The empires strike back. Broken promises: Columbia-Presbyterian Medical Center. Ignoring the community's needs: St. Luke's-Roosevelt Hospital Center

In the fall of 1985 in an issue titled "Fighting Back Against the Empires" (Vol. 16, No. 5), Health/PAC reported on the plans of four of New York City's academic medical center "empires" for major expansion. The focus of our coverage was the efforts of two of the communities served by these institutions to ensure that the plans were responsive to their needs. At the time, we were cautiously optimistic that these events were signs that "although the empires still dominate New York City's health care system, they no longer rule unchallenged." In the past six months, the plans of two of these institutions, Columbia-Presbyterian Medical Center and St. Luke's-Roosevelt Hospital Center, warrant another look at the success of the efforts to hold the major medical centers responsible for the welfare of the communities in which they are located.

Guidelines for pragmatic assessment for health planning in developing countries

Although the primary health care strategy implemented since the Alma Ata declaration of 'health for all' appears to have contributed to improvements in selected health outcomes, the current ad hoc approach to health assessment and planning has impeded more substantial gains. A comprehensive yet pragmatic framework for country-level health programmers is needed that would permit consideration of the multiple steps involved in policy formulation and implementation. In the present paper, drawing upon an epidemiologic model (Iterative Measurement Loop) and an economic model (Cost-Effectiveness Analysis), we present guidelines for a pragmatic assessment for health planning. A format is provided for the conduct of these tasks which is operational in nature, is specific to the target country (or relevant region), can simultaneously consider multiple interventions, and is comprehensible to persons without sophisticated medical and/or economic backgrounds. Such a format enables articulation and consideration of local concerns as well as national and global considerations.

The general practice contract scheme: was it targeted?

OBJECT

to determine whether the contracted general practices were situated in areas of greatest health need.

METHOD

the health and equity index was used to determine the level of health need of the geographical location of the contracted practices.

RESULTS

the health and equity index for the urban contracted practices showed a high level of health need. In the rural practices, the census area unit in which the practices were located showed a high level of health need, however when surrounding census area units were considered, they were located in areas of average health need.

CONCLUSION

the general practice contract scheme was well targeted.

Primary care in New York State: report and recommendations of the associated medical schools of New York

Medical education in New York is unique in the country in its scope and its diversity. It is important, as we go forward, that these strengths be neither eroded nor compromised. The AMS member institutions are making a collective commitment to work together to promote changes that will improve medical education for all students by providing them with enriched experience in primary care. Our major resource is faculty. To whatever degree medical schools can influence career choice, it is essential to this aim that the best possible people are placed in the settings in which primary care is taught. The schools will intensify their efforts to recruit and retain such faculty and, in whatever way is appropriate to each institution, provide them with the stature needed to emphasize the value which the school places on primary care. The schools will also work to provide exposure to primary care early in a student's academic career given anecdotal evidence, at least, that such early experience can influence subsequent specialty choice. Finally, the medical schools will assume greater responsibility for graduate medical education. If, with state support, ambulatory teaching sites are developed, the schools will make every effort to assure that they are staffed with high-quality faculty. Residents and students must see primary care practiced with total commitment to quality. It is hoped that, with state-initiated improvements in the practice environment, the ultimate outcome will be an increase in the number of our graduates selecting primary care disciplines for their practices and locating in areas in need of physicians.2+ Corporation, and the Greater New York Hospital Association. We are ready to work with others toward our common objectives, and we call on all of those who share these concerns to participate with us.

Need for and provision of general practice in London

This study examines the spatial distribution of general practice in London, taking into account both practice and population characteristics. While need for general practice is higher in inner London, some areas of outer London experience high levels of need. Inner London tends to have a greater quantity but lower quality of general practice. However, as in the case of the needs indices, this situation cannot be described as a simple inner city/outer city dichotomy. It is concluded that not all inner London areas suffer from high need and poor general practice and not all outer London areas have low need and good general practice.

[Can the crowd pressure on primary health services be managed?]

The crowd pressure which is placed on Primary Care Services frequently overwhelms the capacity of response of said services. In certain cases the crowd pressure coincides with low demand per inhabitant and year (as compared with the expected average in our environment), while on other occasions there coexist high crowd pressures with high frequencies. The automatic assumption that excess crowding--larger need for human resources obviates the analysis of the organizational factors and of individuals who contribute to the crowding increase. Sometimes, assigning more resources to cope with excess crowding of unidentified origins contributes towards keeping those causes alive, rather than solving them. We propose a method of analysis of excess care demand based on the answer to a short series of questions, while at the same time proposing certain management measures which could be useful to cope with excess demand, depending on the cause or causes which have been found to apply.

