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China's 2009 health care reform agenda has been referred to as one of the most ambitious health policy programmes in modern history. Significant investment has combined with new structures, incentives, and regulations that have aimed to improve access, as well as gain greater control over a health care market much criticised for putting profit before patients. A range of health services research has been undertaken to analyse these efforts. Sociological perspectives have also been documented yet up to now a review and synthesis combining these various contributions has not been undertaken. By drawing on the lens of McDonaldization, the paper presents a narrative review that analyses the extent to which China's 2009 reform agenda has increased efficiency, calculability, predictability, and control over service provision. The review identifies elements of McDonaldization within China's 2009 reform agenda, however, notable gaps remain. In response to the limits of McDonaldization as a lens for understanding China's health care reform, the paper calls for alternative perspectives that are better able to understand the sociocultural dynamics shaping service provision, as well as an interdisciplinary research agenda that is able to generate new insights and understanding regarding health care in China. [ABSTRACT FROM AUTHOR]

The article focuses on the White Paper on community care titled "Caring for People" in relation to the 1990 National Health Service and Community Care Bill pending in the House of Lords. Criticisms levelled against the White Paper, particularly the issue of grant aid, are misplaced. The White Paper's outstanding value is that it outlines a clear structure and a set of general principles which should grant local authorities greater autonomy, authority and responsibility in healthcare administration.

In 2014 the authors of this paper, evaluators from China and Canada, jointly interviewed 12 policymakers in China at the national and provincial levels. This paper describes the needs of policymakers and how they view the evaluation capacity-building needs of the health system. The learnings from the policymaker dialogues informed the evaluation capacity-building efforts at three pilot sites in China. This paper focuses on the evaluation capacities needed by policymakers and implementers specifically to address inequities in the health sector, unlike most publications that focus on evaluation capacities of researchers. [ABSTRACT FROM AUTHOR]

This paper is a statement of the American Geriatrics Society's (AGS) core policy priorities and the Society's positions on federal programs and policies that support older Americans as articulated to the new administration. Among the AGS priorities discussed in this paper are health reform, Medicare, and Medicaid. The AGS is committed to leveraging its expertise to inform regulatory and legislative policy proposals. [ABSTRACT FROM AUTHOR]

Australia is undergoing major aged care reforms, changing from the previous service provider‐driven approach to consumer‐directed care principles. In residential aged care, this has resulted in a significant reduction in government funding in order to support reform initiatives in home and community‐based care. There has been limited research on the impact of structural aspects of the reforms such as the effect of changes in funding focus. Using a qualitative descriptive research methodology, this study explores the impact of the reforms on staff at various levels of operational responsibility in residential aged care. Issues identified by participants centered on the capacity to deliver care in three areas, the impact of funding reduction, challenges in meeting increasingly complex needs of residents and their families, and new requirements for care roles within current limitations. This paper provides an insight into how and why operational issues have informed the findings of the current Australian Royal Commission into Aged Care Quality and Safety. It identifies areas of support for the aged care workforce that are crucial in fulfilling consumer‐focused care delivery. [ABSTRACT FROM AUTHOR]

Evidence-informed health policy making (EIHP) is becoming a necessary means to achieving health system reform. Although Canada has a rich and well documented history in the field of evidence-basedmedicine, a concerted effort to capture Canada's efforts to support EIHP in particular has yet to be realized. This paper reports on the development of EIHP in Canada, including promising approaches being used to support the use of evidence in policy making about complex health systems issues. In light of Canada's contributions, this paper suggests that scholars in Canada will continue engaging in the field of EIHP through further study of interventions underway, as well as by sharing knowledge within and beyond Canada's borders about approaches that support EIHP. [ABSTRACT FROM AUTHOR]

The residential aged care industry in Australia will expand rapidly over the next 10 years leading to substantial increases in government expenditure. Recent and future reforms are likely leading to changes in the structure of the industry with a potential impact on quality of care. The purpose of this paper is to stimulate broader public debate, based on the available evidence, about the preferred structure of this important industry. It examines the literature on the impact structure has on the quality of services and compares this with a fresh analysis of current trends. The paper argues that future policy should be evidence based and explicit about the structure of the industry that will emerge from current policy reforms. [ABSTRACT FROM AUTHOR]

