Background Metaphors are central to the human understanding of complex issues; through the immediate associations they evoke and frame problems and suggest solutions. Our suggestion of Music in the Park as a metaphor for health systems reform brings to the forefront the environmentally diverse but bounded spaces of health services that offer a variety of attractors within their confines, while pushing into the background organizational and economic concerns.Reflections Parks, like health services, are embedded in their local landscape, (...) serving their communities, but most importantly parks are public spaces, publically funded, ideally offering universal access and equity and to be shared by all who want to go there.Music, like health, is tangible, technical and scientific, yet ultimately experiential and based on meaning. While it encompasses a wide range of styles and approaches, music making requires as its most important skill active listening which brings with it to be ‘in the moment’, to take personal risks and to draw energy and inspiration from the participants. Hence ‘audiences’ are equally active participants because music only has meaning if it internally resonates with the listener and only can exist in what is a co-constructed experience.Conclusions Music in the Park is a metaphor for primary health care systems based on shared values of experts and unique local communities. Health professionals are players in this arena, who develop and practise the full range of their skills in response to individual and community needs and preferences. Their leadership works through inspiration and empowerment, making patients ‘co-producers’ of their own health and ‘co-shapers’ of their health services. (shrink)

Partially because of the high cost of developing and maintaining cold chains, systems needed to keep heat-labile vaccines under adequate refrigeration from their points of manufacture to their administration in the field, the Joint WHO/FAO Expert Committee on Zoonoses (i.e., the approximately four fifths of all described human infections that people share with other vertebrate animals) recommended in 1982 operation of common cold chains by health and veterinary services in rural areas. Following this recommendation, a 1984 pilot level initiative (...) in medical-veterinary intersectoral cooperation should be regarded as a practical way to deliver human primary health care to currently neglected African pastoralists, and as a potential core program for development efforts overall within arid and semiarid areas of the African continent. (shrink)

The lack of primary healthcare integration has been identified as one of the main limits to programs’ efficacy in low- and middle-income countries. This is especially relevant to the Millennium Development Goals, whose health objectives were not attained in many countries at their term in 2015. While global health scholars and decision-makers are unanimous in calling for integration, the objective here is to go further and contribute to its promotion by presenting two of the most important challenges (...) to be met for its achievement: 1) developing a “crosswise approach” to implementation that is operational and effective; and 2) creating synergy between national programs and interventions driven by non-State actors. The argument for urgently addressing this double challenge is illustrated by drawing on observations made and lessons learned during a four-year research project evaluating the effects of interventions against malaria in Burkina Faso. The way interventions were framed was mostly vertical, leaving little room for local adaptation. In addition, many non-governmental organizations intervened and contributed to a fragmented and heteronomous health governance system. Important ethical issues stem from how interventions against malaria were shaped and implemented in Burkina Faso. To further explore this issue, a scoping literature review was conducted in August 2016 on the theme of integrated primary healthcare. It revealed that no clear definition of the concept has been advanced or endorsed thus far. We call for caution in conceptualizing it as a simple juxtaposition of different tasks or missions at the primary care level. It is time to go beyond the debate around selective versus comprehensive approaches or fragmentation versus cohesion. Integration should be thought of as a process to reconcile these tensions. In the context that characterizes many low- and middle-income countries today, better aid coordination and public health systems strengthening, as promoted by multisectoral approaches, might be among the best options to sustainably and ethically integrate primary healthcare interventions. (shrink)

El proceso de atención de enfermería es la aplicación del método científico en la práctica asistencial de la disciplina, de modo que se pueda ofrecer cuidados sistematizados, lógicos y racionales. El artículo que presentamos tiene como objetivo describir un sistema de acciones y operaciones para desarrollar la habilidad diagnosticar en el proceso de atención de enfermería y ser aplicado en la docencia de manera que contribuya en la calidad del egresado. A partir del análisis del perfil profesional y del grado (...) de desarrollo científico-técnico alcanzado y su relación con la identificación de los problemas que constituyen la base del plan de cuidados en el proceso de atención de enfermería se estructuran las acciones y operaciones con una secuencia lógica para llegar al diagnóstico. The process of nursing primary health care is the application of the scientific method in the assistencial practice of this discipline in such a way that it can offer systematic, logical and rational care. The present article has the objective to describe a system of actions and procedures to develop the ability of diagnosing in the process of nursery primary health care and be applied in teaching to favour the increasement of the egressed quality. Actions and procedures have been structured with a logical secuence to reach the diagnosing, starting with the analysis of the professional profile, the level of scientific and technical development reached and its relation with the identification of problems that constitute the base of the patient plan of care in the process of nursery primary health care. (shrink)

