Consequences of increased third-party payments for health care services.

The growth of third-party programs to pay the costs of health care has occurred in an unplanned manner. As a result, the country presently is faced with a number of uncoordinated payment programs that sometimes work against each other. While the expansion of health insurance programs has provided the financing necessary to keep our health care system up-to-date, and while such programs doubtlessly have reduced the financial barriers to seeking health care for some population segments, health insurance also has produced some problems. Generally, the contribution of health insurance to these problems is subtle and cannot be quantified. Yet, policymakers increasingly are recognizing that there are factors at work in our health care system that, if continued unabated, will exacerbate the country's health care cost problem. Many of these factors owe their existence to the socially unacceptable incentives provided by most health insurance programs. This article focuses on some of the adverse consequences of health insurance programs and indicates that the future of private health insurance depends upon how these problems are addressed.     

The aging of the population and health services

The demographic revolution--engendered in large part by modern medicine--which has led to the extraordinary and continuing increase in the number and proportion of elderly persons in the population has profound implications for health services. The elderly are disproportionately heavy utilizers of health care, primarily because of the prevalence of chronic disease. In the United States most health care for the elderly is financed through public funds, and costs have been increasing at an alarming rate. There is wide consensus that, for all the excellence of performance of the medical care system in treating acute episodes, care of chronic disease is frequently unsatisfactory in both quality and cost. Given the demographic imperatives, reform of mechanisms for chronic care is thus essential.     

Suicide rates and mental health services in modern China

Suicide rates in China have in the past been reported to be very low for a variety of historical and political reasons. In recent years, however, the reported suicide rates in China have increased alarmingly among certain age groups. This article reviews reports of the national rural suicide rates in China for 1992, gathered from the Annal of Chinese Public Health, which has previously never been reported publicly. The highest suicide rates occur in the rural areas and among young women and men over 60 years. These data reveal that suicide in China may have some unique characteristic associated with a variety of socio-cultural variables, such as traditional culture, social class, economic status, health care levels, and interpersonal problems. The author shows that lack of mental health services in rural areas in China may be considered one of associated reasons to the high rural suicide rate in China.     

Decentralisation and government provision of public goods: The public health sector in Uganda

While many developing countries have devolved health care responsibilities to local governments in recent years, no study has examined whether decentralisation actually leads to greater health sector allocative efficiency. This paper approaches this question by modeling local government budgeting decisions under decentralisation. The model leads to conclusions not all favourable to decentralisation and produces several testable hypotheses concerning local government spending choices. For a brief empirical test of the model we look at data from Uganda. The data are of a type seldom available to researchers–actual local government budgets for the health sector in a developing country. The health budgets are disaggregated into specific types of activities based on a subjective characterisation of each activity's ‘publicness’. The empirical results provide preliminary evidence that local government health planners are allocating declining proportions of their budgets to public goods activities.     

The third sector, user involvement and public service reform: a case study in the co-governance of health service provision

The ‘modernization’ of British public services seeks to broaden public sector governance networks, bringing the views of third sector organizations, the public and service users (among others) to the design, management and delivery of welfare. Building on previous analyses of the contradictions generated by these roles, this paper draws on longitudinal qualitative research to enunciate the challenges faced by one third-sector organization in facilitating service user influence in a UK National Health Service (NHS) pilot programme, alongside other roles in tension with this advocacy function. The analysis highlights limits in the extent to which lateral governance networks pluralize stakeholder involvement. The ‘framing’ of governance may mean that traditional concerns outweigh the views of new stakeholders such as the third sector and service users. Rather than prioritizing wider stakeholders' views in the design and delivery of public services, placing third sector organizations at the centre of governance networks may do more to co-opt these organizations in reproducing predominant priorities.     