Health care is a complex system with multiprofessional staff and multiple patient care pathways. Time pressure and minimal margins for error make it challenging to implement new policies or procedures, no matter how desirable. Changes in health care also requires the participation of the staff. System dynamics (SD) simulations can lead to shared systems understanding and allows for the development and testing of new scenarios in silico before implementing solutions. However, research shows that the actual implementation rate of simulations is low. This paper presents a reanalysis of a successful change project in health care combining SD principles with basic action research (AR) premises. The analysis was done by a multidisciplinary research group using qualitative methodology and identifies that a fruitful combination of AR inquiry and SD modelling potentially can improve implementation rates. [ABSTRACT FROM AUTHOR]

Abstract Within the context of globalization, health care reform is occurring around the world. This paper explores the neoliberal mind set shaping health care reform in the UK, Canada, United States, Australia and New Zealand. Neoliberalism is comprised of three principles: individualism, free market via privatization and deregulation, and decentralization. After describing the nature of a health care system that is shaped by those embracing this mind set, an alternative approach is introduced that could bring dignity and a human face to health care. The basic premise of the paper is that we must broaden our analysis of health care by understanding and challenging the neoliberal mind set. [ABSTRACT FROM AUTHOR]

Aim To explore the debate on the development of the nurse practitioner profession in the Netherlands. Background In the Netherlands, the positives and negatives of nurse practitioners working in the medical domain have been debated since the role was introduced in 1997. The outcome of the debate is crucial for nurse practitioners' professional development and society's justification of their tasks. Method Review of 14 policy documents, 35 opinion papers from nurses, 363 opinion articles from physicians and 24 Dutch research papers concerning nurse practitioners from 1995 to 2012. Results Two discourses were revealed: one related to efficiency and one to the development of the profession. In both, the nurse practitioner role was presented as a solution for healthcare and workforce problems, while arguments differed. The efficiency discourse seemed most influential. Opinions of nurse practitioners were underrepresented; taking up new responsibilities was driven by the wish to improve patient care. While most physicians were willing to delegate tasks to nurse practitioners, they wished to retain final responsibility for medical care. Limitations All available publications were extensively studied, which could not include unpublished policy documents from the government or influential parties. This may have led to some selectivity. Conclusion The case of the Netherlands shows that nurses in developing their advanced role are facing barriers, similar to those in other countries. The dominance of efficiency arguments combined with protection of medical autonomy undermines the development towards nursing care that really benefits patients. Implications for nursing and health policy Nurse practitioners should strive to obtain positions in which they are allowed to make their own decisions and wise use of healthcare resources for the good of patients and society. Nurse practitioners should aim to become members of influential healthcare Boards in their countries, in which they can raise their voices and be involved in policy making. [ABSTRACT FROM AUTHOR]

Health care services represent an extraordinary experimental ground for introducing wider political and institutional transformations of the state. The adoption of entrepreneurialism into European health care systems has strengthened technocratic decision making over traditional mechanisms of political control. In Italy, in the midst of a severe legitimacy crisis affecting the administrative and political systems at the beginning of the 1990s, New Public Management ideas seemed ‘the’ remedy against the pathological politicization of distributive politics. Much hope has been placed since in a new and ascending group of general managers, entrusted with the ambitious mission of running health care services more efficiently and with the unenviable expectation of resuscitating public trust in welfare institutions. By analysing the 1992 Amato government’s landmark health care reform in its substantive changes, this paper explores the last decade’s main reform trajectories of Italian health care reforms that irreversibly transformed its institutional arrangements and organizational structure, namely the enterprise formula and the regionalization of the health care sector. The paper suggests that the political turmoil of 1992–94 served as catalyst for radical policy change and argues that the single most important explanation for the enactment of New Public Management-type reforms rests in a new executive reinterpretation of its legislative prerogatives and function. [ABSTRACT FROM AUTHOR]

The poorest seven countries of the former Soviet Union (CIS-7) moved from a centralized system of health-care funding and delivery to a range of institutional and financial arrangements. The different paths chosen have implied different results in terms of available resources, internal efficiency, health-care inequality, and the corresponding incidence of public expenditures. This paper examines the level, composition and allocation of public spending on health, in light of the evolution of the health systems during the transition. The financial constraints experienced by CIS-7 countries were reflected in the decrease of health-care quality, the collapse of the already inefficient public health activities, and the increased incidence of out-of-pocket expenditures. These factors, alongside the increase in poverty, resulted in a decrease in health-care utilization, suggesting that these countries may experience difficulties in achieving the health-related Millennium Development Goals. [ABSTRACT FROM AUTHOR]