The term 'primary health care' (PHC) has come into widespread use by policy-makers, managers and health professionals in the past two decades. There is a variety of definitions and an even wider variety of uses of the term. The purpose of this paper is to examine critically existing definitions and uses, with a particular focus on their usefulness in health policy, clinical practice and research relating to health care systems. The paper has three (...) parts. First, we examine the principal types of definition and identify core features of primary care common to most definitions. Second, we discuss the application of these criteria to a range of services in the UK National Health Service (NHS). Lastly, we examine the ways in which policymakers, health professionals, researchers and lay people use the term, also drawing primarily on UK experience. We conclude by reflecting on the likelihood of achieving a single unambiguous definition and the usefulness of the term for different purposes. (shrink)

In many countries health policy and health system reforms are giving primary health care (PHC) a more prominent role in the health system. As a result, policy towards PHC is becoming more contested and is posing bigger and more contradictory demands of PHC (e.g. that PHC should at once be more accessible and of higher quality and cheaper). International and professional bodies have responded to the debates about what the role of PHC (...) should be partly by promulgating redefinitions of ‘primary health care’. However, such definitions tend simply to assert a policy standpoint of their own, thereby begging the policy questions noted above. This paper tests some better-known current definitions of ‘primary health care’ against various criteria of validity, including the requirement not to prejudge the aforementioned policy debates. It then constructs a fresh definition from the materials which survive that test and from a general theory of the function of health care. The resulting definition is:Primary health care: goods or services which individuals obtain for maintaining their personal functioning or preventing pain; which they can access directly and receive in settings which allow them to continue their other normal activities of daily life at home and (when applicable) at work.Whilst its present conclusions relate specifically to PHC, the paper’s method for generating and testing definitions applies to health services research generally. (shrink)

Health care systems in different countries and cultures differ and tend toreflect the particular values and, therefore, the particular socialstructure of a given society. Each of these has ethical problems unique toitself. Some of these problems are briefly discussed. So as to have anindividual ethical problem in the context of medical care, access tomedical care needs to be assured. It is argued that individual problems arethe primary issue in societies in which there is fair access (...) whereas theyare of lesser importance in societies which have thus far failed toprovide fair access. (shrink)

The Israeli health care system is looked upon by some people as one of the most advanced health care systems in the world in terms of access, quality, costs and coverage. The Israel health care system has four key components: (1) universal coverage; (2) ‘cradle to grave’ coverage; (3) coverage of both basic services and catastrophic care; and (4) coverage of medications. Patients pay a (relatively) small copayment to see specialists and (...) to purchase medication; and, primary care is free. However, during 2011 the Israeli Medical Association (IMA) spent 5 months on a strike, justifying it as trying to ‘save’ the Israeli public health. This paper describes some aspects of the Israeli Health Care System, the criteria for setting priorities for the expenditures on health care and values underlying these criteria. The paper observes that the new agreement between the IMA and the government has given timely priority to problematic areas of specialization (in which there is an acute shortage of physicians) and to hospitals in the periphery of the country. Yet weak points in the health system in Israel remain. Particularly, the extent to which national health care expenditures are being financed privately—which is rising—and the parallel decline in the role of government financing. (shrink)

Patient responsibilities in primary health care are controversial and, by comparison, the responsibilities of high need patients are less clear. This paper aims to suggest why high need patients receiving targeted entitlements in primary health care are free to have prima facie special responsibilities; why, given this freedom, these patients morally have special responsibilities; what these responsibilities are, and how publicly funded health systems ought to be able to respond when these remain unmet. (...) It is suggested that the special responsibilities and their place in public policy acquire moral significance as a means to discharge a moral debt, share special knowledge, and produce desirable consequences in regard to personal and collective interests. Special responsibilities magnify ordinary patient responsibilities and require patients not to hesitate regarding attendance for primary health care. Persistent patient disregard of special responsibilities may necessitate limiting the scope of these responsibilities, removing system barriers, or respecifying special rights. (shrink)

