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Purpose: Maintaining a healthy and productive workforce is a challenge for most organizations. This is even truer for health organization, facing staff shortages and work overload. The aim of this study is to identify the resources and constraints that influence managers' mental health and better understand how they are affected by them., Design/methodology/approach: A qualitative approach was chosen to document the resources, the constraints as well as their consequences on managers in their day-to-day realities. The sample included executive-, intermediate- and first-level managers from a Canadian healthcare facility. A total of 62 semi-structured interviews were conducted. The coding process was based on the IGLOO model of Nielsen et al . (2018) to which an employee-related level was added (IGELOO)., Findings: Results highlight the importance of considering both resources as well as constraints in examining managers' mental health. Overarching context, organizational constraints and the management of difficult employees played important roles in the stress experienced by managers., Practical Implications: The results offer a better understanding of the importance of intervening at different levels to promote better organizational health. Results also highlight the importance of setting up organizational resources and act on the various constraints to reduce them. Different individual strategies used by managers to deal with the various constraints and maintain their mental health also emerge from those results., Originality/value: In addition to addressing the reality of healthcare managers, this study supplements a theoretical model and suggests avenues for interventions promoting more sustainable organizational health., (© Emerald Publishing Limited.)

Background: Human health is dependent upon environmental health. Air pollution is a leading cause of morbidity and mortality globally, and climate change has been identified as the single greatest public health threat of the 21st century. As a large, resource-intensive sector of the Canadian economy, healthcare itself contributes to pollutant emissions, both directly from facility and vehicle emissions and indirectly through the purchase of emissions-intensive goods and services. Together these are termed life cycle emissions. Here, we estimate the extent of healthcare-associated life cycle emissions as well as the public health damages they cause.Methods and Findings: We use a linked economic-environmental-epidemiological modeling framework to quantify pollutant emissions and their implications for public health, based on Canadian national healthcare expenditures over the period 2009-2015. Expenditures gathered by the Canadian Institute for Health Information (CIHI) are matched to sectors in a national environmentally extended input-output (EEIO) model to estimate emissions of greenhouse gases (GHGs) and >300 other pollutants. Damages to human health are then calculated using the IMPACT2002+ life cycle impact assessment model, considering uncertainty in the damage factors used. On a life cycle basis, Canada's healthcare system was responsible for 33 million tonnes of carbon dioxide equivalents (CO2e), or 4.6% of the national total, as well as >200,000 tonnes of other pollutants. We link these emissions to a median estimate of 23,000 disability-adjusted life years (DALYs) lost annually from direct exposures to hazardous pollutants and from environmental changes caused by pollution, with an uncertainty range of 4,500-610,000 DALYs lost annually. A limitation of this national-level study is the use of aggregated data and multiple modeling steps to link healthcare expenditures to emissions to health damages. While informative on a national level, the applicability of these findings to guide decision-making at individual institutions is limited. Uncertainties related to national economic and environmental accounts, model representativeness, and classification of healthcare expenditures are discussed.Conclusions: Our results for GHG emissions corroborate similar estimates for the United Kingdom, Australia, and the United States, with emissions from hospitals and pharmaceuticals being the most significant expenditure categories. Non-GHG emissions are responsible for the majority of health damages, predominantly related to particulate matter (PM). This work can guide efforts by Canadian healthcare professionals toward more sustainable practices. [ABSTRACT FROM AUTHOR]

In industrial societies, work-related musculoskeletal disorders are common among workers, frequently resulting in recurrent injuries, work disability, and multiple compensation claims. The risk of idiopathic musculoskeletal injuries is thought to be more than twice the risk of any other health problem among workers in the health care sector. This risk is highly prevalent particularly among workers whose job involves frequent physical tasks, such as patient lifting and transfer. Workers with recurrent occupational injuries are likely to submit multiple work disability claims and progress to long-term disability. The objective of this study was to explore the influence of injury type and worker characteristics on multiple compensation claims, using workers’ compensation claims data. This retrospective study analyzed 11 years of secondary claims data for health care workers. Workers’ occupational groups were classified based on the nature of physical tasks associated with their jobs, and the nature of work injuries was categorized into non-musculoskeletal, and traumatic and idiopathic musculoskeletal injuries. The result shows that risk of multiple injury claims increased with age, and the odds were highest for older workers aged 55 to 64 (odds ratio [OR] = 3.5). A large proportion of those who made an injury claim made multiple claims that resulted in more lost time than single injury claims. The study conclusion is that the nature of injury and work tasks are probably more significant risk factors for multiple claims than worker characteristics. [ABSTRACT FROM AUTHOR]