Sweeping changes to the Medicare program embodied in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), including a new prescription drug benefit, changes in payment policies, and reform of the Medicare managed-care program, have major implications for rural health care. The most efficient mechanism for research to affect policy is to provide policy makers with information on issues about which they have voiced concern. The Rural Policy Research Institute's Health Panel conducted 2 focus groups with 16 congressional staff in September 2004 to identify a set of researchable questions concerning the impact of the MMA on rural health care. This paper presents research questions in the following areas that staff identified as having the highest priority: access to health plans and pharmacy services, beneficiary outreach and enrollment, technology capacity, provider payment policy, and demonstration projects. [ABSTRACT FROM AUTHOR]

This paper reviews the current evidence base regarding efforts to overcome constraints to effective health service delivery in low and middle-income countries. A systematic literature review was chosen as the approach to gather and analyse existing knowledge about how to improve the ‘close-to-client’ health system. We focused on three levels of constraints: community and household, the health services delivery level itself, and health sector policy and strategic management. In total, 116 studies were reviewed and their main findings presented. The results should be interpreted with caution due to the considerable limitations in the existing evidence base. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

This paper discusses the development and implementation of structured guidelines that contained a fixed set of questions as part of a project in building evaluation capacity for addressing health inequities in the health sector in China. The ambition of the guidelines was to test whether a structured process of questions could aid teams that did not have a strong background in evaluation to complete equity-focused evaluations and also help raise the salience of health equity as an important goal of health systems reform among the participants of the project. The guidelines were informed by multiple perspectives that included the literature on social determinants of health, realist evaluation, and utilization/influence perspectives. One noteworthy aspect of this project was that the participants in this capacity-building project were local and national policymakers, practitioners, and university researchers. Our original goal was to test these guidelines in equity-focused policy interventions in three separate provinces of China. One key insight from this project was that there is a need to move away from a testing perspective to a developmental approach in formulating evaluation guidelines that can work across multiple organizational and country contexts and also closely reflect the needs of practitioners and policymakers in evaluation capacity-building efforts. [ABSTRACT FROM AUTHOR]

This article focuses on the politics in health care reforms in Great Britain. The state of the National Health Scheme had become an issue in the 1987 general election. Fundamental reform of the service, however, was not an election issue. The government were not committed to such reform, and the government's critics were largely concerned with the level of funding of the service. Only the alliance parties made radical proposals, endorsing aversion of the internal market idea. During 1987 and 1988 the NHS came to be perceived as being in a state of crisis by opposition politicians, commentators, the media and people working in it.

The introduction of individual budgets into English health care is a recent example of the pervasive drive towards personalisation in welfare sector organisation and delivery. As a heavily centralised and highly bureaucratic institution, the National Health Service (NHS) is an obvious target for personalisation. On the other hand, as a symbol of solidarity and nationhood it retains a powerful place within the collective psyche, such that radical reform might expect to encounter resistance. This paper analyses the assumptions that are inherent in personalisation and raises concerns over its ability to transform health-care services. At the heart of these concerns is the tension between appeals to tailored service provision and empowerment on the one hand, and promotion of a strong social contract, public trust in institutions, and collective identity on the other. Lessons are drawn for personalisation in other sectors and settings. [ABSTRACT FROM AUTHOR]

Measuring progress toward systems change, sustainable efforts that address root causes of an issue by changing policies and practices, is a difficult task for communities, evaluators, and foundations. Tracking and documenting changes in resources, power, policy, sustainable funding, structured relationships and roles, and underlying values require multi-level analyses. Systems change analysts must consider at least four “strata” at once: (1) events and trends, (2) patterns of interaction, (3) context and cultural or social models, and (4) the systems themselves. In this paper we provide a brief overview of systems change; a discussion of collaboratives as one “engine” of social change; a discussion of benchmarks and indicators of collaboratives focused on systems change; and suggestions for further research. The analysis draws upon several analytic frameworks described in the literature. We illustrate these concepts with examples from six systems change initiatives funded by The California Endowment. The need for further research is outlined. [ABSTRACT FROM AUTHOR]

Systems change has emerged as a dominant frame through which local, state, and national funders and practitioners across a wide array of fields approach their work. In most of these efforts, change agents and scholars strive to shift human services and community systems to create better and more just outcomes and improve the status quo. Despite this, there is a dearth of frameworks that scholars, practitioners, and funders can draw upon to aid them in understanding, designing, and assessing this process from a systemic perspective. This paper provides one framework—grounded in systems thinking and change literatures—for understanding and identifying the fundamental system parts and interdependencies that can help to explain system functioning and leverage systems change. The proposed framework highlights the importance of attending to both the deep and apparent structures within a system as well as the interactions and interdependencies among these system parts. This includes attending to the dominant normative, resource, regulative, and operational characteristics that dictate the behavior and lived experiences of system members. The value of engaging critical stakeholders in problem definition, boundary construction, and systems analysis are also discussed. The implications of this framework for systems change researchers and practitioners are discussed. [ABSTRACT FROM AUTHOR]