The health care systems are fairly similar in theScandinavian countries. The exact details vary, but inall three countries the system is almost exclusivelypublicly funded through taxation, and most (or all)hospitals are also publicly owned and managed. Thecountries also have a fairly strong primary caresector (even though it varies between the countries),with family physicians to various degrees acting asgatekeepers to specialist services. In Denmark most ofthe GP services are free. For the patient in Norwayand Sweden there are (...) out-of-pocket co-payments for GPconsultations, with upper limits, but consultations forchildren are free. Hospital treatment is free inDenmark while the other countries use a system without-of-pocket co-payment. There is a very strongpublic commitment to access to high quality healthcare for all. Solidarity and equality form theideological basis for the Scandinavian welfare state.Means testing, for instance, has been widely rejectedin the Scandinavian countries on the grounds thatpublic services should not stigmatise any particulargroup. Solidarity also means devoting specialconsideration to the needs of those who have lesschance than others of making their voices heard orexercising their rights. Issues of limited access arenow, however, challenging the thinking about a healthcare system based on solidarity. (shrink)

The care of patients with many illnesses often appears fragmented by many boundaries in the health care system when the care is provided in several locations of primary and secondary care. In the article, boundaries are examined in an interaction between patients and multiple providers in an effort to develop collaboration in inter-organizational provision in a Change Laboratory intervention. Firstly, it will be traced how the boundaries are expressed in the interaction. Secondly, it (...) will be studied how the boundaries expressed in the interaction relate to health care organizations and patient care practices. Thirdly, the practical activity that was embedded in the interaction between patients and providers will be focused on at the laboratory. The expression of boundaries was examined in activity theoretical terms as discursive actions. In discursive actions the ‘lived past’ becomes involved in the situational actions that orient towards future activity. The findings suggest that expressing boundaries uses various linguistic means and it seems relevant to propose that boundaries cannot be studied in a formal way; the analysis needs to be related to the organizational context of the specific study. However, the linguistic means may serve as useful “landmarks” or “pointers” of boundaries that are often expressed implicitly in the interaction. The laboratory session provides an opportunity to study boundaries “on the spot”, or “in their own right”. The realization of the emergent inter-organizational care at the session created challenges for the provision while contradicting some elements of the prevailing provision. During these kinds of interaction, the boundaries between providers became obvious. Furthermore, challenging the boundaries in the normal flow of interaction may be a potential for boundary crossing and even further, a re-constitution of boundaries. Consequently, a boundary crossing represents an interesting unit of analysis for future studies of boundaries and boundary crossing in interaction and discourse. At the laboratory setting was displayed the ability to control others through an indirect use of power that may reflect a simultaneous value system supported by the prevailing hierarchies. In the studies to come, it will be important to pay attention to these implicit power linkages when monitoring the boundaries in horizontal collaborations. (shrink)

Following publication of the influential Flexner Report on medical education in 1910, the US built a health care system on a foundation of science that, by the end of the 20th century, provided some of the best medical care in the world. Now, at the start of the 21st century, we are in real danger of destroying those impressive achievements. The primary reason is the failure over many years to change our increasingly dysfunctional health (...) insurance system. Chief among its problems is reduced access to medical services as growing numbers of Americans lose health insurance altogether, and coverage for the rest is eroding. (shrink)

Patient safety has assumed a prominent role on the policy agenda since the Institute of Medicine report To Err Is Human was released in November 1999. The report maintained that medical error is the predominant mechanism by which patients in the United States and around the world are injured. This finding, along with the report’s recommendation for a “systems” approach to reducing medical error, provided an extremely important insight into the operation of our medical delivery system. Clearly, while advances (...) in medical technology, diagnostic techniques, and knowledge provide the foundation for saving lives, medical error has resulted in their loss. However, recognition that medical error is a primary cause of these avoidable patient injuries and deaths is a key one and may result in improvements within our system of health-care delivery as well as minimization of the emotional and financial toll that iatrogenic injury causes. (shrink)