Background: Much has been written about the state and persistent lack of progress regarding gender equity and the commonly referenced phenomenon of a 'leaking pipeline'. This framing focuses attention on the symptom of women leaving the workforce, rather than the well-documented contributing factors of hindered recognition, advancement, and financial opportunities. While attention shifts to identifying strategies and practices to address gender inequities, there is limited insight into the professional experiences of Canadian women, specifically in the female-dominated healthcare sector., Methods: We conducted a survey of 420 women working across a range of roles within healthcare. Frequencies and descriptive statistics were calculated for each measure as appropriate. For each respondent, two composite Unconscious Bias (UCB) scores were created using a meaningful grouping approach., Results: Our survey results highlight three key areas of focus to move from knowledge to action, including (1) identifying the resources, structural factors, and professional network elements that will enable a collective shift towards gender equity; (2) providing women with access to formal and informal opportunities to develop the strategic relational skills required for advancement; and (3) restructuring social environments to be more inclusive. Specifically, women identified that self-advocacy, confidence building, and negotiation skills were most important to support development and leadership advancement., Conclusions: These insights provide systems and organizations with practical actions they can take to support women in the health workforce amid a time of considerable workforce pressure., (© 2023. The Author(s).)

Objective: To determine the demographic and work characteristics of healthcare workers who were more likely to take sickness absences from work in British Columbia, Canada. Methods: Payroll data were analyzed for three health regions. Sickness absence rates were determined per person-year and then compared across demographic and work characteristics using multivariate Poisson regression models. The direct costs to the employer due to sickness absences were also estimated. Results: Female, older, full-time workers, long-term care workers and those with a lower hourly wage were more likely to take sickness absences and had similar trends with respect to the costs due to sickness absence. For occupations, licensed practical nurses, care aides and facility support workers had higher rates of sickness absence. Registered nurses, and those workers paid high hourly wages were associated with highest sickness related costs. Conclusion: It is important to understand the demographic and work characteristics of those workers who are more likely to take sickness absences in order to make sure that they are not experiencing additional hazards at work or facing detrimental workplace conditions. Policy makers need to establish healthy, safe and in turn more productive workplaces. Further research is needed on how interventions can reduce sickness absence. [ABSTRACT FROM AUTHOR]

Canada's healthcare sector produces the third highest healthcare-related emissions per capita globally. However, Canada has no national strategy toward environmentally sustainable healthcare. Transforming Canada's health systems to be environmentally sustainable requires leadership from many stakeholders and collaboration between trainees and health leaders. This article provides an overview of student and trainee leadership among health-related fields in response to the climate crisis and highlights the formation of a trainee-led organization focused on building capacity among emerging leaders in healthcare. We share key lessons learned by this group that are essential for all leaders seeking to leverage interdisciplinary action toward sustainable health systems in Canada., (Copyright © 2021 Longwoods Publishing.)