Successful community-based interventions require that change agents give attention to the complexities of interwoven systems, described in the literature as complicated or complex, purposeful or purposive. The author further notes the separate standards, norms, principles and/or goals (here-named systems-guides) of systems. This paper describes the author’s experience as a consultant to a multi-system collaboration where observed tensions among participants resulted in the author’s implementation of a three-step systems-guides model, which can increase change agents’ effectiveness with systems. The steps comprise: detection (of systems, systems-guides, and discrepancies between them; here through observation); documentation (of discrepancies; here through small group discussions); dissemination (to systems participants; here to the collaboration). Two small but fundamental systems changes emerged from systems participants, not from the change agent/author who facilitated systems members’ recognition of discrepancies. A major limitation in the implementation of this systems-guides model centers on the critical necessity of the close relationship change agents must have with the involved systems. [ABSTRACT FROM AUTHOR]

This paper highlights the problems of administering health insurance programmes in Latin America and the difficulties of imposing effective reforms. It examines the development, financial collapse and subsequent restructuring of a health insurance programme specifically targeting elderly people in Argentina. By the 1990s the Integrated Healthcare Programme (PAMI) had become one of the largest components of the country’s public welfare system, managing an annual budget of US $2.5 billion. It provided elderly people with a wide range of services, including free and discounted medical care and a national network of day centres. The Programme was widely praised as efficient and innovative both within Argentina and beyond and was considered a model which other developing countries might emulate. However, in 1994 it was discovered that PAMI had accumulated a deficit of US $1.3 billion and was suffering from a large number of serious structural weaknesses. These included a complete absence of financial accountability (both internally and externally), the piecemeal expansion of services, employment featherbedding, political patronage and corruption. Also, the Programme had contributed to long-standing inequalities between different geographical regions and between insured and uninsured populations. Since then, numerous attempts have been made to reform the Programme, some of which have received funding from the World Bank, but these initiatives are only being very gradually implemented. [ABSTRACT FROM AUTHOR]

Policy PointsThe predominantly fee‐for‐service reimbursement architecture of the US health care system contributes to waste and excess spending.While the past decade of payment reforms has galvanized the adoption of alternative payment models and generated moderate savings, uptake of truly population‐based payment systems continues to lag, and interventions to date have had limited impact on care quality, outcomes, and health equity.To realize the promise of payment reforms as instruments for delivery system transformation, future policies for health care financing must focus on accelerating the diffusion of value‐based payment, leveraging payments to redress inequities, and incentivizing partnerships with cross‐sector entities to invest in the upstream drivers of health. [ABSTRACT FROM AUTHOR]

One of the unintended effects of China's health care reforms is the emergence of unregistered practitioners. We discuss reasons for their development and their role in the urban health care provision system under consideration of general developments in health care provision and health governance - thereby drawing scientific attention to a by far under-researched topic. We analyse the basic characteristics and strategies of clinic-based unregistered practitioners in Guangzhou and examine their perception and utilisation by rural-to-urban migrants. The research design followed a qualitative dominant mixed methods research approach, which included expert interviews with representatives of administration, indepth interviews with practitioners and migrants, a quantitative survey with 450 migrants and field observations. According to our results, gaps in the formal health care system - especially lack of access of marginalised population groups and inadequate responsiveness - poor enforcement of regulation and corrupt executive personnel are responsible for their emergence and prevalence. [ABSTRACT FROM AUTHOR]

Government policy in the UK has been to provide comprehensive personalized health care to the whole population free at the point of delivery. However, the first major attempt to unify and regionalize the service in 1974 left a number of problems, and a further restructuring of the, NHS was required. This article reports on the results of research into the 1982 restructuring. The main feature of this second reorganization was the formation of territorial entities called "Districts "', and their organizational subdivision into "Units ". The kind and level of work and authority assigned to Districts and Units is discussed. An important finding, seemingly counter to official policy, is the existence of small Districts which operate at the same level as Units of the larger Districts. [ABSTRACT FROM AUTHOR]