Thermometer or sauna?: Performance measurement and democratic assistance in the United States Agency for International Development (USAID)

This article presents a case study of performance measurement in the United States Agency for International Development's (USAID's) democracy and governance program. Its purpose is to illustrate the juxtaposition (and sometimes contradiction) between the high standards of causal logic and accuracy required of performance measurement, and the untidiness involved in the 'politics of democratization'. Based on USAID experiences in numerous countries, the article concentrates on four specific themes drawn mainly from the literature on re-engineering but also from new public administration. These are: the complexity of politics; the challenge of attribution; the danger of distortive incentives; and the interrelated questions of product and process and quantitative and qualitative measures. Problems of measurement are clearly complicated by the fact that the Agency does not deliver service directly, has limited control over its expenditures, and, in the case of democracy assistance, by the need to operate in a complex and sensitive area, across international borders and diverse political systems and cultures. The article includes a discussion of some innovative qualitatively-oriented USAID responses to these problems.     

New Labour's modernization in the public sector: a neo-Durkheimian approach and the case of mental health services

Five accounts of New Labour's style of public management reform can be identified in the recent academic literature. Although each has merits, none is wholly convincing. After a discussion of their scope and limits, this article offers a distinctive account, grounded in wider social theory, which also synthesizes the most valuable elements in the five mainstream accounts. The article then uses the case of New Labour's reforms of the mental health system to support this account, showing how it exemplifies each of the 15 major strands of reform activity that have together been the hallmark of what in practice New Labour has meant by 'modernization'. This provides the basis for a critique of the limits and dangers of the New Labour style.     

Transition to the single currency in europe and its implications for financial institutions

This paper discusses the changeover to single currency in the European Union and provides a preliminary analysis of the timing and nature of the steps to be taken by financial institutions. It uses data from the literature and a recent survey of financial institutions operating in Europe to provide an overall view on conversion issues that both these institutions and policy-makers are facing. This paper could therefore serve as a background for future studies that pertain to the strategies of individual financial institutions, their competitive positioning for the long term, and their attempts to minimize their cost of conversion in the short term. The European Currency Unit, by virtue of its design, is a viable candidate for use as the single currency. Its current status in member countries shows that it meets the basic “money” criteria but that legal obstacles have kept it from wider use. However, these legal obstacles are being lifted. Financial institutions should start planning for potential implementation problems. The analysis of conversion costs categorized by product/service and by function shows that the move to single currency requires financial institutions to modify selected functions within a very short period of time. A lengthy dual currency period on all functions would cause duplication of efforts and large losses to banks. There are other intangible costs and benefits that are social and political, which are associated with the changeover. These are touched upon and discussed briefly in the context of the motivation behind the European Monetary Union.     

Obstacles and Opportunities for Sustaining Performance Management Systems

Measuring performance in public organizations has been a growing trend for several decades. Designing, adopting, and implementing this style of management system have been the topic of much practitioner and academic deliberation. One struggle those determined to adopt performance measurement and management systems have faced, though, is the ability to sustain them over time and actually engrain them into their decision-making frameworks. Countless barriers to long-term success exist for public organizations and this article seeks to identify and categorize them. Using a mixed-method survey design, this research shows which factors are the most important to organizations hoping to build a performance system that can stand the test of time. Capacity, knowledge, and buy-in limitations pose serious threats to these reforms and it takes a concerted effort to cultivate not only support from employees and management to pursue performance management but the technical and conceptual capacity to design the right system for the organization.     

Towards developing new partnerships in public services: users as consumers, citizens and/or co-producers in health and social care in England and Sweden

The causes and effects of marketization of public services have been analysed extensively in the literature, but there is relatively little research on how those policies impact on the development of new forms of governance, and the role of users in these new arrangements. This study reviews examples of competition, freedom of choice and personalized care in health and social services in England and Sweden, in order to examine the type of relationships emerging between the user/consumer vis-à-vis market driven providers and various agencies of the state under the marketized welfare. The article focuses on the possible roles users might assume in new hybrid arrangements between markets, collaborations and steering. A user typology: namely, that of a consumer, citizen, co-producer and responsibilized agent in various governance arrangements, is then suggested. The article concludes by arguing that pro-market policies instead of meeting the alleged needs of post-modern users for individualized public services are likely to promote a new type of highly volatile and fragile partnerships, and create a new subordinated user who has no choice but to ‘choose’ services they have little control over.     