Background: Anthropogenic climate change poses a major health risk to humankind. The healthcare sector both contributes to climate change and is vulnerable to its impacts. Healthcare's greenhouse gas emissions are primarily derived from its supply chain: the production, transport, and disposal of goods., Methods: Document analysis was used to investigate the workplace policies of one large, Western Canadian healthcare organization. Policies that indicated how employees should engage with resources were reviewed through the lens of environmentally responsible practice and planetary health. Content and thematic analysis were applied., Results: Four themes were identified: procurement of resources, resource utilization, resource conservation, and waste management., Conclusion: There was little evidence of environmental or climate impact consideration within the organization's policies., Implications: Healthcare organizations could benefit from integrating a planetary health perspective into their policies to deliver healthcare that considers the health and safety of both humans and the climate., Competing Interests: Declaration of Competing Interest The authors have no conflicts to report. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: To monitor the magnitude of the drug shortage problem in Canada, since 2017, Health Canada has required manufacturers to report drug shortages. This study aimed to identify the factors associated with drug shortages in Canada., Methods: We conducted a retrospective cohort study of all prescription drugs available on the market between Mar. 14, 2017, and Sept. 12, 2018, in Canada. All drugs of the same active ingredient, dosage form, route of administration and strength were grouped into a "market." Our main outcome was shortages at the market level, determined using the Drug Shortages Canada database. We used logistic regression to identify associated factors such as market structure, route or dosage form, and Anatomic Therapeutic Chemical (ATC) classification., Results: Among the 3470 markets included in our analysis, 13.3% were reported to be in shortage. Markets with a single generic manufacturer were more likely to be in shortage than other markets. Markets with oral nonsolid route or dosage form were more likely to be in shortage than those that were oral solid with regular release (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.11 to 2.49). Markets for sensory organs were more likely to be in shortage than most other ATC classes. Markets with a higher proportion of drugs covered by public insurance programs were more likely to be in shortage (OR 1.03, 95% CI 1.00 to 1.05 per 10% increase)., Interpretation: Markets with a single generic manufacturer were most likely to be in shortage. To ensure the security of drug supply, governments should be vigilant in monitoring markets with a single generic manufacturer, with complex manufacturing processes, with higher demand from public programs or those that are in certain ATC classes., Competing Interests: Competing interests: Aidan Hollis has received compensation for having provided expert reports relating to patent litigation on behalf of Apotex, Mylan and Pharmascience. Paul Grootendorst has received compensation for expert reports relating to patent litigation on behalf of Apotex and Teva, and reports commissioned by the Canadian Generic Pharmaceutical Association. None of these reports are related to the topic of the paper. All authors report a grant from the Canadian Institutes of Health Research supporting the conduct of the study., (Copyright 2020, Joule Inc. or its licensors.)

Background: Public health and primary care are distinct sectors within western health care systems. Within each sector, work is carried out in the context of organizations, for example, public health units and primary care clinics. Building on a scoping literature review, our study aimed to identify the influencing factors within these organizations that affect the ability of these health care sectors to collaborate with one another in the Canadian context. Relationships between these factors were also explored.Methods: We conducted an interpretive descriptive qualitative study involving in-depth interviews with 74 key informants from three provinces, one each in western, central and eastern Canada, and others representing national organizations, government, or associations. The sample included policy makers, managers, and direct service providers in public health and primary care.Results: Seven major organizational influencing factors on collaboration were identified: 1) Clear Mandates, Vision, and Goals; 2) Strategic Coordination and Communication Mechanisms between Partners; 3) Formal Organizational Leaders as Collaborative Champions; 4) Collaborative Organizational Culture; 5) Optimal Use of Resources; 6) Optimal Use of Human Resources; and 7) Collaborative Approaches to Programs and Services Delivery.Conclusion: While each influencing factor was distinct, the many interactions among these influences are indicative of the complex nature of public health and primary care collaboration. These results can be useful for those working to set up new or maintain existing collaborations with public health and primary care which may or may not include other organizations. [ABSTRACT FROM AUTHOR]