This paper seeks to analyze the political factors involved in health care delivery in a modern industrial welfare state and to illustrate how the transformation of the French state has affected the policymaking environment surrounding this particular issue. Cultural traditions rooted in the nineteenth century seriously circumscribed the role of the state in defining the conditions of medical practice. Nonetheless, pressures emerging since 1945 for the provision of a wide array of social services have drawn the state into ever closer regulation of the health sector. The economic constraints of the past decade resulted in state-imposed cost-containment policies which accentuated the trend toward politicization of health care. In consequence, and despite the rear-guard defensive tactics of the medical profession, the French state has succeeded in firmly establishing its primacy in this major area of public policy. [ABSTRACT FROM AUTHOR]

Work on resilience in health and illness has been approached from a number of perspectives. These are the biological and psychosocial with a focus on the individual's responses to cope and adapt to changing circumstances wrought by changing physical health states. This we argue has a place but is far too narrow emphasizing the neoliberal view that the sick or imperfect individual is ultimately responsible for their own health outcomes. In this perspective, the individual's failure to cope or adapt may be seen as a personal failure to interact with the health system on offer. A broader sociological approach focuses on the overarching sociopolitical system within which health and illness occur and looks at the role of concepts such as growing social and economic inequity and the process by which neoliberalism establishes the framework of unequal opportunity and life chances. At this broader level, resilience relates to interplay between the sociopolitical and health systems and the individual. It is the role of the health system to provide opportunities, and supports and to reduce inequities to promote healthy lifestyle and beneficial coping approaches. We aim to understand and describe the mechanisms and opportunities afforded to individuals by their place in the social structure and to argue for health reform that makes a health system that assists all individuals be resilient. Longitudinal data from the Australian Epilepsy Longitudinal Survey are used to understand how income, inequity, and social isolation affect resilience over time. [ABSTRACT FROM AUTHOR]

Copyright of Politics & Policy is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

China faces an aging tsunami. By the end of 2016, the number of older adults aged 60 and older reached 230 million. This number is projected to reach 418 million by 2035 and peak at 487 million by 2053. The number of individuals aged 80 and older, the oldest adults, reached 26 million and continues to grow by 1 million a year. The socioeconomic context, characterized by an inverted pyramid family structure and the number of “empty nesters,” has greatly compromised traditional Chinese family support for older adults. This article aims to provide an overview of geriatrics development in China. It begins with a brief account of the dramatic demographic shift, major socioeconomic factors, China's healthcare system, and reform related to senior health with a historical perspective. It then describes recent advances in government policy and support and development of a geriatrics physician workforce, care models, primary care networks, and privately owned senior care facilities and support services. Although it is impossible to cover all aspects of the topic, it is hoped that this article provides readers an overall picture of Chinese geriatrics and senior healthcare development in a complex and evolving healthcare system. Geriatrics communities in the United States and around the world will undoubtedly learn and benefit from the unparalleled and continued efforts to address this unprecedented opportunity and challenge in China. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Administrative Sciences (John Wiley & Sons, Inc.) is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of International Social Security Review is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The United States continues to experiment with health care delivery and financing innovations, but relatively little attention is given to the public health system and its capacity for improving health status in the U.S. population at large. The public health system operates as a multisector enterprise in which government agencies work in conjunction with private and voluntary organizations to identify health risks in the population and to mobilize community-wide actions that prevent and contain these risks. The Affordable Care Act and related health reform initiatives are generating new interest in the question of how best to expand and integrate public health approaches into the larger U.S. health system. The research articles featured in this issue of Health Services Research cluster around two broad topics: how public health agencies can deliver services efficiently and how public health agencies can interact productively with other elements of the health system. The results suggest promising avenues for aligning medical care and public health practices. [ABSTRACT FROM AUTHOR]

In 2009 the national government of China launched massive health reforms, together with other social and economic reforms. For the first time, evaluation was included in the draft national plan of health reforms and development-the so-called '12th Five-Year National Plan for Health Development (2011-2015).' The Chinese and Canadian researchers, with the support of the International Development Research Centre, Canada, helped to facilitate a deliberative process by various actors by conceptualizing an indicators system and mapping out key questions to be addressed by evaluating implementation of the national health plan. The conceptual indicators system serves as a platform for users and implementers of evaluation program to understand needs for evaluation better and sharpen focus on more prominent dimensions such as equity and contextual analysis. [ABSTRACT FROM AUTHOR]