Health policy brief: obstetrics in nonmetropolitan Oklahoma

This brief is a summary of a 68-page analysis of a survey conducted by the Center for Health Policy Research, Oklahoma Medical Research Foundation, Tulsa. There are 9 appendices and 96 data analysis tables in the complete analysis. The survey was conducted in the summer and fall of 1988. Survey instruments were mailed to all Oklahoma obstetricians and family and general practitioners not practicing in Tulsa or Oklahoma counties. There were 300 responses, 274 of which were validated for inclusion into the study. The complete survey will be of interest to some institutions and groups and is available upon request. Customized analysis of the survey variables also is available to interested parties upon request.

A mobile surgery for single homeless people in London

Little is known about the social and medical characteristics of people who regularly sleep rough, or whether medical care can be targeted at these people. In 1987 a mobile surgery was used to provide primary health care at two sites in central London where many single homeless people sleep outdoors. One hundred and forty six patients were seen with illnesses ranging from scabies to osteomyelitis and tuberculosis. Sociodemographic data showed the patients to be generally an isolated group with deprived and unstable backgrounds, often compounded by alcohol abuse. Over a third of the patients from one site attended a drop in surgery for homeless people in Soho within a month after seeing a doctor in the mobile surgery. This suggests that the project can be a first step in integrating this isolated group with health care facilities.

Primary health care in rural areas: an agenda for research

The confluence of forces slowing the growth of the physician supply despite a continued shortage of primary care physicians, the encouragement of competitive medical practices that centralize resources in larger places, and the changing of the rural population's character to one of more dependence on medical care may bring on another "rural health crisis" in the decade ahead.

[Volume and demand of rheumatologic problems and their management at a primary health care center]

The present study was carried out as a part of the elaboration process of the Program of Rheumatologic Diseases of the health center of Chapela. The following rates are reported: the volume of patients affected by these problems (14.5%), the generated care demand (6.9% of the overall demand), the age and sex distribution, their importance as a reason of disability (14.4% of the overall number of sick leaves), and the different specific diagnoses. To evaluate how these patients were managed by the team, a series of indicators were used, such as the number of identified patients, the quality of the documentation, the types of complementary investigations, the referral of patients to the secondary level, and the adequacy of therapies. As conclusions, a significant volume of rheumatologic consultations and work disabilities was found, with a high use rate of radiological studies and a low use rate of laboratory investigations, the use of basically NSAI drugs in the therapy, and the need for a specifically oriented clinical record to be used in the diagnosis and follow up of these conditions.

Impact of federal primary health care policy in rural areas: empirical evidence from the literature

This review examines the equity, efficiency and effectiveness of federal rural primary care policy as documented by the existing literature. The focus is on the Community Health Center and National Health Service Corps programs which have constituted the major components of the policy. The literature relating to the policy is limited in the number of studies available and in the quality of the research. The available evidence indicates that the policy is associated with an improvement in the distribution of health resources between rural and urban areas,and among rural areas. There is also partial evidence that the policy has been cost-efficient. For federally subsidized practices,the cost of delivering a similar quality of health care is shown to be up to 50 percent less in rural than in urban areas. Rural private practitioners, though, may be more cost-efficient than federally subsidized rural practitioners, at least under certain conditions which have yet to be fully delineated. Program effectiveness is the least well documented, but the literature does suggest that the policy has had a positive effect on the health status of rural populations. Substantially more research on the efficiency, and particular the effectiveness, of federal rural primary care policy is required for the development of a rational basis for the policy.

List of designated primary care health manpower shortage areas (HMSAs); list of withdrawals from primary care HMSA designation--HRA

This notice provides two lists. The first is a list of all areas, population groups or facilities designated as primary care health manpower shortage areas (HMSAs) as of August 31, 1987. Second is a list of previously-designated primary care HMSAs that have been found to no longer meet the HMSA criteria and are therefore being withdrawn from the HMSA list. HMSAs are designated or withdrawn by the Secretary of HHS under the authority of section 332 of the Public Health Service Act.

Access to primary health care: a comparison of the US and the UK

This paper examines the extent to which low household income influences access to primary health care in both the US and the UK. The basic approach is to ask whether, given data about a person's age, sex, and self-reported general health status and history, extra information about whether or not they come from a low-income household adds a statistically significant amount to the probability of their obtaining various amounts of primary medical care. The measure of primary medical care is derived from the number of physician visits and it, along with the other data, is drawn from the 1977 US National Medical Care Expenditure Survey and the 1980 UK General Household Survey. Although the two surveys cover different sample periods, they are similar enough to make comparisons between the two countries possible. The main conclusion drawn from the study is that low household income is not an important determinant of the actual use of primary health care resources. Only with subgroups of the low-income population (UK women and US relatively unhealthy individuals) does there appear to be a statistically significant effect, which is quite small in comparison to other factors.

