The significance of outcomes within european health sector reforms: towards the development of an outcomes culture

Recently, policy makers, managers and users of health services have focused their attention on questions about service outcomes and effectiveness. However, the stakeholders in health care-communities, patients, clinicians, insurers, purchasers, managers and policy-makers - may, for various reasons, desire different outcomes to be realised over different timescales. Whilst a focus on outcomes forms a key evaluative criteria within the reforms of European health care systems, the significance of information and the priorities given to outcomes vary across Europe. A central tension lies between the pursuit of individual as opposed to population health gain. Other key issues include the need to separate the evaluation tools from their use and the importance of user choice and user involvement. The article outlines a model of the possible roles and needs for outcomes information. It differentiates between the uses of outcomes information at the patient care and population levels and for considering individual and population health gain. The needs to enhance country-based outcomes databases and to aid the development of an outcomes culture across health care systems in Europe are discussed. The article also discusses issues relating to developing an outcomes culture as an essential element of the health care reform process.     

Indonesia: The politics of inclusion

Much commentary on Indonesian politics since the fall of President Suharto in May 1998 has suggested that Indonesia's political system has remained just as exclusionary as it was prior to his fall, despite becoming much more democratic and decentralised. In contrast to this view, we argue that Indonesia's political system has become more inclusive, if only somewhat more so. The fall of Suharto and the subsequent process of democratisation have removed key obstacles to organisation by poor and disadvantaged groups and their NGO allies, making it easier for them to engage in collective action aimed at achieving pro-poor policy change. By making attainment of political office dependent on the support of the voting public, many of whom are poor and disadvantaged, these developments have also created an incentive for politicians to pursue policy changes that favour these groups or at least that appeal to them. At the same time, however, we argue that poor and disadvantaged groups have not become major players in the policy-making process. Despite the fall of Suharto and democratisation, these groups continue to lack the resources possessed by other participants in the policy-making process. Whereas the politico-bureaucrats and well-connected business groups have been able to exercise influence over policy by buying support within representative bodies such as parliament and mobile capital controllers, the IFIs and Western governments have been able to exercise influence by virtue of their structural power, poor and disadvantaged groups have had to rely on less potent ways of exercising influence such as holding demonstrations, engaging in lobbying activity and participating in public debates. We illustrate these points with reference to two policy issues: land reform and mining in protected forests. The article concludes by considering the future prospects for inclusive policy-making in Indonesia.     

Imperialism’s effects on China

Abstract

Three years ago in this journal, James Peck argued that “the professional ideology of America’s China watchers” has tended to blind them to certain approaches to modern Chinese history that might be labelled “revolutionary Marxist” interpretations. As an example, Peck argued that the China watchers have explained China’s nineteenth and early twentieth century difficulties (prolonged economic and military weakness, failed reforms and revolutions) by reference to internal factors (culture, social structure), while a revolutionary Marxist perspective would seek explanations in the effects of imperialism. He provided several examples of the types of effects imperialism may have had on China: “The power of the metropolitan countries to block the formation of vital domestic industries in the dependent countries competitive with their own operations; the domination of mercantile over industrial capital; and the subordination of the economic life of a dependent nation to the severe fluctuations of the primary commodities market.” But he did not have space in his article, which was primarily concerned with a critique of existing work in the China field, to provide a fuller outline of what the imperialism approach to modern China might involve.     

The Conventional Missile Capabilities of China's Second Artillery Force: Cornerstone of Deterrence and Warfighting

Abstract

Since its establishment in the early 1990s, the conventional missile component of the People's Liberation Army's Second Artillery Force (SAF) has emerged as a centerpiece of China's accelerating military modernization program. The conventional missile force has grown in size and sophistication, and China has developed a doctrine for its employment. Chinese military publications emphasize that it plays an increasingly important role in deterrence and warfighting. In particular, Chinese sources underscore its role in achieving information dominance, air superiority, and sea control as well as countering third-party intervention. China's development of advanced conventional missile capabilities highlights the growing vulnerability of fixed bases and surface ships. Moreover, organizational tendencies, could fuel dangerous escalation. In response to these challenges, the United States must adapt its traditional approach to military operations and deterrence in the Asia-Pacific.     