A considerable section of the population in India accesses the services of individual private medical practitioners (PMPs) for primary level care. In rural areas, these providers include MBBS doctors, practitioners of alternative systems of medicine, herbalists, indigenous and folk practitioners, compounders and others. This paper describes the profile, knowledge and some practices of the rural doctor in India and then discusses the reasons for lack of equity in health care access in rural areas and possible solutions (...) to the problem. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Managed Health Care: New Ethical Issues for All*Martina Darragh (bio) and Pat Milmoe McCarrick (bio)Changes in the way that health care is perceived, delivered, and financed have occurred rapidly in a relatively short time span. The 50-year period since World War II encompasses enormous growth in medical technology, soaring health care costs, and significant fragmentation of the two-party patient- physician relationship. This relationship (...) first grew to include the third-party payer, the health insurance industry, and now “with great speed and relatively little public awareness, a significant change has occurred in the way some decisions are made about a patient’s medical care” (III, Institute of Medicine 1989).The new means of providing health care bring an increasing number of parties into clinical decision-making processes. With this change, ethical issues that once concerned only health care professionals, the physician or the nurse, have expanded to include the patient and the groups who “manage” care—e.g., health maintenance organizations (HMOs), preferred provider organizations (PPOs), point of service groups (POSs), independent practice associations (IPAs), insurance reviewers, hospital administrators, institutional managers, and, the most recent players, purchasers of group health care who base their decisions on competitive pricing.The term “managed care” refers to a variety of continually adapting and developing arrangements that involve four groups. These groups, which have been labeled by the world of business, not health, are the “consumer” (once the patient), the “provider” (the physician and other health care professionals), the “insurer” (the reimburser for any care), and the “purchaser of care” or the primary buyer of health services (the large employer organization). Capitation is a common way to pay for health services in managed care systems. A certain dollar amount is negotiated for health services for a specified number of patients whether the care is delivered or not; the provider shares with the [End Page 189] insurer any financial risk for the actual cost of care (III, Centers for Disease Control 1995).When the Clinton administration’s health care reform movement failed to gain support in the U.S. Congress, the use of managed care to control rising health care costs accelerated. The literature on managed care and its effect on the patient-physician relationship reflects this shift. During the era of health care reform, “debate centered on how managed care could control costs, on the use of technology and patient satisfaction, [and] on access and barriers to care” (IV, Emanuel and Dubler 1995). When managed care organizations began contracting with physicians to provide health care services subject to the plans’ provisions, these plans became agents in clinical decision making on a wide-spread basis. HMO enrollment grew to 51 million persons by 1994 (III, Centers for Disease Control 1995). This “corporatization” of health care has sparked a plethora of articles about the effects of the marketplace on the physician’s ability to do what is best for the patient, and on the patient’s ability to trust the physician to do so.Many authors make it clear that managed care itself is not the problem, but rather the development of for-profit managed care plans by “corporate conglomerates with billions of dollars in assets that compensate their executives as grandly as basketball players” (V, Kassirer 1995) “in a marketplace that is largely unregulated” (I, Zoloth-Dorfman and Rubin 1995). “Some, mostly older plans that were created when cost containment was an unexpected benefit rather than their central purpose, deliver high-quality care economically. Unfortunately, others cut costs by recruiting the healthiest patients, excluding the sickest, rationing care by making it inconvenient to obtain, and denying care by a variety of mechanisms” (V, Kassirer 1995).These cost-containment features now play an intimate role in clinical practice. When a managed care plan contracts with a physician, the doctor becomes a “double agent” with contractual obligations to the plan to provide a preset amount of services and professional responsibilities to each patient to authorize necessary treatment (V, Angell 1993). This duality can undermine the physician’s fiduciary responsibility to the patient wherein the physician “has power over the affairs of [the patient]...and is required by law to act on that person’s... (shrink)

