Search

The author presents the main features of the organization of the French health care system, revealing an important mixture of public and private actors and institutions and a large number of political restraints that oppose resistance to privatization. In spite of traditional references to "liberal medicine" and recurrent debates opposing public and private intervention, neither the doctors nor the political decision makers have really supported the few projects that have been proposed for privatization or liberalization of health care. On the contrary, the cost-control policy introduced growing State intervention and new management methods into the health care sector, whose actors were not used to it. The privatization and liberalization debates appear as a rhetoric necessary to accommodate these difficult changes.

Privatization has received significant attention in the popular and professional press. The notion has gained increasing political acceptance with the private sector being seen as cost-effective, innovative, and responsive. Private mental health initiatives will grow because the private sector is seen as an efficient allocator of resources and because there are profit opportunities in traditionally public services. However, a partnership between the private and public sectors will be required in planning and development, serving difficult groups, and defining and measuring quality of care.

Housing went through a major transition between 1940 and 1980 as the proportion of home owners nearly doubled. This article examines how that change took place. Compositional changes in the population and process changes led by post--World War II housing policies and programs are tested as explanations for the growth of home ownership. A process analysis and a decomposition of the change in home ownership between cohorts are used to evaluate each interpretation of change. A combination of both explanations accounts for the change in home ownership.

Health services in the Republic of South Africa (RSA) are provided by a mixture of public and private providers and institutions. Estimates of total health-related expenditure for 1985 range between 5.3% and 5.9% of gross national product (GNP), divided on approximately a 55:45 basis between public and private sectors. Basic preventive and curative services are provided by a hospital- and clinic-based public system. The public system does not adequately serve the rural areas and African tribal bantustans, and racial discrimination and/or segregation are obvious in its organisation and funding. The public sector's strength is the provision of state-subsidised care to many citizens who are unable to afford private medicine. The vast majority of hospitals are operated on a non-profit basis by government, industries, and voluntary agencies. Excluding hospitals that receive state subsidies, private investor-owned hospitals control about 10% of all hospital beds in the RSA. One-third of these investor-owned beds are held by state-dependent contractors providing long-term care. Two-thirds are wholly independent. Growth has been rapid in the independent hospital sector, and major corporations have entered the market. In 1985, over 85% of the white population was privately insured by a variety of prepayment programmes, including those organised through parastatal corporations and government departments. Despite major enrollment growth in the preceding decade, only 8% of blacks held private insurance by 1985; their coverage also tended to be less comprehensive. Faced with deficit financing, a sluggish economy, complaints from its white constituency about taxation levels, and pressure from private sector interest groups, the Nationalist government has endorsed the concept of privatisation of health care. Exponents of privatisation claim that it will permit differentiation by income to supplant discrimination by race. However, the direct links between disposable income and race, the rapidly rising costs of private insurance, and the still-limited extent of private coverage among the black majority, indicate that privatisation is likely to co-opt a comparatively small proportion of the total black population. It may exacerbate the urban-rural imbalance in health status and health services, promote growth of hospital-intensive curative services rather than needed expansion of community-centred preventive and primary care, and create financial barriers to access for low-income patients.(ABSTRACT TRUNCATED AT 400 WORDS)

The supply of acceptable quality, paid custodial home care is threatened by the increasingly precarious financial condition of providers. Examined were the trends of the publicly-owned, for-profit providers. Restrictive public payments and the lack of private insurance coverage have contributed to the financial woes. Changes are urgently needed which address the financing of home care.

The Second Vatican Council's emphasis on coministry--wherein clergy, religious, and laity share responsibility and assume accountability--has opened the way for new forms of ministry that respond to contemporary needs. One such need is in large institutional ministries traditionally sponsored by religious institutes or dioceses. As fewer religious are available to enter the health care ministry, some religious institutes are being forced to consider the transfer, sale, or closure of their institutions. In addition to these pressures on traditional forms of sponsorship, the health care needs of the poor also may demand lay sponsorship of some facilities. Since the laity are called to consider the "needs of the times" in determining the focus of their ministry, they should seriously consider the possibility of direct sponsorship of institutions dedicated to the health care of the poor. Although conditions prevailing in the Church and in society present a compelling challenge to the laity, this situation eventually may lead to a more positive understanding of the laity's place in the sponsorship of institutional ministries.

