[A reaffirmed French psychiatric public sector]

Psychiatry in France is considered here with regard to patient care systems, long-term treatments, treatment without consent and the place of the users in the system. The implementation of the new law in 2011 relating to admission to hospital without consent will have to be revised as a result of the problems identified during its application.

Managing environmental risks: the benefits of a place-based approach

CONTEXT

Effective management of environmental risks such as food and water contamination requires both high quality scientific information and effective, informed social policy. Not only must health practitioners and policy-makers recognize the complexities of human health as a social phenomenon, they must also negotiate the vagaries of uncertainty, precaution, and ethics in their implementation of public health guidelines and advisories. For example, some health practitioners in Alaska have argued against implementation of US Environmental Protection Agency and World Health Organization's standardized consumption advisories for methylmercury (MeHg) in fish, in favor of place-based approaches to evaluating and communicating risk. They stress the importance of traditional subsistence foods and lifestyles, along with other local environmental, economic, and cultural drivers and determinants of environmental health. Such place-based approaches have been successful in improving health outcomes in Alaska and elsewhere.

ISSUE

Nevertheless, debate continues regarding the validity and ethics of place-based approaches to developing and communicating standards and advice for managing environmental risks. Recent critiques suggest that place-based approaches to environmental health represent an undesirable kind of regional 'exceptionalism': the implication of which is that precaution, in respect to acting on the best available objective science, is undermined by attention to subjective local values. In this article we comment on this debate, a debate rooted in concerns regarding the delineation between science-based and policy-based decision-making.

LESSONS LEARNED

Our experience with the social and ecological dimensions of MeHg contamination of fish and game in Alaska and elsewhere offers three considerations regarding the potential benefits available through place-based approaches: (1) they can contribute to the accuracy and systematic characterization of risks and their relationship to multiple direct and indirect health outcomes; (2) they are more likely to inform actual changes in behavior; and (3) they afford greater transparency to the risk management process and therefore facilitate environmental justice. We stress that standardized risk assessments and advisories remain important for providing a precautionary baseline that can inform the management and enforcement of industrial and other polluting activities at the state level. However, the management of environmental health at the regional and local level requires an approach that is cognizant of local circumstances and needs, and addresses health in a systemic and integrative fashion capable of incorporating qualitative social, cultural, and economic drivers and determinants. Thus, we recommend a two-tiered approach that blends state-based and place-based environmental risk management.

Area agencies on aging: a community resource for patients and families

This article presents an overview of the Older Americans Act (OAA) so that home health clinicians may become more knowledgeable about this healthcare legislation. The OAA was passed in 1965 and has evolved significantly over time. The purpose of the OAA is to help older adults maintain their highest level of functional activity to remain in their homes as long as possible. Embedded within the OAA are key programs and services for older adults called Area Agencies on Aging (AAAs). It is vital that home health clinicians understand how the AAAs can help their patients and families. This article educates clinicians about the available services that AAAs have to offer.

[The role of regional and local authorities in shaping health-conducive environmental determinants in the light of the Polish legislation]

BACKGROUND

This study is a continuation of earlier research concerning the role of public health administration (governmental and self-governmental) in health protection and health promotion. The aim of the study was to specify the function of local self-governments (at county, community and district levels) in shaping health-conducive environmental determinants.

MATERIAL AND METHODS

Polish legal acts concerning biological, chemical and physical hazards, binding up to November 30, 2009 were the subject of the study. All these acts were analyzed and the provisions referring to the control of the above mentioned hazards and obligations imposed on local self-governments to promote health-conducive environmental factors were identified.

RESULTS AND CONCLUSIONS

Of the 41 environment protection legal acts, 24 were selected as the most important from the point of the aim of the analysis. It was found that these acts underline the significance of environmental health determinants and explicitly formulate the role and duties of local authorities in the area of environmental health promotion, as well as in controlling and monitoring harmful biological, chemical and physical factors. The participation of local societies in these activities is also emphasized.