Background: Work-related asthma (WRA) is the most common chronic occupational lung disease in the developed world. Several factors including sociodemographic status and occupation/industry increase the risks of developing WRA. In this study, we sought to identify changes in patterns and characteristics among patients with WRA over a 15-year period in an occupational lung disease clinic., Methods: We performed a retrospective analysis of patients with WRA charts at the Occupational Lung Disease Clinic of a University Hospital in Toronto, Canada. Patients were divided into two periods classified by first attendance at the clinic 2000 through 2007 and 2008 through 2015. Comparisons between the two periods included: sociodemographic characteristics, smoking status, occupations, exposures, and submitted workers' compensation claims., Results: Fewer occupational asthma cases were seen in the more recent period vs the earlier period (40 vs 74 cases), with a smaller reduction in work-exacerbated asthma cases (40 vs 58). The recent period included a significantly smaller proportion employed in the manufacturing industry and isocyanate-induced cases compared with the earlier period. An increased proportion were employed in health-care and education industries (primarily cleaners and teachers) in the recent period, consistent with a corresponding increased frequency of cleaning agents and dust exposures., Conclusions: The changes observed in work sectors in the patients with WRA in this clinic in Toronto are consistent with reductions reported in Ontario workers' compensation claims for occupational asthma and may relate to preventive measures. Cleaners and teachers should be a focus of further intervention measures for work-related asthma., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Although information systems (IS) have been extensively applied in the health sector worldwide, few initiatives have addressed the health and safety of health workers, a group acknowledged to be at high risk of injury and illness, as well as in great shortage globally, particularly in low and middle-income countries., Methods: Adapting a context-mechanism-outcome case study design, we analyze our team's own experience over two decades to address this gap: in two different Canadian provinces; and two distinct South African settings. Applying a realist analysis within an adapted structuration theory framing sensitive to power relations, we explore contextual (socio-political and technological) characteristics and mechanisms affecting outcomes at micro, meso and macro levels., Results: Technological limitations hindered IS usefulness in the initial Canadian locale, while staffing inadequacies amid pronounced power imbalances affecting governance restricted IS usefulness in the subsequent Canadian application. Implementation in South Africa highlighted the special care needed to address power dynamics regarding both worker-employer relations (relevant to all occupational health settings) and North-south imbalances (common to all international interactions). Researchers, managers and front-line workers all view IS implementation differently; relationships amongst the workplace parties and between community and academic partners have been pivotal in determining outcome in all circumstances. Capacity building and applying creative commons and open source solutions are showing promise, as is international collaboration., Conclusions: There is worldwide consensus on the need for IS use to protect the health workforce. However, IS implementation is a resource-intensive undertaking; regardless of how carefully designed the software, contextual factors and the mechanisms adopted to address these are critical to mitigate threats and achieve outcomes of interest to all parties. Issues specific to IS development, including technological support and software licensing models, can also affect outcome and sustainability - especially in the North-south context. Careful attention must be given to power relations between the various stakeholders at macro, meso and micro levels when implementing IS. North-South-South collaborations should be encouraged. Governance as well as technological issues are crucial determinants of IS application, and ultimately whether the system is seen as a tool, weapon, or white elephant by the various involved parties."You may call me a fool, But was there a rule The weapon should be turned into a tool? And what do we see? The first tool I step on Turned into a weapon. - Robert Frost""White (albino) elephants were regarded as holy in ancient times in Thailand and other Asian countries. Keeping a white elephant was a very expensive undertaking, since the owner had to provide the elephant with special food and provide access for people who wanted to worship it. If a Thai King became dissatisfied with a subordinate, he would give him a white elephant. The gift would, in most cases, ruin the recipient. - The Phrase Finder"

There are two sectors in the Canadian health ecosystem: the public sector, composed of hospitals, and the private sector, consisting of suppliers of drugs and services; both are aimed at providing optimal patient care. Currently, both sectors are struggling with the uncertainty and unpredictability plaguing the health environment. A mentoring pilot was aimed at providing solutions for both sectors by strengthening leadership development and accelerating the relationships with organizations from the other sector. The extra-organizational mentoring program included people from Roche Canada (private sector) and hospitals (public sector) whose participants are members of the Canadian College of Health Leaders. An evaluation of the program demonstrated that it was a positive and productive leadership development process for the majority of participants. The mentoring pilot helped advance partnerships based on trust and respect across the two sectors. The pragmatic process and demonstrable success of the program have gained far-reaching attention, and the program has influenced the development of other mentorship initiatives. Extra-organizational mentoring should be encouraged and actively developed with other health organizations., (Copyright © 2013 Longwoods Publishing.)

Introduction: There has been a surge of interest in the area of bias in industry-supported continuing medical education/continuing professional development (CME/CPD) activities. In 2007, we published our first study on measuring bias in CME, demonstrating that our assessment tool was valid and reliable. In light of the increasing interest in this area, and building on our experience, we wanted to further understand the application of this tool in different environments. We invited other CME/CPD providers from multiple sites in Canada to participate in a second CME bias study., Methods: A new steering committee was established with representatives from 5 academic CME/CPD offices nationally, the Royal College of Physicians and Surgeons, and the College of Family Physicians of Canada to outline the project in terms of review of the literature, refining items on the tool, updating the training guide for implementation, and establishing a resource Web site for reviewers. Training involved a train-the-trainer session with the event coordinators at each of the 5 participating centers via videoconferencing., Results: The content reviews from the study showed moderate inter-rater reliability (ICC = 0.54), and the live reviews showed poor overall inter-rater reliability; however, one center achieved substantial inter-rater reliability (ICC = 0.68)., Discussion: The analysis from this study suggests that the tool can be used as a part of a multistage process to introduce quality control mechanisms to help raise standards for CME/CPD. It is imperative to develop a cost-effective standardized training protocol that can be implemented at all sites to maximize the reliability of the tool., (Copyright © 2011 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.)

