In the period since the Alma-Ata Declaration, there has been much activity in many countries in drawing up strategies for primary health care (PHC). This paper argues that the UK, though a signatory to the Declaration, has failed to provide an adequate framework for such a strategy, and that, in spite of the strong record of the National Health Service (NHS) as a system of social medicine, much remains to be done in order to achieve the principles of PHC. The paper analyses the record of the NHS in these areas, as set against the principles of PHC. It argues that such a review is important, not only for the NHS itself, but for some overseas students of the NHS who, through the strong links between the NHS and their own health services and the strong tradition of the NHS as a (nearly) free health system, might consider it a suitable blueprint for their own health services. THough there are a number of elements of the NHS, such as its resource allocation mechanism, that are relevant to PHC, it is argued that, as a whole, its structure may not be a suitable model. (+info)
Choices without reasons: citizens' juries and policy evaluation.
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Citizens' juries are commended as a new technique for democratising health service reviews. Their usefulness is said to derive from a reliance on citizens' rational deliberation rather than on the immediate preferences of the consumer. The author questions the assertion of critical detachment and asks whether juries do in fact employ reason as a means of resolving fundamental disagreements about service provision. He shows that juries promote not so much a critically detached point of view as a particular evaluative framework suited to the bureaucratic idiom of social welfare maximisation. Reports of jury practice reveal a tendency among juries to suppress by non-rational means the everyday moral language of health care evaluation and substitute for it a system of thought in which it can be deemed permissible to deny treatment to sick people. The author concludes that juries are chiefly concerned with non-rational persuasion and because of this they are morally and democratically irrelevant. Juries are no substitute for voting when it comes to protecting the public from zealous minorities. (+info)
Democratic prioritization of maternity care: a rational basis for planning a clinical effectiveness programme.
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BACKGROUND: The aim of the study was to evaluate the use of a democratic process for prioritizing the ASQUAM (Achieving Sustainable Quality in Maternity) clinical effectiveness programme. METHODS: Twenty-two improvements in the standards of maternity care were chosen as top-topic priorities at the 1996 and 1997 ASQUAM meetings. We wished to assess the relative priorities of local and national delegates, by comparing their voting patterns at the two meetings. The setting was North Staffordshire ASQUAM prioritization days, and the subjects were all the delegates at the 1996 and 1997 ASQUAM meetings. Main outcome measures were comparison of numbers of votes cast by local and national delegates for each of the 20 topics presented at the two ASQUAM meetings, and proportions of the 11 top-topics decided at each meeting that were chosen by local and national delegates. RESULTS: In 1996, significantly more local than national delegates voted for two topics related to maternal mortality or morbidity (incontinence and hypertensive diseases of pregnancy), but there were no statistically significant differences between the proportions of votes cast for any of the other 18 topics presented on the day. Indeed, local delegates had prioritized 11/11 of the final top-topics, and only one was omitted by the national delegates (10/11). In 1997, significantly more national than local delegates voted for three topics relating to professional stress levels, user involvement in working groups and antibiotic prophylaxis, but there were no statistically significant differences between the proportions of votes cast for any of the other 17 topics presented on the day. Again, local delegates had prioritized 11/11 of the final topics, with only one being omitted by the national delegates (10/11). CONCLUSION: There appeared to be a remarkable concordance between local and national delegates at both meetings, suggesting an underlying rationality to decision making. We believe this to be a reflection of the process of careful evaluation of outcome and intervention supported by the protection of a secret ballot, allowing free expression of individual's values. (+info)
Involvement of consumers in the development of evidence based clinical guidelines: practical experiences from the North of England evidence based guideline development programme.
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BACKGROUND: Consumer involvement in clinical guidelines has long been advocated although there are few empirical accounts of attempts to do so. It is therefore not surprising that there is a lack of clarity about how and when to involve consumers and what to expect from them within the process of guideline development. METHODS: The North of England evidence based guideline development programme has used four different methods of consumer involvement. RESULTS: When individual patients were included in a guideline development group they contributed infrequently and had problems with the use of technical language. Although they contributed most in discussions of patient education, their contributions were not subsequently acted on. In a "one off" meeting with a group of patients there were again reported problems with medical terminology and the group were most interested in sections on patient education and self management. However, their understanding of the use of scientific evidence in order to contribute to a more cost effective health care remained unclear. In a workshop it was possible to explain the technical elements of guideline development to patients who could then engage with such a process and make relevant suggestions as a consequence. However, this was relatively resource intensive. A patient advocate within a guideline development group felt confidence to speak, was used to having discussions with health professionals, and was familiar with the medical terminology. CONCLUSIONS: Consumers should be involved in all stages of guideline development. While this is possible, it is not straightforward. There is no one right way to accomplish this and there is a clear need for further work on how best to achieve it. (+info)
A seat at the table: membership in federal advisory committees evaluating public policy in genetics.