An “Assertive” China? Insights from Interviews

Abstract

Recent years have witnessed the emergence of a more assertive China. What happened to China's “peaceful rise” and “charm offensive”? What explains the changes in China's foreign policy? According to interviews with Beijing and Shanghai-based analysts, China's assertiveness between 2008 and 2010 can be divided into two waves, each triggered by a different cause. The first wave seems triggered by a sense in Beijing that Washington, DC was more differential to China's interests, and less committed to East Asia. The second wave seems best explained as China's response to what it perceived as a far more assertive and threatening United States. Both waves were amplified by two domestic challenges: Chinese leaders’ hypersensitivity to popular nationalism and poor bureaucratic coordination among an expanding number of foreign policy actors.     

Kyrgyzstan between democratization and ethnic intolerance

The international community has expressed great concern about the treatment of the Uzbek minority in the south of Kyrgyzstan and has called on the majority community to make major efforts to improve the situation. The article compares the treatment of minorities in Kyrgyzstan with analogous situations in the Balkans and contends that, given the European-style ethno-national state model and democratic political system that have been adopted by independent Kyrgyzstan, such calls are unrealistic.     

Coalitions,convergence and corporate governance reform in Indonesia

This paper argues that Indonesia's corporate governance system is unlikely to converge on the outsider model of corporate governance, at least in so far as this means an exact replication of this model. While the Indonesian government has introduced a range of corporate governance reforms aimed at bringing in key elements of the outsider model since the mid-1980s, and especially since the onset of the Asian crisis, there have been serious problems with the implementation and enforcement of these reforms. Underlying this outcome, it is argued, has been the structure of power and interest within Indonesia: the balance of power between the main coalitions of interest has been such that the political preconditions for the proper operation of the outsider model have not yet been established.     

Development,foreign aid and post-development in Timor-Leste

Post-development theories have successfully challenged many of the ways in which we think about development but have yet to substantially influence development practice. In this paper I explore what opportunities exist for applying post-development ideas within the current development apparatus of Timor-Leste. Four types of community-focused programmes are analysed: sectoral project-based initiatives, institutional capacity-building programmes, community partnerships and small grants programmes. While alternative opportunities are clearly shown to be present, it is argued that they are rarely realised because of the overwhelming priority to produce better agents of development, rather than those able to pursue ‘alternatives-to-development’. The paper concludes by suggesting that the development apparatus itself may not be inherently faulted; instead this apparatus could be usefully utilised by those inspired by alternative imaginaries to pursue post-development goals.     

Central-Local Relations in an Era of Multi-Level Governance: The Case of Public Participation Policy in England, 1997-2001

The election of a 'New Labour' UK government in 1997 promised a new era of central-local relations facilitated by a programme of local government reform which recognised local government's 'community leadership' role. Other aspects of the agenda supported the development of multi-level governance, for example, the establishment of sub-national institutions such as the Scottish Parliament and the promotion of neighbourhoods as key sites for action. Despite these actions this paper will argue that in England the central state retains considerable influence over the key agents of local governance. Using the example of public participation policy, and drawing on the findings of a recent study in two English cities, the paper will explore how national policy aspirations were reflected locally. It concludes that while local action generally complemented national priorities, there were important points of contrast, and that localities' capacity to act in their own interests is supported by the opportunities presented in a multi-level governance environment.     

Local Politics,Central Power: The Future of Representative Local Government in England

When Labour took power in 1997, local government was battered and bruised, but it had survived, and indeed retained much of its vitality. What would happen next? Where the Conservatives had used the language of competition, New Labour promoted its policies around an ideology of modernisation, and rapidly introduced a new legal framework, new powers and strong incentives to improve performance. But by 2004, in the run-up to another general election, Labour increasingly emphasised the rights of consumers to choose providers of services, and the value of involving the private sector in public sector provision. There were proposals to take the finance for education and social services out of local authority control. A complex geography of partnerships and networks had developed, which required small executives of salaried councillors, far fewer than the large numbers needed by the committee system. But turnout in local elections remained low, and membership of both Labour and Conservative parties declined. The paper uses a simple stakeholder analysis to show how councillors and local activists were marginalised. It suggests that the government has a choice: it could either accept that the era of multi-skilled councillors responsible for the multi-purpose local authorities is ending, or it could radically rationalise the present quangos, partnerships and other governance structures to re-create it.