In the Chronicles of Narnia series by C.S. Lewis, Aslan the all-powerful but benevolent lion does not need to have his tail twisted; rather, he twists tails to create convergence and harmony in his dream world. In this issue's lead article, "Twisting the Lion's Tail: Collaborative Health Policy Making in British Columbia," the authors discuss the problems regarding better coordination of health services research, knowledge translation and policy making. The roles of academia, health authorities and government are presently unclear, with leadership differences, power discrepancies, conflicting agendas, lag times and systemic structural complexity. Exploring these issues in British Columbia, Lindstrom, MacLeod and Levy advocate a change in perspective from practice gaps to bridging knowledge boundaries. Recommendations include networking of academia, action research and strengthening of relationships between stakeholders. However, a key cohesive element seems missing. Health technology assessment (HTA) is a formidable, dynamic driving force. With over 20 years' experience in HTA, Canada has a number of world-class innovative agencies federally and provincially that actively involve academia to generate evidence for informed policy making. Increased use of evidence-based medicine in research and the clinic may be achieved by augmenting HTA's scientific capacity through the creation of pan-Canadian exchange forums and by boosting the demand for knowledge translation.

Growing demand from clients waiting to access vital services in a healthcare sector under economic constraint, coupled with the pressure for ongoing improvement within a multi-faceted organization, can have a significant impact on the front-line staff, who are essential to the successful implementation of any quality improvement initiative. The Lean methodology is a management system for continuous improvement based on the Toyota Production System; it focuses on two main themes: respect for people and the elimination of waste or non-value-added activities. Within the Lean process, value-added is used to describe any activity that contributes directly to satisfying the needs of the client, and non-value-added refers to any activity that takes time, space or resources but does not contribute directly to satisfying client needs. Through the revision of existing models of service delivery, the authors' organization has made an impact on increasing access to care and has supported successful engagement of staff in the process, while ensuring that the focus remains on the central needs of clients and families accessing services. While the performance metrics continue to exhibit respectable results for this strategic priority, further gains are expected over the next 18-24 months.

This study investigated whether both supervisor and coworker support may be positively related to affective commitment to the organization on one hand; and on the other hand, it examined the moderating effect of job resource adequacy and ambient conditions on these relationships. The sample included 215 participants working within a health care organization. Results of regression analysis showed that supervisor and coworker support have an additive effect on affective commitment. Hierarchical regression analyses indicated that supervisor and coworker support are more strongly related to affective commitment when job resource adequacy is high. Furthermore, ambient conditions moderate the relationship between supervisor support and affective commitment in such a way that favorable ambient conditions strengthen this relationship. Overall, these findings reinforce the importance of taking into account contingent factors in the study of antecedents of affective commitment to the organization.

As healthcare groups continue to communicate and collaborate at a distance, information and communication technology (ICT) has come to play an increasingly important role in supporting such interactions. In this paper, we describe key lessons learned from a two-year case study (2004-2006) on the impacts of conferencing technologies on social interaction norms within knowledge exchange groups.

Alas, there's nothing like a pinch of reality to pop an overinflated hype bubble. Yet not all software vendors that have fallen on hard times in recent years have succumbed to bankruptcy. In fact, Canadian software firms--MediSolution and Ormed--are proof that turnarounds are possible.

Objective: To provide a descriptive analysis of Canadian utilization (prescriptions, cost, cost per prescription) of antidepressants (ATC-code: N06A)., Methods: IMS Canada provided prescription volumes and costs from 1981 to 2000. We analyzed time trends for antidepressants in general and 4 subclasses (tricyclic antidepressants [TCAs], selective serotonin-reuptake inhibitors [SSRIs], dual action antidepressants [DAAs], and monoamine oxidase inhibitors [MAOIs]). Costs were discounted using the consumer price index, adjusting for population growth using data from Statistics Canada., Results: Between 1981 and 2000, total prescriptions increased from 3.2 to 14.5 million. Market share of TCAs (23.7%) and MAOIs (2.1%) remained constant, despite the introduction of the first SSRI, fluoxetine, in 1989. SSRI prescriptions increased to 6.7 million (market share 46.3%). DAA use increased gradually after 1994 to 3.5 million prescriptions (23.9% market share) in 2000. The number of prescriptions expanded (possibly due to SSRIs) by 238%, with an increased cost of 2.7 billion dollars. Total expenditures for antidepressants increased exponentially, from 31.4 million dollars in 1981 to 543.4 million dollars in 2000 (y = 4E - 130e(0.1556x) [R(2) = 0.99]). Cost per prescription increased linearly from 9.85 dollars in 1981 to 37.44 dollars in 2000 (y = 1.72x + 7.92 [R(2) = 0.96])., Conclusions: Utilization and costs of pharmacotherapy for depression have increased above the inflation rate and are expected to exceed 1.2 billion dollars (50 dollars per prescription) in 2005. Increased costs may be due to increased availability of new products with increased safety, efficacy, and acquisition cost; increased number of users; and increasing costs.