Improved budgeting and financial management as a tool for enhancing the performance of local government in developing countries

Rapid economic and social changes in developing countries are impacting on their governments' ability to manage those changes, and local governments in these countries are becoming the core of decentralization experiments. This article examines the problems local governments face in meeting the challenges of rapid transformation and change. This paper suggests that budgeting be used as a means for strengthening local governments' abilities to deal with such changes. Until now, budgeting has not been used as a key intervention tool for strengthening local governments. A working model to assess the state of financial and related management conditions of local governments is provided. This model can serve as a useful point of reference for change agents involved in the strengthening of local governments.     

Scottish devolution: identity and impact and the case of community care for the elderly

This article examines the emergent identity and impact of devolution in Scotland. Using the case of community care for the elderly, a model is set out for capturing the different interpretive perspectives evident in relation to a particular policy area in 1999–2001. The political story of the 'free personal care' issue, in which the Scottish Executive were unexpectedly forced into adopting a markedly different policy from the rest of the UK, is examined in some detail. Setting the episode in a broader context, four discursive thematics are identified in relation to the policy case. A model is demonstrated for examining different aspects of devolution including constitutional level and sub-system aspects of post-devolution governance. Conclusions are drawn as to the meaning which should be ascribed to the discourse associated with devolution and community care for the elderly.     

A comprehensive model for the evaluation of standard expenditure needs and standard level of local services

ABSTRACT

This paper addresses the problem of the simultaneous evaluation of local governments’ standard expenditure needs together with the related level of standard public services proposing a new approach to fiscal equalisation based on quantitative methods. Standard expenditure needs are estimated using quantile regression, moreover robust non-parametric methods are employed for the computation of composite indicators of demand and supply factors. Data from English local authorities over the period 1997–2006 have been used to test the internal and external validity of the model.     

Tax harmonization in the european community: lessons for free trade areas and common markets

Economic cooperation in the context of free trade areas and common markets requires tax harmonization. On its way to a single internal market, the European Community (EC) has acquired substantial experience in the design of tax systems that leave member states as much tax sovereignty as is compatible with free trade and free competition. This experience indicates that tax harmonization and tax reform must go hand in hand.     

Public policy and quality of community life in american cities: a search for linkage

The purpose of this research is to identify and examine linkages that exist between public policy and quality of life in American cities. A review and analysis of public policy research and social indicators research over the past twenty years is included. Social indicators are further defined into both objective and subjective indicators. The developing confluence of the two areas of research constitutes the basis for the remainder of the paper.

The data for this study are derived from a nationwide survey conducted by Louis Harris and Associates, Inc., in late December, 1977 and early January, 1978, for the U.S. Department of Housing and Urban Development (HUD). Interviews were conducted for a sample of 7,074 adults, asking them about their perceptions on the quality of community life, government services, social problems, and future possibilities. The findings are analyzed through use of a frequency distribution of the quality of life measures and the quality of public service variables.

The pattern of statistical relationships indicates that the nine public service variables are sharply divided into two groups. One, seven variables (police, garbage, street lighting, fire, public schools, parks and playgrounds, and road and street maintenance) are all highly inter-correlated. The correlation coefficients among them range from a high of .411 (police and fire) to a low of .218 (garbage and public schools). The other, public transportation and public health service are also closely inter-correlated, but their relationships with the other seven are all uniformly weak.

These two groups of public services have distinct political and policy implications. The first group of services tends to represent those traditionally well-established public services that are considered “vitally important” for the well-being of the general public. The second group, in contrast, tends to represent those public services that are relatively new and serving primarily the needs of low income or minority groups in the community whose political influence is most likely to be marginal.

A few generalizations may be drawn from the statistical relationships. First, the general indicators of community life quality such as feelings about the overall community and neighborhood are more strongly correlated with the quality ratings of public services than the quality indicators of specific life domains. Second, some of the strongest relationships are found between specific public services and specific domains of life quality that might be expected logically to have close association such as police and safety (r=.317) and public schools and child raising (r=.427). Third, those public services that are considered part of mainstream local services and important for the daily life of the general public (such as police, fire, public schools, parks and playgrounds, etc.) tend to be very strongly correlated with the measures of community life quality. Fourth, in contrast, those services that are primarily affecting underprivileged groups in the community and not considered part of the mainstream of local services are poorly or insignificantly correlated with the measures of community life quality.