (CSDH) ascribed health disparities within and between countries to “a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.” This article analyzes the relevance of the international human rights framework (IHRF) to the Commission’s goal of reducing health disparities with reference to both social scientific and legal scholarship. We begin with an overview of the IHRF, demonstrating its potential as a challenge to the normative foundations of the emerging global economic order. We then survey the research literature on mechanisms to ensure accountability for realization of health-related rights, emphasizing the potential effectiveness of making human rights enforceable through the courts, and the special need for mechanisms to hold countries and international institutions accountable for obligations related to the human right to health. We conclude by identifying three key directions for further research, policy and advocacy: comparative human rights litigation, specifically the willingness of courts to address broad policy and budgetary issues; the conditions under which governments legislate or constitutionalize economic and social rights; and how rich, powerful countries affect economic and social rights outside their borders.     

Health workforce governance and oral health: Diversity and challenges in Europe

Throughout the life course, oral diseases are some of the most common non-communicable diseases globally, and in Europe. Human resources for oral health are fundamental to healthcare systems in general and dentistry is no exception. As political and healthcare systems change, so do forms of governance. The aim of this paper is to examine human resources for oral health in Europe, against a workforce governance framework, using England as a case study. The findings suggest that neo-liberalist philosophies are leading to multiple forms of soft governance at professional, system, organisational and individual levels, most notably in England, where there is no longer professional self-regulation. Benefits include professional regulation of a wider cadre of human resources for oral health, reorientation of care towards evidence-informed practice including prevention, and consideration of care pathways for patients. Across Europe there has been significant professional collaboration in relation to quality standards in the education of dentists, following transnational policies permitting freedom of movement of health professionals; however, the distribution of dentists is inequitable. Challenges include facilitating employment of graduates to serve the needs and demands of the population in certain countries, together with governance of workforce production and migration across Europe. Integrated trans-European approaches to monitoring mobility and governance are urgently required.     

Individual social capital, neighbourhood deprivation, and self-rated health in England

Individual social capital is increasingly considered to be an important determinant of an individual's health. This study examines the extent to which individual social capital is associated with self-rated health and the extent to which individual social capital mediates t.he relationship between neighbourhood deprivation and self-rated health in an English sample. Individual social capital was conceptualized and operationalized in both the social cohesion- and network resource tradition, using measures of generalized trust, social participation and social network resources. Network resources were measured with the position generator. Multilevel analyses were applied to wave 2 and 3 of the Taking Part Surveys of England, which consist of face-to-face interviews among the adult population in England (N(i) = 25,366 respondents, N(j) = 12,388 neighbourhoods). The results indicate that generalized trust, participation with friends and relatives and having network members from the salariat class are positively associated with self-rated health. Having network members from the working class is, however, negatively related to self-rated health. Moreover, these social capital elements are partly mediating the negative relationship between neighbourhood deprivation and self-rated health.     

Capitalism,the state and health care in the age of austerity: a Marxist analysis

The capacity to provide satisfactory nursing care is being increasingly compromised by current trajectories of healthcare funding and governance. The purpose of this paper is to examine how well Marxist theories of the state and its relationship with capital can explain these trajectories in this period of ever‐increasing austerity. Following a brief history of the current crisis, it examines empirically the effects of the crisis, and of the current trajectory of capitalism in general, upon the funding and organization of the UK and US healthcare systems. The deleterious effect of growing income inequalities to the health of the population is also addressed. Marx's writings on the state and its relation to the capitalist class were fragmentary and historically and geographically specific. From them, we can extract three theoretical variants: the instrumentalist theory of the state, where the state has no autonomy from capital; the abdication theory, whereby capital abstains from direct political power and relies on the state to serve its interests; and the class‐balance theory, whereby the struggle between two opposed classes allows the state to assert itself. Discussion of modern Marxist interpretations includes Poulantzas's abdication theory and Miliband's instrumentalist theory. It is concluded that, despite the pluralism of electoral democracies, the bourgeoisie do have an overweening influence upon the state. The bourgeoisie's ownership of the means of production provides the foundation for its influence because the state is obliged to rely on it to manage the supply of goods and services and the creation of wealth. That power is further reinforced by the infiltration of the bourgeoisie into the organs of state. The level of influence has accelerated rapidly over recent decades. One of the consequences of this has been that healthcare systems have become rich pickings for the evermore confident bourgeoisie.     