State-funded healthcare systems increasingly recognize accountability as an important public policy issue. This article explores significant aspects of current theory and practice in order to describe an accountability framework for the Canadian health system. Stakeholders include governments, institutions, providers and patients. Their relationships may be framed in constitutional, political, financial, managerial, clinical or ethical terms. The specific processes and instruments to operationalize accountability depend on the terms by which it is framed.

Purpose: To explore Canadian health sector initiatives addressing poverty., Methods: Information about 224 health sector initiatives addressing poverty was collected from Health Canada, provincial/territorial health ministries, and health regions., Results: Health Canada, 12 provincial/territorial health ministries, and at least one third of health regions have been undertaking poverty-related initiatives. Almost two thirds (64.7%) of initiatives focused on the consequences of poverty. Much less frequent were initiatives that aim to: raise awareness about poverty; prevent people from becoming poor; enhance skills and education of people in poverty; and alter social and economic conditions contributing to poverty., Discussion and Conclusions: While strategies that focus on the consequences of poverty likely enhance the health of Canadians in poverty, these strategies do little to reduce poverty rates. Efforts to improve the health of both individual Canadians in poverty and society as a whole will be limited until the health sector uses more strategies that challenge fundamental structural conditions contributing to poverty.

This paper analyzes the welfare economics of three arrangements for purchasing health insurance: competitive markets in which consumers are free to choose among options with different levels of coverage and prices; systems with compulsory partial pooling which permit private firms to sell supplementary coverage; and government-run pools that purchase comprehensive coverage at a single price for all consumers. Competitive insurance markets are assumed to face the problem of 'adverse selection'. This refers to a situation in which the insurer cannot observe characteristics of individuals that affect the cost of insurance and that are known to the individuals. Competitive markets with adverse selection are not efficient because low risks cannot purchase comprehensive insurance coverage. However, government-run pools with comprehensive coverage are an inefficient solution to the problem of adverse selection. Compulsory partial coverage may represent an attractive alternative to both competitive markets and comprehensive pools. We discover two situations when government intervention of this type will succeed: when there are not many high risks in the population, and when the risk types are similar. We discuss the implications of these results for health insurance programs in several countries. Our results also have implications for the allocation of public funds for disease-prevention projects. A project targeted at high risks will produce external benefits for low risks, even though they are not directly affected by the program. However, a successful project might eliminate the market for private insurance; in this case the government should consider mandating partial insurance coverage.

This article presents the findings from a research study conducted on the use of mission statements in not-for-profit health care organizations. In particular, the study sought to determine if a relationship exists between the initial "rationales" that led to the creation of a mission statement and hospital performance. The findings suggest that some of the rationales for developing mission statements are indeed more important than others and that organizational alignment with the mission statement is of key importance to both the mission's and the hospital's success.

Once again the United States is in a ferment of health policy reform. Proposals abound but sage observers remark that national health insurance has been "just around the corner" more than once in the last forty years. This time may be different, however. Proposals from all across the ideological spectrum are converging on the notion of "managed care" which is perhaps best known in its guise as a health maintenance organization (HMO). Other forms of managed care exist but they have neither the history nor the incentives found in traditional HMOs. The discussion on national health insurance (NHI) proposals has focused on financing issues to the virtual exclusion of public health concerns. In this article, the author addresses rural health and public hospitals in the United States; two problems that have been with us for a long time. Then articles examining the Canadian and English medical care systems are reviewed, illustrating some of the weaknesses of these approaches to national medical care. Research studies relating to Europe and the developing nations are next. Once again, these are intended to highlight public health problems found in differing medical care systems. Finally, the author examines utopian views of the United States medical care system of the future: the reform proposal offered by the National Association for Public Health Policy, the experimental policy in Washington State, and a vision of a planned system. The review is intended to draw together the lessons offered by public health policy research in other countries and the United States and apply them to the issue at hand: reforming the United States medical care system.