[Representatives of consumer associations and the "hôpital, patients, santé et territoires" law: an outline of the issues and twelve proposals]

Since 1996, consumers have been able to become involved in the development and implementation of national, regional and local healthcare policies, thereby demonstrating the possibility of establishing a model of democratic institution in healthcare at all levels of decision-making and policy implementation. Despite this 13-year political ambition, it is open to question whether the bill on the reform of the hospital will serve to extend the same dynamic for patients, healthcare institutions and local authorities. On 15 November 2008 and 18 April 2009, fifty-four consumer association representatives in the Franche-Comté region convened to conduct an audit of their commitments with a view to making proposals to adapt the bill aimed at reforming hospitals for the benefit of patients, healthcare and territories (HPST) before the bill is debated in Parliament (National Assembly and Senate). Despite significant investments since 1996 and some notable successes, for these representatives of consumer healthcare associations, the results are distinctly mixed. This is because they sometimes feel instrumentalized in healthcare facilities and believe that their opportunities for participation have declined since 2002. Their view is that this may diminish the power they wield at a time when the economy may be seen as becoming a substitute for public healthcare and participatory democracy. In a context of inequality in healthcare and at a time of economic crisis, this paradigm shift has tended to mobilize representatives of consumer associations. In their view, a strong counter-power is required to ensure fair and equal access to healthcare for all. They suggest twelve proposals concerning organization and professionalism at both territorial and national levels, articulated around the following principle : a representative of a consumers' association can become a regional reference in the management of the agency's regional healthcare system and may be given the means to coordinate the work of other representatives of consumer associations for each of the regional healthcare plans.

[Regional health conferences: assessment, observations, risks, challenges and prospects]

The Public Health Bill of August 9 2004 established that regions are the optimal level for governing interventions. The new law resulted in the creation of the National Health Conference and the new Regional Health Conferences. The Permanent Assembly of the Regional Health Conferences was created in 2006 with a view to fostering closer relations between representatives of the 26 Regional Health Conferences. Three specific missions were officially devolved to the Regional Health Conferences. The object of this article is to provide an overview of these duties and to highlight the difficulties raised by their implementation, as well as their strengths. To conclude, the new Regional Health Conferences are discussed in the light of their recent work.

[The regionalization of health: an opportunity for health democracy?]

Health democracy in France has consisted in recognizing individual and collective rights attributed to users of the health system and in making decision-making procedures in health more contradictory. However, this movement has encountered a number of obstacles and barriers since the adoption of the law of March 4, 2002. Seven years later, the recent Act of July 21, 2009, aims to renovate a more vigorous health democracy, including restoring regional conferences on health and governance with the autonomous powers that were conferred to them in the 2002 Act. However, nothing is yet secured; vigilance is essential and should remain high on the agenda.

One step forward, one step back: Quebec's 2003–04 health and social services regionalization policy

This article focuses on Quebec's most recent reform in the regionalization of health care to understand why the government chose to transform the regional boards into agencies. This case study used interviews and documentary analysis. Rooted in a political science perspective, the conceptual framework is inspired by the work of John Kingdon (1995) and draws on the four variables that influence the choice of policy: ideas, interests, institutions and events. Results of the case study suggest that Quebec's Commission of Study for Health and Social Services (the Clair Commission) in 2000 and the 2002 pre-electoral environment put the issue on the agenda. In 2003, the newly elected Liberal government passed Bill 25 – An Act Respecting Local Health and Social Services Network Development Agencies, which represented a political compromise: originally slated for eradication, the regional tier survived but in a new form. The element that sparked reform was the change in government following the elections. Different inquiry reports spread the reform's ideas, while interest groups articulated contrasting visions on the transformation. Above all, regional institutions showed great resilience in the face of change. From a historical perspective, this regionalization policy is a step backward: the regional tier is now stronger from a managerial and technocratic point of view, but it is politically and democratically weakened. This suggests a government intention, at that time, to maintain the regional level as a means of retaining centralized control over Quebec's health-care system.