Medicine and Money explores the role of beneficence and cost control in health-care systems. The book's primary concern of morally improving medicine is achieved by dividing the argument into two parts. The first defines the crisis in health-care and justifies beneficence. The second part offers practical suggestions on implementing beneficence into the system. Medicine and Money is one of the few books to provide concrete suggestions on improving the health-care system from (...) the micro level for addressing cost concerns in a morally acceptable manner. (shrink)

This dissertation serves as a monograph on the moral and social implications of a utilitarian-based system of health care which recognizes and takes rights seriously. Though the design and claims are stated primarily in terms of utilitarianism, admittedly, there are elements of communitarian, deontological, and rights theories which have been incorporated. ;Such a commingling of theoretical elements, under the claim of being utilitarian, may seem ambiguous, however, it is my contention that such inclusions only serve to enhance (...) the plausible nature of this sphere-specific form of utilitarianism and the adjudication of rights. Additionally, though there are other components of theories included, the basis of utilitarianism still serves as the foundation by which all other actions, decisions, and values are judged. ;While it is true that utilitarianism offers a standard for all areas of life, the idea of examining a sphere or environment of utility, in this case, the utility associated with the sphere of health care, allows for the good to be clearly defined. One primary weakness of classical utilitarianism is that it ignores, or at least does not do full justice to, the notion of personal responsibility or sense of obligation. If the only duty or requirement is to produce some obscure sense of the "greatest good" or the "greatest happiness," the question of how the good is identified and who is to have the good remains unanswered by the traditional utilitarian construct. ;The classical view of utilitarianism is too broad in its scope of defining "the greatest good" or realm of value. But to narrow the area of value to a particular sphere or environment allows for the utility and associated rights in question to be identified, the value measured, and the success more easily interpreted. ;While maintaining the general premise of utilitarianism, that is, "the greatest good for the greatest number," the notion is not from some nebulous concept or subjective position about life or feelings in general. This sphere-specific position also acknowledges and defines the "rights" of the individual within the particular sphere being considered, in this case, the sphere of health care. (shrink)

Background: Direct–to–consumer genetic testing (DTCGT) offers risk estimates for a variety of complex diseases and conditions, yet little is known about its impact on actual users, including their decisions about sharing the information gleaned from testing. Ethical considerations include the impact of unsolicited genetic information with variable validity and clinical utility on relatives, and the possible burden to the health care system if revealed to physicians. Aims: The qualitative study explored primary care patients’ views, attitudes, (...) and decision making considerations regarding DTCGT. This article focuses on the disclosure decisions participants made regarding participation, testing, and results of DTCGT, a topic which arose as a secondary aim of the study. Methods: Through four longitudinal interviews (pre–test, results, 3 and 12 months post–test) we examined twenty primary care patients’ decisions, expressed intentions, and actions regarding disclosure to immediate and extended family, friends and coworkers, and physicians about participation in and results of DTCGT. Individual interviews were analyzed using qualitative content analysis and a summative approach to describe the global themes. Results: Most participants disclosed to some immediate family; less than half disclosed to extended family; approximately half talked to friends. Most participants stated they would or might disclose to physicians about DTCGT and a few did. Conceptual themes that emerged from the data analysis include ambivalence about disclosure, consistency between intention and actual disclosure behavior and decisions, and conditional information sharing. Conclusions: Participants’ intentional and actual disclosure patterns offer insight into how they view DTCGT, weigh results, and the potential impact of DTCGT. (shrink)