Priority for primary health care: its development and problems

National health policies of many countries stress priority for primary health care (PHC). This emphasis has arisen as a reaction to large expenditures on hospitals and sophisticated technology in major cities of developing countries, while vast rural populations have been virtually ignored. The paradox developed from colonial and neo-colonial emulation of European and North American medical models. In 1978, an international conference of WHO/UNICEF at Alma-Ata, USSR defined the meaning of PHC, along with several principles of organization and equity under which it should be provided. To reach rural people with PHC, thousands of community health workers have been prepared and stationed in villages. Their training, however, is very brief and, with weak supervision, their performance has been disappointing. To achieve the WHO goal of "Health for All" through PHC requires greatly expanded education of public health leaders, who can supervise and inspire community personnel.

An economic evaluation of "Health for All"

The World Health Organization's 'Global Strategy' is an ambitious vision, but to achieve its goals it must first be implemented. Implementation will require careful and detailed planning. This paper evaluates the possibilities of transforming the Global Strategy from a laudable policy initiative into an actual 'Plan for Health', from the point of view of a health economist. This economic evaluation assesses the probable costs of implementing various activities of the Strategy, and the likelihood that developing countries will be able to afford these costs, either on their own, or with the assistance of the developed countries. A final section considers the current global situation and presents trends over the last two decades. The numbers of countries that have already achieved the goals of the Strategy, that can be expected to achieve the goals of the Strategy by the year 2000, and that are unlikely to achieve these goals (on the basis of current trends) are shown. The WHO 'success indicator' based on numbers of countries is compared to a more epidemiological one based on deciles of the world's population. It is argued that, even several years after the initiation of the Global Strategy, insufficient information exists on the next logical step of transforming the Policy into a Plan. Unless adequate attention is paid to this vital step, implementation of the Strategy will inevitably be ad hoc and patchy. Further research on the costs of the activities proposed by the Global Strategy, and the probable effects on health of those activities, is desperately needed.

Access to primary health care: developing state and local strategies for high risk groups

Competition and a rapidly changing market place have dramatically altered the dynamics of primary health care delivery in urban areas across the US, focusing new attention on access to care for the indigent. Public and private sector policymakers in Boston, Massachusetts, addressed these issues by examining the health status, payer coverage and availability of providers of primary health care for individuals at risk. Strategies were targeted in the areas of health insurance, reimbursement, and provider organisations to improve access to services at the state and local level.

Planning and politics of resource allocation for primary health care: promotion of meaningful national policy

Securing resources for primary health care (PHC) involves consideration of the entire health sector: the higher levels of the health service as well as the primary level, and the private and/or social security sub-sectors as well as the government service. Reshaping resource distribution is less a redistribution of existing resources than the allocation of new resources in accordance with PHC priorities. In this the planning of future current costs is a crucial element and requires a budgetary system that identifies expenditures by geographical area and level of care. Resources should be allocated geographically to reduce health care inequalities through the provision of an appropriate mix of different levels of care. Central resource planning and local health care programming (with 'dialogue' between the two) should be the basic planning division of labour, which largely resolves the so-called top-down/bottom-up dichotomy. The private medical sub-sector exerts economic, ideological and political influences on the public health service. Compulsory health insurance schemes can have some similar effects. Success of a PHC policy requires that governments adopt a holistic approach to the health sector. The allocation of health care resources on the bases of need and equity, as opposed to demand, is a political decision. The establishment of a national PHC policy backed up by adequate resources involves a specific politico-technical exercise with four components: research, planning, policy formulation, and government policy decision-making. The resource planning method, based on social epidemiology, is contrasted with conventional health planning methods, based on epidemiology. The articulation of these two approaches is discussed in terms of WHO's Managerial Process for National Health Development.

Primary health care in developing countries: the case of Nigeria, Sri Lanka and Tanzania

The country health programmes reviewed in this paper are aimed at meeting the World Health Organization's (WHO) target of providing basic health services for all by the year 2000. In accordance with the objective of the programme, each of the country health programme is expected to focus on the mechanisms for expanding health facilities and strengthening the health planning machinery in order to achieve an equitable distribution of health facilities in the foreseeable future as part of social development and in the spirit of social justice. Although there are marked differences in the approach to the realization of the objectives of the various country programmes reviewed in this paper, the primary aim is to bridge the widening gap between the health 'haves' and the health 'have-nots' in the respective countries. A substantial part of the resources of these countries are now being set aside for the implementation of the health care programmes so as to meet the health aspirations of their people. It is our belief that the health programmes of these countries are laudable and if properly implemented they will meet the health needs of the people of the various countries. A continuous evaluation of the programmes will enable each country to assess the successes and failures of the schemes and the organizational bottlenecks that may make the realization of stated objectives a well nigh impossible task.

Hazard, Perry County, Kentucky

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