[Methodology of strategy development for the improvement of efficiency of sanatorium-resort services in the regional healthcare system]

Methodological aspects of the development of the strategy for the improvement of efficiency of sanatorium-resort services in the regional healthcare system based on the experience of "Prokopievsky" sanatorium, Kemerovo region. Different stages in the history of the sanatorium are described with special reference to its role in continuous medico-social rehabilitation of the patients and in the maintenance of continuity of medical care provided by municipal outpatient, inpatient, and sanatorium settings. Transition to new forms of organization and work of sanatorium-resort facilities required in-depth analysis of their day-by-day activities as well as problems and obstacles hindering their further development. After having overcome the crisis of 2001-2006, sanatorium "Prokopievsky" strengthened its position at the market of sanatorium-resort services not only by continuing basic activity but also by developing new lines of medical aid and attracting new categories of patients. In 2007, the share of proceeds from medical and commercial services reached 93.3% and 1.2% respectively compared with 0.12% and 1.32% in 2002.

The role of ERISA preemption in health reform: opportunities and limits

It should come as no surprise to any observer of health policy debates that the preemption provisions of the Employee Retirement Income Security Act (ERISA) will play a major role in determining the contours of any health reform initiative. For the past few years, many states have been aggressively pursuing health reform experiments, while congressional action has essentially been deadlocked along partisan political lines. Yet after the 2008 election results, there is reason to expect considerable congressional attention to health reform. President Obama has made health reform a priority of his administration, and several members of Congress have long been waiting for an opportunity to pursue health reform legislation.

[Evaluation of occupational medicine service tasks in the context of the Occupational Medicine Service Act, article 12, on the basis of statistical indicators in the Pomorskie voivodship]

BACKGROUND

Occupational health service is based on legal regulations. We have made an attempt to estimate the implementation of the tasks resulting from article 12 of the Occupational Medicine Service Act introduced in 1998.

MATERIALS AND METHODS

In this paper we analyzed statistical data concerning the number of prophylactic health contracts, economic entities and health insurance payers. The data come from the Nofer Institute of Occupational Medicine, Central Statistical Office and Social Insurance Institution.

RESULTS

Contract Coverage Rate (CCR) has been introduced for the purpose of this research. The data show that in 2007, the Contract Coverage Rate (CCR) for the Pomorskie voivodeship (province) accounted for 45.7%, with the median value of 14.4% for all voivodeships in Poland.

CONCLUSIONS

According to the gathered statistical data, it should be concluded that the implementation of article 12 is insufficient. The amendment to the Act introducing the provision on written contracts is an opportunity to provide an effective mechanism, by which the present situation can be improved and the rates raised to a satisfactory level.

[Health protection and health promotion in formal structures of executive county authorities and executive offices of municipalities having the county status]

BACKGROUND

An analysis of the role of public administration in the Polish health system, essential for the effectiveness of health protection and health promotion, is a very important and urgent task faced by scholars. This issue also concerns the authorities of counties (powiaty) and municipalities having the county status (MHCS), and these structures were chosen as the subject of our study. The aim of the study was to analyze whether health related rules and regulations of these administrative structures comply with the requirements of relevant Polish legislation acts.

MATERIAL AND METHODS

The survey, performed in 2008, covered all the 378 counties and municipalities having the county status. On the basis of 171 Acts reviewed, a list of 11 groups of obligations and duties assigned to county and municipality units were prepared and used as a research tool.

RESULTS AND CONCLUSIONS

It was found that the provisions of the Health Care Institutions Act of 1991 were most evidently (87%) reflected in the rules and regulations of the studies structures; more than a half (57%) refer to prophylaxis and health promotion, however, the most important Act as far as health protection and health promotion are concerned, i.e., the Act of 2004 was reflected in only 11.6%. Also the presence of some outdated regulations was discovered. The results of the study may indicate that the mechanisms, by which the execution of legal regulations on health protection and health promotion tasks should be supervised, are insufficient.

[MADEsmart: a web-based system for accessing data and healthcare indicators]

Methods for accessing information have evolved making thus possible the planning of a new generation of web applications. In the Piemonte region, tools for accessing demographic data and main health and epidemiologic indicators are available since several years. A new application named MADEsmart (from the Italian for "Engine for demographic and epidemiological analysis") provides various functions that allow the user to obtain information useful for creating health reports and health profiles at the subregional level.