Managed care has brought wide-ranging changes to the health care system. Some of these changes have been well publicized. Among them are the financial pressures that have resulted in numerous mergers of health care institutions, the restriction on the ability of patients to select their physician of choice, and the ever diminishing number of days that patients are permitted to stay in the hospital. Individual physicians, too, have been affected. For example, they are under (...) pressure to see more patients per unit time and to use fewer resources. Utilization review and payment methods may make them reluctant to undertake the full set of diagnostic tests and therapeutic interventions when they might otherwise have done so. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Working on the Clinton Administration's Health Care Reform Task ForceNancy Neveloff Dubler (bio)This narrative is based on my understanding of the elements of the Health Security Act that may have ethical implications. I have reconstructed these elements from my experience on the Health Care Reform Task Force and they are part of the health care plan that the President presented to Congress. (...) (At the time this article went to press, the actual legislation, which should answer my remaining specific questions more clearly, had not yet been released.) I perceive the most important features of the plan to be:• The legislation will create a "right" to health care for all citizens—access to care will be universal;• The plan will involve some form of managed competition in which groups of providers (called Approved or Accredited Health Plans (AHPs)) will offer comparable benefit packages at slightly (or widely) different costs;• The AHPs will negotiate with the Health Alliance (HA) to determine the price that they will charge their consumer-patients;• There will be open enrollment with no barriers to coverage, such as exclusions for pre-existing conditions;• Community rating will be in effect in different localities and enrolled persons in any AHP will pay the same premium;• The coverage for any enrolled person will be portable;• The overall structure will be a cooperative federal/state enterprise in which the states will have quite extensive abilities to fashion variations of the basic plan to meet their particular needs;• Primary care will be encouraged and incentives for physicians to train in primary care specialties provided;• Non-physician providers will be central to the functioning of the health care plans;• Efforts will be made to develop a "person power" pool so that people with an abstract "right" to health care will have real access to providers, in their localities, who can fulfill the promise that the right creates; [End Page 421]• The goal of cost containment will be central to the organization and regulation of the system;• Administrative simplicity and quality protections will be central.Co-chairing the Bioethics Working Group (BWG) of the White House Task Force on Health Care Reform was a unique experience. Approximately 40 Task Force working groups were established by Hillary Rodham Clinton, the President, and the senior Task Force staff. Various members of the President's office and other knowledgeable members of the Executive Branch selected the participants. In our group, appointments were made largely on the recommendations of the co-chairs. The BWG, among the last of the groups formed, carried the official name "The Working Group on the Ethical Foundations of the New System" and was jointly led by me and Marion Gray Secundy, a Professor of Bioethics at Howard University. The fact that the leadership of the Task Force saw fit to establish such a group, thereby confirming that bioethics is a player in the arena of health care policy, was in itself significant and was made no less so by the lack of clarity regarding the group's aims and goals.The working groups of the Task Force were organized into clusters, determined by the relatedness of the somewhat distinct, but always overlapping, content of their investigations. Separate clusters and working groups, for example, looked at mental health, long term care, and the benefit package and coverage for low-income and non-working families. On this last issue there was also a working group that explored health policy initiatives for underserved populations. This multiple focus on related issues proved to be an excellent method for ensuring that the complexity of these topics was sufficiently explored. There was a published schedule for when these groups met together, and members of other groups who had similar or overlapping concerns were invited to attend and to participate.Every week or so, all of the working groups reported to the Task Force leadership, under the direction of Ira Magaziner, in a process called a "tollgate." Prior to the tollgate, the working groups were required to submit formal written analyses of the problems they had most recently been considering. Copies of these documents were placed in a special room so that those who were interested could review... (shrink)

Restructured health care reimbursement systems and new requirements for nonprofit hospitals are transforming the U.S. health system, creating opportunities for enhanced integration of public health and health care goals. This article explores the role of public health practitioners and lawyers in this moment of transformation. We argue that the population perspective and structural strategies that characterize public health can add value to the health care system but could get (...) lost in translation as changes to tax requirements and payment systems are rapidly implemented. We urge public health leaders to take a more active role in hospital assessments of community health needs and evaluation of the patient outcomes for which providers are accountable. (shrink)

This paper is aimed at a critical assessment of the moral framework of the current Chinese health system from a Confucian perspective, by focusing on the debate between the individual directed approach and the family-oriented approach to a health care system. Concerned with the nature and status of the family in communal life, the paper deals with the following questions: to cope with the frailties of material life (including susceptibility to disease), what good is presupposed (...) by human existence and flourishing; why it is the family that serves as the primary locus of bearing and realizing this unique good; and what kind of society might possess the structures necessary to achieve the good thus conceived. All these questions lead to a revision of the theory of justice required in health care, in favor of family health saving accounts as an important institutional guarantee. (shrink)