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OBJECTIVES: This study examined who participates in federal government advisory committees regarding public policy in human and medical genetics, what parties they represent, and to what extent the general public is meaningfully represented. METHODS: Analysis focused on 7 federal government documents published from January 1990 to February 1995. Advisors were categorized into 4 groups based on the professional affiliations that were listed in the publications. After a search of several references and data-bases, the study examined whether these individuals also had other affiliations not listed in the government publications. RESULTS: Individuals whose principal affiliations were with academia (n = 32; 44%) or industry (n = 19; 26%) represented nearly three fourths of the sample, followed by government employees (n = 13; 18%) and consumer advocates (n = 8; 11%). At least 16% of the advisors serving on the federal committees, mostly members of academia, had a dual affiliation. CONCLUSIONS: These data indicate that the public has modest representation on key federal advisory committees making policy recommendations regarding human genetics technology and clinical practice and that there is ample room for additional public participation. (+info)
Partnering with communities to improve health: the New York City Turning Point experience.
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Concurrent with the New York City Department of Health's reorganization efforts, the Robert Wood Johnson and W.K. Kellogg Foundations launched Turning Point, a national initiative designed to strengthen the nation's public health system. The Turning Point initiative has emphasized broad-based partnership building and planning as key prerequisites for improving public health practice. In response to the foundations' request for proposals, the department formed a New York City Public Health Partnership, which in turn applied for and was granted a Turning Point planning grant. This funding allowed New York City Turning Point to initiate a public health planning process, part of which involved convening forums in each of the five boroughs. With over 1,100 community participants, these forums provided both a starting point for establishing public health priorities and an interactive setting for sharing health and demographic data. Included among the issues that emerged as priorities were: access to care, environmental health, mental health, housing, asthma, education, and dietary issues. Building on the forum outcomes, the New York City Public Health Partnership developed a public health system improvement plan. The goals delineated in this plan are: (1) to create and support public health partnerships at the community, borough, and citywide levels; (2) to identify community health concerns and develop strategies responsive to these concerns; and (3) to develop policies to support and sustain a community health approach to improve health status. This article also discusses possible roles for local health departments in promoting a community health approach to address public health concerns. (+info)
Community participation in local health boards in a decentralized setting: cases from the Philippines.
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Decentralization has been associated traditionally with participation and empowerment in local decision-making. This study of four cases analyzed the role of local health boards in enhancing community participation and empowerment under a decentralized system in the Philippines. Local government units (LGUs) with functioning local health boards were compared with LGUs whose health boards were not meeting regularly as mandated by law. The study found that there were more consultations with the community, fund-raising activities, health initiatives and higher per capita health expenditure in LGUs with functioning local health boards. Only the mayors and municipal health officers felt empowered by devolution. In general, awareness of devolution and their potential roles in health decision-making was low among members of the community. These findings can be attributed to the socio-cultural and historical traditions of centralized governance with little popular participation, overall attitudes of the community and board members, perceptions of health as primarily a medical matter, economic circumstances of LGUs, and insufficient preparation for devolution. Recommendations are suggested in response to these findings. (+info)
Boards of Health as venues for clean indoor air policy making.
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OBJECTIVES: This study sought to determine the tobacco industry's strategies for opposing health board actions and to identify elements necessary for public health to prevail. METHODS: Newspaper articles, personal interviews, and tobacco industry documents released through litigation were reviewed. RESULTS: Twenty-five instances in which the tobacco industry opposed health board regulations were identified. It was shown that the tobacco industry uses 3 strategies against health boards: "accommodation" (tobacco industry public relations campaigns to accommodate smokers in public places), legislative intervention, and litigation. These strategies are often executed with the help of tobacco industry front groups or allies in the hospitality industry. CONCLUSIONS: Although many tobacco control advocates believe that passing health board regulations is easier than the legislative route, this is generally not the case. The industry will often attempt to involve the legislature in fighting the regulations, forcing advocates to fight a battle on 2 fronts. It is important for health boards to verify their authority over smoking restrictions and refrain from considering non-health factors (including industry claims of adverse economic impacts) so as to withstand court challenges. (+info)