Lifestyle drift and the phenomenon of ‘citizen shift’ in contemporary UK health policy

Despite political change over the past 25 years in Britain there has been an unprecedented national policy focus on the social determinants of health and population‐based approaches to prevent chronic disease. Yet, policy impacts have been modest, inequalities endure and behavioural approaches continue to shape strategies promoting healthy lifestyles. Critical public health scholarship has conceptualised this lack of progress as a problem of ‘lifestyle drift’ within policy whereby ‘upstream’ social contributors to health inequalities are reconfigured ‘downstream’ as a matter of individual behaviour change. While the lifestyle drift concept is now well established there has been little empirical investigation into the social processes through which it is realised as policies are (re)formulated and implementation is localised. Addressing this gap we present empirical findings from an ethnography conducted in a deprived English neighbourhood in order to explore: (i) the local context in the process of lifestyle drift and; (ii) the social relations that reproduce (in)equities in the design and delivery of lifestyle interventions. Analysis demonstrates how and why ‘precarious partnerships’ between local service providers were significant in the process of ‘citizen shift’ whereby government responsibility for addressing inequity was decollectivised.     

Impact of the politics of austerity in the quality of healthcare: ethical advice

This article aims to provide a series of reflections before implementing a restructuring of health system management and cutbacks in health due to the possible consequences this may have on citizens' health. The Universal Declaration of Human Rights states that public healthcare shall be extended to the whole population in conditions of effective equality and overcoming geographical and social imbalances, based on a comprehensive approach to the healthcare system. All of this – while we are aware of the current situation of economic crisis – should be taken into account before carrying out adjustments that will harm the health of citizens and options or alternatives that will not affect equity and healthcare should be weighed up. In conclusion, management models that enable the empowerment of nursing are more justified than ever before, because it is nurses who mostly defend positions of patient advocacy towards attitudes of greater commitment and participation.     

The Irish health disadvantage in England: contribution of structure and identity components of Irish ethnicity

Background. Irish people living in Britain face a significant health disadvantage when compared to the white British host population.

Objectives. Using recent survey data, determine whether there is an ‘Irish health disadvantage’ independent of socio-economic factors and explore whether there is an Irish ethnic identity effect which operates on health.

Design. Data from the Census 2001 Individual Licensed SARs was analysed using binary logistic regression to study the relationship between the self-reported Irish ethnicity measure (which is presumed to reflect self-identification with Irish culture and community), considering country of birth subgroups, and the self-reported health measures of general health and limiting long-term illness. The analysis was adjusted for key demographic and socio-economic factors.

Results. When compared to the white British reference population, the self-reported ‘white Irish’ population overall, the Irish born in Northern Ireland, and UK-born Irish, show a significantly increased risk of both self-reported poor general health and limiting long-term illness. The increased risk of poor health of the Irish born in the Republic of Ireland is greatly diminished after the socio-economic adjustments, and only statistically significant in the case of general health. Finally, the Irish born in Northern Ireland who self-report as Irish are significantly more likely than those who self-report as British to report poor general health, which may suggest an Irish ethnic identity effect.

Conclusions. The findings demonstrate a persistent ethnic health disadvantage for first generation and UK-born Irish people living in England with respect to self-reported general health and limiting long-term illness, which cannot be fully explained by demographic and key socio-economic factors. Aspects of ethnicity related to both structure and identity may affect Irish self-reported health.     

Area social fragmentation, social support for individuals and psychosocial health in young adults: evidence from a national survey in England

This paper uses national survey data for young adults in England to explore empirically the relationships between social fragmentation in communities (measured for geographical areas), social support experienced by individuals from their immediate social circle, and psychosocial health of young adults. After reviewing previous research about these associations, we adopted an empirical approach to these questions, which was innovative in using data on area social fragmentation from a different source to the survey data on individuals. Also, we have examined the relevance for mental health of interactions between individual social support and area social fragmentation, as well as their independent associations with health. To test these ideas empirically, we present a statistical analysis, using survey data from the national Health Survey for England on young people aged 16-24 years, linked to a geographical indicator of social fragmentation, derived from the population census and with a measure of material poverty. The outcome variable was distress measured by the General Health Questionnaire (GHQ). In a logistic regression model that controls for grouping of individuals within areas we included data on individuals' sex, ethnic group, employment status, social class and educational level. Controlling for these indicators, we demonstrate that risk of individual distress (indicated by GHQ score of 3+) was significantly and positively associated with area social fragmentation and there was a significant association with social support received within the individual's immediate social circle, which was negative ('protective'). An index of material poverty in one's area of residence did not predict individual distress. There was no evidence that social support was more 'protective' in areas of greatest social fragmentation. We also note that while being in employment was associated with better mental health in this sample, higher educational level was associated with worse average levels of distress (controlling for age). We consider some of the policy implications of the findings.     