As health care systems have been recast as innovation assets, commercial aims are increasingly prominent within states’ health and medical research policies. Despite this, the reformulation of notions of social and of scientific value and of long-standing relations between science and the state that is occurring in research policies remains comparatively unexamined. Addressing this lacuna, this article investigates the articulation of ‘actually existing neoliberalism' in research policy by examining a major Australian research policy and funding instrument, the (...) Medical Research Future Fund. We identify the MRFF and allied initiatives as a site of state activism: reallocating resources from primary and preventive health care to commercially-oriented biomedical research; privileging commercial objectives in research and casting health as a “flow on effect”; reorganising the publicly funded production of health and medical knowledge; and arrogating for political actors a newly prominent role in research grant assessment and funding allocation. We conclude that rather than the state’s assumption of a more activist role in medical research and innovation straightforwardly serving a ‘public good’, it is a driver of neoliberalisation that erodes commitments to redistributive justice in health care and significantly reconfigures science-state relations in research policy. (shrink)

Patients’ experience of symptoms does not follow the body–mind divide that characterizes the classification of disease in the health care system. Therefore, understanding patients in their entirety rather than in parts demands a different theoretical approach. Attempts have been made to formulate such approaches but many of these, such as the biopsychosocial model, are still basically dualistic or methodologically reductionist. In primary care, patients often present with diffuse symptoms, making primary care the ideal (...) environment for understanding patients’ undifferentiated symptoms and disease patterns which could readily fit both bodily and mental categories. In this article we discuss theoretical models that have attempted to overcome this challenge: The psychosomatic approach could be called holistic in the sense of taking an anti-dualistic stance. Primary care theorists have formulated integrative views but these have not gained a foothold in primary care medicine. McWhinney introduced a new metaphor, ‘the body–mind’, and Rudebeck advocated cultivating ‘bodily empathy’. These views have much in common with both phenomenological thinking and mentalization, a psychological concept for understanding others. In the process of understanding patients there is a need for the physician to enter an intersubjectivity that aims at understanding the patient’s experiences and sensations without initially jumping to diagnostic conclusions or into a division into mental and physical phenomena. Mentalization theory could form the basis of an approach to a more comprehensive understanding of patients. The success of such an approach is, however, dependent upon structural and organizational conditions that do not counteract it. (shrink)

The purpose of cultural competence education for medical professionals is to ensure respectful care and reduce health disparities. Yet as Berger and Miller (2021) show, the cultural competence framework is dated, confused, and self-defeating. They argue that the framework ignores the primary driver of health disparities—systemic racism—and is apt to exacerbate rather than mitigate bias and ethnocentrism. They propose replacing cultural competence with a framework that attends to two social aspects of structural inequality: health and (...) social policy, and institutional-system activity; and two psychological aspects of structural inequality: the clinical encounter, and the epistemic. -/- We agree with the structural approach. To that end, we think it would be fruitful to include attention to physical contributors to structural inequality, namely the material artifacts used in medicine. Devices, tools, and technologies can materialize biases, perpetuate oppression, and contribute to health disparities. Granted, not everything that interests philosophers can be squeezed into medical education. Nevertheless, there are compelling reasons for including the study of material artifacts in education designed to reduce health disparities. First, devices and tools often carry forward biases from the past, and keep biases hidden from plain sight. Second, by studying these artifacts, future clinicians can begin to see themselves as part of a larger sociotechnical system. Finally, as medicine becomes increasingly tech-laden, it’s important for clinicians to see how material artifacts (including algorithms) connect individuals to structures. This will help to undermine oversimplified narratives according to which objective tools and technologies can correct for the bias and subjectivity of flawed human beings. (shrink)

Definition of the problemHealth Apps are becoming increasingly important for a preventive and responsible orientation of the health system. Currently, most of these digital health applications (DiGA) are based on so-called self-tracking technologies which record physiological and psychological data via sensors, usually combined with personalized everyday information. In the last few years, these digital developments have launched an intense and clearly polarized debate about the opportunities and dangers of self-tracking in healthcare.ArgumentsAfter a brief overview of medical self-tracking, (...) this essay wants to systematize and check the polarized discourse on the basis of its decisive individual and social potentials. It turns out that self-measurement techniques have long been an integral part of medical practice in diagnostics and therapy.ConclusionThe area of tension between individual empowerment and potential loss of control by the users will be emphasized as being especially important for the implementation of health Apps in primary health care. Finally, possible implications for the current design of the new German Digital Care Law (Digitale-Versorgung-Gesetz) are shown and some existing “blind spots” are highlighted. (shrink)

