Small fish in a big pond? External aid and the health sector in South Africa.
(25/1275)
Since a new government was elected in 1994, South Africa has become a favoured nation for the many bilateral and multi-lateral agencies providing aid to developing countries. Despite several relatively large pledges of 'transition support', however, external resources constitute less than 2% of the annual government budget. This non-dependence has established a degree of equilibrium in a relationship normally regarded as highly unequal in other African countries. Although international donors funded the antiapartheid movement in South Africa prior to 1994, the new government inherited a chaotic administration that had little institutional experience of conventional development aid. Many of the new cadres entering government had not been exposed to the workings of government, let alone donor, bureaucratic processes. It is not surprising, therefore, that in the first few years after 1994, the aid relationship was characterized by low disbursements, unrealistic expectations and a degree of conflict. Since 1997, however, aid supported projects have started to become more visible. Within the broad objective of supporting transformation of the health system, one of the key areas of donor support is managerial capacity development, particularly of district, hospital and provincial health structures. These initiatives tend to be poorly coordinated, a problem compounded by a quasi-federal system in which provinces have large amounts of autonomy. The contribution of donor aid to strengthening the health system could be enhanced by the establishment of a clear national framework to guide the many externally supported projects building managerial skills and systems. (+info)
To boldly go....
(26/1275)
The threshold of the new millennium offers an opportunity to celebrate remarkable past achievements and to reflect on promising new directions for the field of public health. Despite historic achievements, much will always remain to be done (this is the intrinsic nature of public health). While every epoch has its own distinct health challenges, those confronting us today are unlike those plaguing public health a century ago. The perspectives and methods developed during the infectious and chronic disease eras have limited utility in the face of newly emerging challenges to public health. In this paper, we take stock of the state of public health in the United States by (1) describing limitations of conventional US public health, (2) identifying different social philosophies and conceptions of health that produce divergent approaches to public health, (3) discussing institutional resistance to change and the subordination of public health to the authority of medicine, (4) urging a move from risk factorology to multilevel explanations that offer different types of intervention, (5) noting the rise of the new "right state" with its laissez-faire attitude and antipathy toward public interventions, (6) arguing for a more ecumenical approach to research methods, and (7) challenging the myth of a value-free public health. (+info)
Food refusal in prisoners: a communication or a method of self-killing? The role of the psychiatrist and resulting ethical challenges.
(27/1275)
Food refusal occurs for a variety of reasons. It may be used as a political tool, as a method of exercising control over others, at either the individual, family or societal level, or as a method of self-harm, and occasionally it indicates possible mental illness. This article examines the motivation behind hunger strikes in prisoners. It describes the psychiatrist's role in assessment and management of prisoners by referring to case examples. The paper discusses the assessment of an individual's competence to commit suicide by starvation, legal restraints to intervention, practical difficulties and associated ethical dilemmas. Anecdotal evidence suggests that most prisoners who refuse food are motivated by the desire to achieve an end rather than killing themselves, and that hunger-strike secondary to mental illness is uncommon. Although rarely required, the psychiatrist may have an important contribution to make in the management of practical and ethical difficulties. (+info)
Power and the teaching of medical ethics.
(28/1275)
This paper argues that ethics education needs to become more reflective about its social and political ethic as it participates in the construction and transmission of medical ethics. It argues for a critical approach to medical ethics and explores the political context in medical schools and some of the peculiar problems in medical ethics education. (+info)
Autonomy, liberalism and advance care planning.
(29/1275)
The justification for advance directives is grounded in the notion that they extend patient autonomy into future states of incompetency through patient participation in decision making about end-of-life care. Four objections challenge the necessity and sufficiency of individual autonomy, perceived to be a defining feature of liberal philosophical theory, as a basis of advance care planning. These objections are that the liberal concept of autonomy (i) implies a misconception of the individual self, (ii) entails the denial of values of social justice, (iii) does not account for justifiable acts of paternalism, and (iv) does not account for the importance of personal relationships in the advance care planning process. The last objection is especially pertinent in light of recent empirical research highlighting the importance of personal relationships in advance care planning. This article examines these four objections to autonomy, and the liberal theoretical framework with which it is associated, in order to re-evaluate the philosophical basis of advance care planning. We argue that liberal autonomy (i) is not a misconceived concept as critics assume, (ii) does not entail the denial of values of social justice, (iii) can account for justifiable acts of paternalism, though it (iv) is not the best account of the value of personal relationships that arise in advance care planning. In conclusion, we suggest that liberalism is a necessary component of a theoretical framework for advance care planning but that it needs to be supplemented with theories that focus explicitly on the significance of personal relationships. (+info)
Altruism, blood donation and public policy: a reply to Keown.
(30/1275)
This is a continuation of and a development of a debate between John Keown and me. The issue discussed is whether, in Britain, an unpaid system of blood donation promotes and is justified by its promotion of altruism. Doubt is cast on the notions that public policies can, and, if they can, that they should, be aimed at the promotion and expression of altruism rather than of self-interest, especially that of a mercenary sort. Reflections upon President Kennedy's proposition, introduced into the debate by Keown, that we should ask not what our country can do for us but what we can do for our country is pivotal to this casting of doubt. A case is made for suggesting that advocacy along the lines which Keown presents of an exclusive reliance on a voluntary, unpaid system of blood donation encourages inappropriate attitudes towards the provision of health care. Perhaps, it is suggested, and the suggestion represents, on my part, a change of mind as a consequence of the debate, a dual system of blood provision might be preferable. (+info)
Tax subsidies for health insurance: costs and benefits.
(31/1275)
The continued rise in the uninsured population has lead to considerable interest in tax-based policies to raise the level of insurance coverage. Using a detailed microsimulation model for evaluating these policies, we find that while tax subsidies could significantly increase insurance coverage, even very generous tax policies could not cover more than a sizable minority of the uninsured population. For example, a generous refundable credit that costs $13 billion per year would reduce the ranks of the uninsured by only four million persons. We also find that the efficiency of tax policies, in terms of the cost per newly insured, inevitably would fall as more of the uninsured were covered. (+info)
A political history of the Indian Health Service.
(32/1275)
One of the few bright spots to emerge from the history of relations between American Indians and the federal government is the remarkable record of the Indian Health Service (IHS). The IHS has raised the health status of Indians to approximate that of most other Americans, a striking achievement in the light of the poverty and stark living conditions experienced by this population. The gains occurred in spite of chronically low funding and can be attributed to the combination of vision, stubbornness, and political savvy of the agency's physician directors and the support of a handful of tribal leaders and powerful allies in the Congress and the White House. Despite the agency's imperfections and the sizeable health problems that still exist among American Indians and Alaskan Natives, the IHS is an example of one federal program that has worked. (+info)