Commencing in 2017, the Medicare Access and CHIP Reauthorization Act ( MACRA) of 2015 will change how Medicare pays health professionals. By enacting MACRA, Congress brought an end to the (un)sustainable growth rate formula while also setting forth a vision for how to transform the U.S. healthcare system so that clinicians deliver higher-quality care with smarter spending by the Centers for Medicare and Medicaid Services ( CMS). In October 2016, CMS released the first of what stakeholders anticipate will be a number of (annual) rules related to implementation of MACRA. CMS received extensive input from stakeholders including the American Geriatrics Society. Under the Quality Payment Program, CMS streamlined multiple Medicare value-based payment programs into a new Merit-based Incentive Payment System ( MIPS). CMS also outlined how it will provide incentives for participation in Advanced Alternative Payment Models (called APMs). Although Medicare payments to geriatrics health professionals will not be based on the new MIPS formula until 2019, those payments will be based upon performance during a 90-day period in 2017. This article defines geriatrics health professionals as clinicians who care for a predominantly older adult population and who are eligible to bill under the Medicare Physician Fee Schedule. Given the current paucity of eligible APMs, this article will focus on MIPS while providing a brief overview of APMs. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits.Data Sources: West Virginia Medicaid enrollment and claims data from 2005 to 2010.Study Design: We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps.Data Collection: Data were obtained from the West Virginia Bureau for Medical Services.Principal Findings: We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan. [ABSTRACT FROM AUTHOR]

In Canada, as in other industrialized welfare states, definitions of health system sustainability reflect different goals and correspondingly diverse ways of understanding exactly what is to be sustained and how. In this article, we report on results from a survey of documents and groups involved in and/or concerned about sustainability of the healthcare system. We identify four broad narratives of sustainability in Canadian healthcare reform discourse, and explore what these different sustainability narratives tell us about the character and contours of these often-fractious debates. We argue that sustainability itself may not be a paradigm shift, as has been suggested, but a plot device that helps to steer the story in a particular direction, 'black-boxing' certain aspects of context and emphasizing others. [ABSTRACT FROM AUTHOR]

This article evaluates the efforts underway in India to achieve universal health care coverage and the conditions that fostered its contemporary evolution. It finds that India's health system is characterized by private provision and financing, horizontal and vertical fragmentation, and weak governance arrangements. The article argues that these defining characteristics, which have solidified over time, account for poor health outcomes and make the system impervious to reforms as they deny the government levers to intervene and shape outcomes in the sector. While the government's recent efforts of increased public funding of national programmes have helped to reduce out of pocket spending, these are unlikely to work in the long run unless the government addresses the sources of the problems. The article argues that building health care governance, strengthening regulatory architecture, and stewardship over the system, in conjunction with increased public spending, are essential if the health care system is to provide affordable care to the entire population. [ABSTRACT FROM AUTHOR]

There have been two major attempts to introduce market mechanisms into England's National Health Service: the 'internal market' reform project of the 1990s, and the 'quasi-market' of the 2000s. Despite their similarities, the former attempt was on balance unsuccessful while the latter succeeded. This article examines and compares the outcomes of the two periods, analysing the reasons for their relative successes and failures. It goes on to highlight options for future reforms that would build on those achievements. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The concept of emergence offers a new way of thinking about multimorbidity and chronic disease. Results and conclusions Multimorbidity and chronic disease are the end results of ongoing perturbations and interconnected activities of simpler substructures that collectively constitute the complex adaptive superstructure known as us, the person or patient. Medical interventions cause perturbations of many different subsystems within the patient, hence they are not limited to the person's bodily function, but also affect his general health perception and his interactions with his external environments. Changes in these domains inevitably have consequences on body function, and close the feedback loop of illness/disease, recovery and regained health. [ABSTRACT FROM AUTHOR]

Mexico has implemented several important reforms in how health care for its poorest is financed and delivered. Seguro Popular, in particular, a recently implemented social insurance program, aims to provide new funds for a previously underfunded state-based safety net system. Through in-depth ethnographic structured interviews with impoverished farmers in the state of Chiapas, this article presents an analysis of Seguro Popular from the perspective of a highly underserved beneficiary group. Specific points of tension among the various stakeholders-the government system (including public clinics, hospitals, and vertical programs), community members, private doctors, and pharmacies-are highlighted and discussed. Ethnographic data presented in this article expose distinct gaps between national health policy rhetoric and the reality of access to health services at the community level in a highly marginalized municipality in one of Mexico's poorest states. These insights have important implications for the structure and implementation of on-going reforms. [ABSTRACT FROM AUTHOR]

SUMMARY Corruption in Vietnam is a national concern that could derail health sector goals for equity, access and quality. Yet, there is little research on vulnerabilities to corruption or associated factors at the sectoral level. This article examines current patterns and risks of corruption in Vietnam's health sector and reviews strategies for addressing corruption in the future. The article builds on the findings and discussion at the sixth Anti-Corruption Dialogue between the Vietnamese government and the international donor community. Development partners, government agencies, Vietnamese and international non-governmental organisations, media representatives and other stakeholders explored what is known about important problems such as informal payments, procurement corruption and health insurance fraud. The participants proposed corruption-reduction interventions in the areas of administrative oversight, transparency initiatives and civil society participation and health reforms to change incentives. The analysis assesses the prospects for success of these interventions, given the Vietnamese institutional context, and draws conclusions relevant to addressing health sector corruption in other countries. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article focuses on federal budget and Medicare. It states that 20 percent of overall health care spending in the U.S. was accounted to Medicare. It says that the share of Medicare for national health expenditures (NHE) in federal actuaries project could be stable or decline between 2011 and 2019. It mentions that viewing health care costs through the lens of federal budgeting has been conventional. It adds that three major approaches to Medicare reform have been in reality including the voucher program, proposals to moderate program spending such as the Accountable Care Organizations (ACOs), and the protection of federal budget through the direct reduction of program benefits.

During the 1980s and 1990s, innovations in the organization, funding, and delivery of primary health care in Canada were at the periphery of the system rather than at its core. In the early 2000s, a new policy environment emerged. This policy analysis examines primary health care reform efforts in Canada during the last decade, drawing on descriptive information from published and gray literature and from a series of semistructured interviews with informed observers of primary health care in Canada. Primary health care in Canada has entered a period of potentially transformative change. Key initiatives include support for interprofessional primary health care teams, group practices and networks, patient enrollment with a primary care provider, financial incentives and blended-payment schemes, development of primary health care governance mechanisms, expansion of the primary health care provider pool, implementation of electronic medical records, and quality improvement training and support. Canada's experience suggests that primary health care transformation can be achieved voluntarily in a pluralistic system of private health care delivery, given strong government and professional leadership working in concert. [ABSTRACT FROM AUTHOR]

U.S. health policy is engaged in a struggle over access to health information, in particular, the conditions under which information should be accessible for research when appropriate privacy protections and security safeguards are in place. The expanded use of health information—an inevitable step in an information age—is widely considered be essential to health system reform. Models exist for the creation of data-sharing arrangements that promote proper use of information in a safe and secure environment and with attention to ethical standards. Data stewardship is a concept with deep roots in the science and practice of data collection, sharing, and analysis. Reflecting the values of fair information practice, data stewardship denotes an approach to the management of data, particularly data that can identify individuals. The concept of a data steward is intended to convey a fiduciary (or trust) level of responsibility toward the data. Data governance is the process by which responsibilities of stewardship are conceptualized and carried out. As the concept of health information data stewardship advances in a technology-enabled environment, the question is whether legal barriers to data access and use will begin to give way. One possible answer may lie in defining the public interest in certain data uses, tying provider participation in federal health programs to the release of all-payer data to recognized data stewardship entities for aggregation and management, and enabling such entities to foster and enable the creation of knowledge through research. [ABSTRACT FROM AUTHOR]

Background. Computer models played an important role in the health care reform debate, and they will continue to be used during implementation. However, current models are limited by inputs, including available data. Aim. We review microsimulation and cell-based models. For each type of model, we discuss data requirements and other factors that may affect its scope. We also discuss how to improve models by changing data collection and data access procedures. Materials and Methods. We review the modeling literature, documentation on existing models, and data resources available to modelers. Results. Even with limitations, models can be a useful resource. However, limitations must be clearly communicated. Modeling approaches could be improved by enhancing existing longitudinal data, improving access to linked data, and developing data focused on health care providers. Discussion. Longitudinal datasets could be improved by standardizing questions across surveys or by fielding supplemental panels. Funding could be provided to identify causal parameters and to clarify ranges of effects reported in the literature. Finally, a forum for routine communication between modelers and policy makers could be established. Conclusion. Modeling can provide useful information for health care policy makers. Thus, investing in tools to improve modeling capabilities should be a high priority. [ABSTRACT FROM AUTHOR]

Introducing market-like structures to public services is a key aspect of New Public Management. The restructuring of the NHS into an internal market of the 1990s is an example. Recent policies have further developed this notion. A new aspect of the restructuring is a focus on increasing the diversity of types of provider of healthcare organisations. The objectives of the restructuring policy entailing the increase in supply side diversity are examined, and the challenges raised by these changes are discussed. It is argued that the government is too optimistic about the benefits, and insufficiently concerned about possible undesirable consequences. [ABSTRACT FROM AUTHOR]