The Canadian health care system is a publicly fundedsystem based on the philosophy that health is a right,not a commodity. The implementation of thisperspective is hampered by the fact that the CanadianConstitution makes health care a matter of provincialjurisdiction, while most taxing powers lie in thehands of the federal government. Further problemsarise because of Canada's geographic nature and a moveto regionalization of provincial health careadministration. The issue is compounded byrecent developments in reproductive technologies,aboriginal (...) health, changes in consent law, etc. (shrink)

Digital health and welfare technologies and artificial intelligence are proposed to revolutionise healthcare systems around the world by enabling new models of care. Digital health and welfare technologies enable remote monitoring and treatments, and artificial intelligence is proposed as a means of prediction instead of reaction to individuals’ health and as an enabler of proactive care and rehabilitation. The digital transformation not only affects hospital and primary care but also how the community meets (...) older people's needs. Community care is often provided by informal and formal care‐givers, most of whom are women. Gender equality is at the heart of many national strategies, but do all genders have equal rights, responsibilities and opportunities when it comes to community care and its digital transformation? The digital transformation of community care is entangled with how care is provided to older people and the working conditions of community‐care professionals. Current and, even more so, future community‐care systems are and will be partly constituted by networks of technological artefacts. These health and welfare technological artefacts and the discourse surrounding them mediate and constitute social relations and community care. This article looks into how health and welfare technology and artificial intelligence‐based devices and systems mediate and constitute gender relations in community care and presents an argument for reflexivity, embodiment, pluralism, participation and ecology as an alternative strategy to treating community care as one‐size‐fit‐all and being blind to gender‐related issues. (shrink)

This four-volume collection covers the organization, financing and regulation of health care systems in four distinct contexts: financing and delivering health care, reforming health care systems, new forms of health system, and rethinking health care systems. A general introduction provides a review of the collection as a whole, and individual introductions set the context for each volume, providing a unique and valuable resource for student and scholar alike.

An orthodoxy has arisen which claims that there is a crisis in the United States health care system such that the system needs to be reformed. This essay challenges that orthodoxy by showing that we do not have a health care system in the United States. We have a non-system of health care, just as we do for virtually all basic social institutions. Challenging the current orthodoxy surfaces two ethical issues (...) that have been ignored: creating a health care system will (a) cause resurgent paternalism and (b) pose a threat to moral pluralism. Keywords: Health care policy, managed care, paternalism, moral pluralism, institutional integrity, total quality management, continuous quality improvement CiteULike Connotea Del.icio.us What's this? (shrink)

The “learning health care system” is being heralded as offering great potential for improving the quality and cost-worthiness of medical care by closely integrating the care of patients with the accumulation of aggregate data that can guide evidence-based medicine. By using electronic medical records, routine patient care and administrative data will be available for systematic observational studies. With the aid of these electronic medical records, quality-improvement studies of institutional practices and pragmatic, comparative effectiveness randomized (...) trials of individual treatments could become standard features of the medical care environment in the LHS. In this.. (shrink)

Japan is one of several East Asian countries that share an ethical system of mutual support. A review of Japan’s health care system reveals a strong egalitarian ethos often considered unique by outside observers.

Ethics support in primary health care has been sparser than in hospitals, the need for ethics support is probably no less. We have, however, limited knowledge about how to develop ethics support that responds to primary health-care workers’ needs. In this article, we present a survey with a mixture of closed- and open-ended questions concerning: How frequent and how distressed various types of ethical challenges make the primary health-care workers feel, how (...) important they think it is to deal with these challenges better and what kind of ethics support they want. Five primary health-care institutions participated. Ethical challenges seem to be prominent and common. Most frequently, the participants experienced ethical challenges related to scarce resources and lack of knowledge and skills. