Effects of purchaser competition in the Dutch health system: is the glass half full or half empty?

In 2006, the Dutch health insurance system was radically reformed to strengthen competition among health insurers as purchasers of health services. This article considers whether purchaser competition has improved efficiency in health-care provision. Although supply and price regulation still dominates the allocation of health services, purchaser competition has already significantly affected the provision of hospital care, pharmaceuticals and primary care, as well as efforts to gather and disseminate information about quality of care. From this perspective, the glass is half full. However, based on the crude performance indicators available, the reforms have not yet demonstrated significant effects on the performance of the Dutch health system. From this perspective the glass is half empty. The article concludes that the effectiveness of purchaser competition depends crucially on the success of ongoing efforts to improve performance indicators, product classification and the risk equalisation scheme.     

The fundamental law that shapes the United States health care system: is universal health care realistic within the established paradigm?

In this article, the author draws from his own experience as a doctor in describing the issues the uninsured patient population faces. Pointing out that neither the U.S. Constitution nor case law provides a positive right to health care, the author describes the parameters of federal health care funding and ultimately concludes that universal health care cannot be fully achieved in the U.S.     

Family caregivers: a shadow workforce in the geriatric health care system?

Based on two years of fieldwork, conducted between March 2003 and March 2005 in the health care industry of the northeastern United States, this study shows that the work of family caregivers of elders goes far beyond previously recognized care in the home to acknowledge care inside health care facilities and in conjunction with community services. It reveals that family caregivers--untrained, undersupported, and unseen--constitute a "shadow workforce," acting as geriatric case managers, medical record keepers, paramedics, and patient advocates to fill dangerous gaps in a system that is uncoordinated, fragmented, bureaucratic, and often depersonalized. Detailed examination of what family caregivers actually do in traversing multiple domains reveals the extent of their contribution to and the weaknesses in the present geriatric health care system. It suggests that the experiences of family caregivers must be central to the creation of new policies and a more coordinated system that uses the complex work of family caregivers by providing the training and support that they need.     

Who shall lead: is there a future for population health?

Despite renewed interest in population health concerns, elevation of this field in policy considerations faces many challenges. At present there is much concern about disparities and meeting improved population health objectives, but interest waxes and wanes with scientific developments and especially with dominant political alignments and ideologies. If the field of population health is to have sustained policy influence, it requires a persistent constituency, a strong organizational base both within and outside of government, and academic respectability. Population health faces many issues in seeking to become legitimized as both a unique field of study and as a significant force in public policy. Among these are a clear definition of the boundaries of the field, a continuing flow of resources for development, and attractive career structures for new recruits and future leaders.     

The right to health in public health: is this a new approach?

The international human rights community has frequently reaffirmed the importance of full respect for the right to health. However, there remains a large gap between the standards set out in Art 12 of the International Covenant on Economic, Social and Cultural Rights and the situation prevailing in most countries. While there has been a substantial amount of work done to expand upon the content of the right to health, there has been little consideration of what a right to health means for public health programming generally. This article addresses this issue by considering the compatibility of the essential elements of contemporary public health programming practice with the principles contained in General Comment No 14, para 43(f) (a minimum core obligation of the right to health). The article considers that while both contemporary public health practice and para 43(f) do contain compatible elements, the right to health brings with it new elements of monitoring (through right to health indicators) and accountability, both of which will require new tools to be adopted by the public health sector.     

Hypernatremia and subdural hematoma in the pediatric age group: is there a causal relationship?

Several researchers in the 1950's proposed that hypernatremia causes water to leave brain cells, shrinking the brain, thus tearing the bridging veins and resulting in subdural hematomas. Although the old literature suggests mechanisms linking the two in a cause and effect relationship, there is controversy as to whether hypernatremia leads to subdural bleeding or whether the reverse is true. This issue is important for forensic pathologists who must distinguish natural disease from trauma. An etiologic link between hypernatremia and subdural hematomas was suggested recently, and was proposed originally before Kempe's 1962 paper "The Battered Child Syndrome" which widely disseminated the concepts of child physical abuse, and of subdural bleeding resulting from non-accidental injury. Our study is a multifaceted investigation of infants which includes: a literature review, retrospective chart reviews of both living and deceased hypernatremic infants, a retrospective review of infants hospitalized with subdural hematoma, and a prospective collection of head injured, hypernatremic children. We conclude that hypernatremia, if present in association with subdural hemorrhage, is most likely secondary to intracranial pathology, and that hypernatremia often develops in critically ill infants suffering from a variety of medical conditions.     

Medical Samaritans: is there a duty to treat?

This article argues that doctors and other health care professionals should be obliged to provide emergency treatment to those in immediate and nearby need regardless of the absence of any prior professional relationship between the parties. It concludes that the common law should accordingly recognize a specific duty of 'medical rescue'. It examines some of the conventional objections to affirmative duties, finding them unconvincing in this particular context. It draws on two recent appellate decisions, one Australian and the other English, for support, as well as on more general arguments concerning moral sentiment, professional ethics, public expectation, and respect for human rights.     

Surrogacy: is there a case for legal prohibition?

Surrogacy arrangements are a complex and challenging issue for legal regulation. On the one hand, if we wish to promote personal autonomy and enable the infertile to experience parenthood, there is a case for allowing these arrangements to proceed. However, objections to legal sanctioning of surrogacy include concerns for the surrogate and the child born through the surrogacy arrangement. Legally sanctioning surrogacy may also adversely affect social conceptions of women's roles or may be considered a form of commodifying women's reproductive capacities. This article examines these challenges to allowing surrogacy, but concludes that surrogacy should not be legally prohibited.     

Terrorism and mental illness: is there a relationship?

This article examines the connections between mental illness and terrorism. Most social scientists have discounted a causal relationship between mental illness and terrorism. This is not necessarily always the case within terrorism studies, the media, or political circles where the psychology of terrorism is often expressed in the language of mentalisms, and theories of pathologisation continue to exist. This article reaffirms the view that apart from certain pathological cases, there is no causal connection between an individual's mental disorder and engagement in terrorist activity. The individual terrorist's motivations can be explained by other factors, including behavioural psychology. However, there may be a connection between an individual engaging in terrorist activity and developing a mental disorder[s]. Certain stressors that occur because of terrorist activity may result in psychological disturbance in terrorist individuals. These factors may partially explain terrorist group instability and should be taken into account when detaining and interrogating terrorist suspects.     

Role-Switching in the Dutch Parliament: Reinvigorating Role Theory?

The lack of explanatory power of roles in the study of legislative behaviour has led to questioning of the utility of role theory. The problem may be that scholars tend to focus on classifying legislators according to one role orientation, thereby running the risk of oversimplification. Using questions from the 1990, 2001 and 2006 Dutch Parliamentary Studies, this study explores whether MPs specialise in a particular role or switch between roles depending on the situation at hand. A general trend towards specialisation in the partisan role is detected, accompanied by a decrease in the number of role-switching MPs. Furthermore, it is found that whereas government MPs tend to specialise in the role of the parliamentarian, opposition MPs are more prone to put on their partisan hats.