Context: Large-scale, whole-systems interventions in health care require imaginative approaches to evaluation that go beyond assessing progress against predefined goals and milestones. This project evaluated a major change effort in inner London, funded by a charitable donation of approximately $21 million, which spanned four large health care organizations, covered three services (stroke, kidney, and sexual health), and sought to “modernize” these services with a view to making health care more efficient, effective, and patient centered. Methods: This organizational case study draws on the principles of realist evaluation, a largely qualitative approach that is centrally concerned with testing and refining program theories by exploring the complex and dynamic interaction among context, mechanism, and outcome. This approach used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the case and follow its fortunes over the three-year study period. The methods included ethnographic observation, semistructured interviews, and scrutiny of documents and other contemporaneous materials. As well as providing ongoing formative feedback to the change teams in specific areas of activity, we undertook a more abstract, interpretive analysis, which explored the context-mechanism-outcome relationship using the guiding question “what works, for whom, under what circumstances?” Findings: In this example of large-scale service transformation, numerous projects and subprojects emerged, fed into one another, and evolved over time. Six broad mechanisms appeared to be driving the efforts of change agents: integrating services across providers, finding and using evidence, involving service users in the modernization effort, supporting self-care, developing the workforce, and extending the range of services. Within each of these mechanisms, different teams chose widely differing approaches and met with differing success. The realist analysis of the fortunes of different subprojects identified aspects of context and mechanism that accounted for observed outcomes (both intended and unintended). Conclusions: This study was one of the first applications of realist evaluation to a large-scale change effort in health care. Even when an ambitious change program shifts from its original goals and meets unforeseen challenges (indeed, precisely because the program morphs and adapts over time), realist evaluation can draw useful lessons about how particular preconditions make particular outcomes more likely, even though it cannot produce predictive guidance or a simple recipe for success. Noting recent calls by others for the greater use of realist evaluation in health care, this article considers some of the challenges and limitations of this method in the light of this experience and suggests that its use will require some fundamental changes in the worldview of some health services researchers. [ABSTRACT FROM AUTHOR]

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In the search for improved healthcare systems able to cope with rising costs, policy-makers are likely to turn to mixed-economy solutions. The lure of integrating ‘the best of both worlds’ generally leads to a blend of public and private providers, high regulation density as well as legal constraints on consumers based on top-down political prerogatives. The Swiss and Singaporean healthcare systems perfectly exemplify this strategy. Both combine market features and government planning. They differ significantly, however, when it comes to the specific policies being implemented and the scope of private sector involvement in each country. This article discusses the Swiss and Singaporean healthcare systems and highlights the dissimilarities between the two countries. [ABSTRACT FROM AUTHOR]

Objectives  To examine the management of recent policies for stronger patient and public involvement in Latin American health systems, identifying common features and describing local practice examples of relevance to the UK. Context  Participation is a core principle of many contemporary policies for health system reform. In Latin America, as in the UK, it is frequently associated with innovations in primary care services and their organizational developments. This shared interest in alternative models of local engagement offers new opportunities for collaborative research and policy development. Design  Commissioned by UK policy makers, a 4-year research programme was designed to promote exchanges with international counterparts focusing on how modern reform policies are being implemented. The selected countries possessed comparable principles and timeframes for their reforms. A series of individual country case studies were undertaken. Data were drawn from literature and documentary reviews; semi-structured interviews with national policy makers and expert advisers; and with management representatives at local exemplar sites. The aggregate data were subjected to thematic analysis applying a model for sustainable development. Results  Six common factors were identified in Latin American policies for stronger patient and public involvement. From these the most significant transferable learning for the UK relates to the position and status of professions and non-governmental agencies. Illustrative case exemplars were located in each of the eight countries studied. [ABSTRACT FROM AUTHOR]

The widespread development of comprehensive community initiatives that aim to improve community health is driven by the need to change the systems charged with delivering the services and creating the policies related to a variety of health outcomes. Georgia’s Family Connection initiative is the nation’s largest statewide network of community collaboratives for health, with collaboratives operating in 159 counties. Data on community context, collaborative processes, engagement in systems change, and changes in programs and activities implemented, gathered consistently at the collaborative level over 3 years, will be used to answer the following questions. How do community contexts and the structure and processes of collaboratives affect implementation of systems change? How do systems changes affect intermediate outcomes such as the type of programs offered in a community? Longitudinal change in systems change and program implementation is described and significant predictors of between-collaborative variation in longitudinal change for each outcome are identified. [ABSTRACT FROM AUTHOR]