The contemporary expansion of investor-owned health care facilities has stimulated much controversy but little response from policymakers. We believe this results from the apparently ambiguous relationship between ownership and socially valued outcomes. In our assessment, this ambiguity occurs largely because the effects of ownership are mediated in complex ways by characteristics of the services being delivered and the training of health care providers. Reviewing both the history and current performance of nonprofit and for-profit health care facilities, we identify some of the more important of these mediating factors. Taking these into account, there is a consistent influence of ownership on the delivery of health services. On the basis of this analysis, we discuss appropriate policy responses to the future growth of investor-owned health care organizations.

The crumbling of the nation's public health care system is nowhere better illustrated than in St. Louis, Mo., where the city administration recently removed its ailing municipal hospital and clinics from public control in one quick, autocratic stroke. Helping the mayor "rescue" St. Louis "out of the health care business" were the city's business elite and the highly paid managers of National Medical Enterprises, one of the nation's largest for-profit health care corporations. The St. Louis story is just one local chapter of an unfolding tragedy which finds the poor and uninsured increasingly shut out and shunted aside as the nation's public and voluntary health sectors fall prey to what is euphemistically called "privatization."

The rapid development of private medicine in Sweden poses a challenge to that nation's traditional commitment to equity and a public system of health care. Economic constraints in public-sector spending, physician intent in private practice, popular interest in individual choice, and criticism of the public system have been the stimulus. The dominant Social Democrats will likely accept those elements of the private sector that are ideologically compatible, but resist others.

Most often, a county decides to sell its hospital without considering all of the alternatives for revitalizing the hospital or the ultimate consequences of the sale. Issues and recommendations regarding sale to investor-owned chains and not-for-profit systems as well as other arrangements are examined in this article.

Because of the religious values of their founders, Catholic colleges and universities are characterized by a dimension of service in addition to the goals of teaching and research. Through service to immigrants, minorities, older students, and the poor, they give evidence of their Catholic character. The responsibility for continuing the Catholic mission of higher educations rests with each institution's board of trustees and must involve a genuine partnership between lay and religious Catholics. The shift in governance, or "laicization," that has occurred in the last 20 years does not signify that a role for the original sponsoring body no longer exists. Rather, as Rev. David Hassel, SJ, recommends, a religious community must exercise "significant influence" and promote its corporate leadership in ways that do not intrude into governing authority. The fact that many institutions already have as presidents laypersons or religious from another community suggests that Catholic identity can be retained in the absence of the sponsoring group. Openness to such leadership and to new structures is essential to continuing the work of those who founded Catholic higher education.

The "privatization" of mental health services during the last decade has literally reshaped the way state and county departments of mental health go about fulfilling their statutory responsibilities. In Tennessee, a conference and later a task force examined the implications of this trend for the future. Two issues came to the forefront: Is it appropriate or possible for the private sector to take over the delivery of all mental health services, and if so, who will ensure that the poor receive adequate care? The Tennessee task force concluded that the privatization trend is appropriate and should be encouraged by government. It further concluded that government is ultimately responsible for ensuring access to care for the poor and uninsured although private facilities should provide some free care. Government best serves the poor by providing them the financial means to purchase care from private providers.

Many medical groups experience dilemma in negotiating buy-in agreements between owners and non-owner group members of clinic property. Anything less than broad-based ownership can promote a divisive undercurrent within the organization and the group's very perpetuity may be held in jeopardy. The author offers a complicated financing strategy which redistributes building equity, thereby reducing buy-in value.