Governing people's lives. Strategies for improving the health of the nations in England, Denmark, Norway and Sweden.

Public health strategies reflect governments' wish to make people's lives longer and healthier. This can either be achieved by influencing the frames of people's lives and activities or the way they behave, i.e. to try to 'conduct their conduct'. In this paper the motivations for and methods of four national public health strategies are analysed. They are the English, the Norwegian, the Danish and the Swedish. Four questions are addressed: i) how is the governing activities aimed at improving the health of the population justified; ii) which issues are defined as problems; iii) which causes of the problems are identified; and iv) which governing techniques are suggested to solve the problems. The English and Danish programmes focus on mortality while the others give high priority to non-lethal diseases and conditions. The Danish programme mainly aims at making people conduct themselves in a more healthy way, i.e. change their behaviour, often guided by health professionals. The Norwegian paper has empowerment as its central strategy. The strategy is based on the assumption that if people get more power over their own lives they will become more healthy and behave in a more healthy way. The Swedish emphasis is on changing people's living conditions and much less is said about the role of the individual. The English programme launches a national contract where individuals and authorities should work both to change people's behaviour and their living conditions. All strategies deal with the increasing social inequality in health, the English and Swedish strategies more than the others. There does not seem to be a specific Nordic model in this field of welfare state politics.     

Health workforce governance: Processes,tools and actors towards a competent workforce for integrated health services delivery

A competent health workforce is a vital resource for health services delivery, dictating the extent to which services are capable of responding to health needs. In the context of the changing health landscape, an integrated approach to service provision has taken precedence. For this, strengthening health workforce competencies is an imperative, and doing so in practice hinges on the oversight and steering function of governance. To aid health system stewards in their governing role, this review seeks to provide an overview of processes, tools and actors for strengthening health workforce competencies. It draws from a purposive and multidisciplinary review of literature, expert opinion and country initiatives across the WHO European Region's 53 Member States. Through our analysis, we observe distinct yet complementary roles can be differentiated between health services delivery and the health system. This understanding is a necessary prerequisite to gain deeper insight into the specificities for strengthening health workforce competencies in order for governance to rightly create the institutional environment called for to foster alignment. Differentiating between the contribution of health services and the health system in the strengthening of health workforce competencies is an important distinction for achieving and sustaining health improvement goals.     

Worksite health promotion programs in the United States: progress, lessons and challenges

Worksite health promotion programs have become increasinglyprevalent in the United States, and one or more health promotionprograms are found in two-thirds of all private worksites with50 or more employees. Reasons for recent growth in program frequencyinclude increased concern for worker health, rapidly escalatingemployer payments for health care benefits to workers, and growingevidence of a strong linkage between employee health and productivity.Published results of evaluations to date suggest that worksitehealth promotion programs can have positive impacts on healthbehaviors and health status. In addition, economic analysesare suggesting that some programs can affect the slope of healthcare costs and have the potential of high cost-effectivenesscompared to some clinical interventions. A number of researchchallenges remain, particularly understanding the influencesof the worksite environment and how employee health promotionprograms affect individual and organizational productivity.     

Health needs of prisoners in England and Wales: the implications for prison healthcare of gender, age and ethnicity

This paper aims to provide evidence of the healthcare needs of prisoners in relation to gender, age and ethnicity, drawing from a larger systematic overview of the policy and research literature concerning primary care nursing in prisons in England and Wales. The literature overview shaped the initial stages of a research project funded by the Department of Health to examine the views and perspectives of prisoners and nurses working in prisons, and to identify good primary care nursing in the prison environment. At total of 17 databases were searched using search terms related to primary healthcare in prisons (health, nurs*, primary care, healthcare, family medicine, prison*, offender*, inmate*) with terms truncated where possible in the different databases. Following this, a sifting phase was employed using inclusion/exclusion criteria to narrow and focus the literature perceived as relevant to the research questions. All papers were critically appraised for quality using standardised tools. Findings from the literature overview show that prisoners are more likely to have suffered some form of social exclusion compared to the rest of society, and there are significantly greater degrees of mental health problems, substance abuse and worse physical health in prisoners than in the general population. Women, young offenders, older prisoners and those from minority ethnic groups have distinct health needs compared to the prison population taken as a whole, with implications for the delivery of prison healthcare, and how these needs are met effectively and appropriately.