Examining fiscal federalism, regionalization and community-based initiatives in Canada's health care delivery system

This study focuses on the ability of Canadian provinces to shape in different ways the development of various provincial health delivery systems within the constraints of the mandates of the federal Canada Health Act of 1984 and the fiscal revenues that the provinces receive if they comply with these mandates. In so doing, it will examine the operation of Canadian federalism with respect to various provincial health systems. This study applies a comparative analysis framework developed by Heisler and Peters to facilitate an understanding of the dimensionality of provincial health delivery systems as applied to the case of provincial regionalization and community-based initiatives. The three sets of relationships touched upon are: first, the levels of government and the nature of their involvement in public policy concerning the provincial health care delivery systems; and secondly, understanding of the factors influencing provincial governments' political dispositions to act in various directions. A third dimension that is taken are the factors influencing the "timing" of particular decisions. A fourth area noted by Heisler and Peters and other comparative analysts is the nature and characteristics of public and private sector activities in health care and other social policy areas. While the evolving nature of public and private sector health care delivery activities within Canada's provincial and territorial systems is a significant policy matter in the Canadian context, due to the space limitations of this article, they are not discussed herein.

[The Amazon Sanitation Plan (1940-1942)]

The article addresses the Amazon Sanitation Plan and the political context in which it was formulated between 1940 and 1941. It examines the role of Getúlio Vargas, the activities of the plan's main protagonists (such as Evandro Chagas, João de Barros Barreto, and Valério Konder), its key proposals, and its demise as of 1942 upon creation of the Special Public Health Service (Sesp), which grew out of cooperation agreements between Brazil and the US following both nations' involvement in World War II. A reproduction of the Plan as published in the Arquivos de Higiene in 1941 is included.

Executive federalism and Medicaid demonstration waivers: implications for policy and democratic process

Executive federalism emphasizes collaboration between the executive branches at the national and state levels to transform grant programs through the implementation process. In this regard, Medicaid demonstration waivers loomed large during the presidencies of Bill Clinton and George W. Bush. This article documents and compares the volume and substance of section 1115 Medicaid waiver activity under the two presidencies. From the perspective of policy performance, Medicaid demonstration waivers provide modest support for the view that states serve as laboratories for policy learning in the health care arena. More broadly, the waivers have not yielded a major solution to the problem of the uninsured and are unlikely to do so. At the same time, they have not (as some have suggested) been a subterranean force for the erosion of Medicaid. To the contrary, these waivers have often enhanced health services for low-income people; above all, they have helped preserve Medicaid as an entitlement by undercutting support for those seeking to convert the program into a block grant. From the perspective of the democratic process, we find that Congress has been a more significant player in shaping waivers than the executive federalism model suggests. While the decision processes surrounding Medicaid waivers often fall short of democratic standards with respect to transparency and opportunities for public input, they still compare favorably to certain alternatives.

Telemedicine Licensure in the United States: The Need for a Cooperative Regional Approach

The extraordinary successes and refinement of modern telemedicine applications in recent years have been diminished somewhat by the anachronistic licensure laws of the 50 state jurisdictions that limit the practice of medicine to specific state geographic boundaries. This approach is deficient when applied to telemedicine because, with the advent of the Internet and modern technological advances, differences in space and time are rendered nearly meaningless. It is recommended in this paper that the practice of telemedicine be handled differently than the practice of face-to-face medicine, as related to licensure. Although it may be argued persuasively that a national licensure model for telemedicine should be advanced, the political and constitutional hurdles may be too great to overcome. It is therefore recommended that a voluntary, regional geographic approach be instituted by jurisdictions already demonstrating a commonality of interests, such as through the Southern Governors' Association or the Western Governors' Association. The benefits to be derived from this approach would include improving access to healthcare and medical specialists, enhancing the quality and timeliness of care, cutting medical costs by moving information instead of people, securing patients' access to medical records and information, and facilitating commercial export of American telemedicine services.

The regional genetic and newborn screening service collaboratives: the first two years

Newborn screening and genetic technologies are expanding and changing rapidly, increasing the demand for genetic specialty services. Because of the scarcity and geographic maldistribution of genetic specialty services, access to these services is a critical issue. This article discusses some of the efforts initiated by the Maternal and Child Health Bureau of the Health Resources and Services Administration, particularly the establishment of regional genetic and newborn screening collaboratives to improve access to these services and expertise.

[Preconditions and factors in implementation of regional policy in the field of healthy nutrition in Russia]

The article sheds light on problems of farming and full realization of regional programs of healthy nutrition of the population.

Local Health Integration Networks: will "made in Ontario" work?

This article analyzes the prospects for success of the new LHINs and whether or not a "made in Ontario" model is likely to work. It concludes with some advice for independent healthcare corporations in the province.

Medicare program; establishment of the Medicare Advantage Program; interpretation. Final rule; interpretation

This final rule clarifies our interpretation of the meaning of "entity" in the final rule titled "Medicare Program; Establishment of the Medicare Advantage Program" published in the Federal Register on January 28, 2005 (70 FR 4588). Subsequent to the publication of the Medicare Advantage (MA) final rule on January 28, 2005, we have received inquiries from parties interested in offering an MA Regional Plan concerning whether they could jointly enter into a contract with us to offer a single MA Regional Plan in a multistate region. The participating health plans wish to contract with each other to create a single "joint enterprise." They have asked us whether such a joint enterprise could be considered an "entity" under sections 1859(a)(1)and 1855(a)(1) of the Social Security Act, for purposes of offering an MA Regional Plan. The MA final rule is scheduled to take effect on March 22, 2005. Our interpretation of the word "entity" that follows in the "Supplementary Information" section of this final rule is deemed to be included in that final rule.

[Human resources and activities in the occupational medicine service of Poland in 2003]

BACKGROUND

The presented paper shows the most essential data concerning the state of human resources and activities of occupational medicine services in Poland in 2003.

MATERIALS AND METHODS

The reports (around 10 000) obtained from primary occupational medicine service units and regional occupational medicine centers (forms: MZ-35A and MZ-35) are the source of information about human resources and occupational medicine services activities.

RESULTS

A majority of regional centers, due to their restructuring, have approached the legal and organizational model described in the Occupational Medicine Service Act. The assessment of activities of primary occupational medicine centres units, performed by regional occupational medicine centers, indicates the need for constant training of physicians authorized to perform prophylactic examinations of employees.

CONCLUSIONS

The year 2003 did not witness any new significant changes in the structure of occupational medicine service. One can speak rather about the continuation of trends observed in previous years.

[Evaluation of the public health service law of the Saxony-Anhalt region--community affairs, transfer of power and loss of control]

AIM

In the state of Saxony-Anhalt, a new Public Health Service law came into force in 1998. Our study investigated whether this new legislation has led to an extension of duties performed by regional health departments and to a subsequent increase in expenditure.

METHODS

Guided interviews at all administrative levels of the public health system were conducted. The catalogue of duties was systematized and a questionnaire was developed and distributed to all regional health departments (response rate: 17 out of 24). Data concerning revenues and expenditures of the regional health departments were analysed on the basis of the administrative districts' budget data.

RESULTS

Regional health departments stated that there had been practically no change in their activities over the last few years. When questioned about the coverage of 58 specific duties, a considerable disparity was evident between departments. A core group of "classical" duties comprising environmental health and hygiene, child health protection, individual health appraisal, and public health supervision are carried out on an established basis. Some duties were handled by external institutions, others, mostly community health duties, were not performed on an extensive scale. When asked about the desired model for their health department, most departments preferred the model of being an executor of sovereign duties, however a corporate model was deemed to be almost as acceptable. The following fields will gain increasing significance in the future: environmental medicine, health reporting, preventive medicine, co-ordination of regional health care, and health promotion. Since 1995, staff has been reduced in all regional health departments (-10.4%; 1999: 2.92 employees per 10,000 inhabitants). In 1999, expenditures amounted to an average of 24.64 German Marks per capita (range 14.20-44.58 DM). The number of inhabitants and the revenue of the regional districts were determinants of their health budgets.

CONCLUSION

Our results showed that no uncompensated additional expenditure by regional authorities resulted from this law. So far, most districts have not perceived regional health as a community affair offering possible competitive advantages. The federal state lost considerable influence at the regional level. Recommended are regional health priorities, conjoint staff development, and state guidance by a head agency providing leadership and support, while leaving responsibility with the districts.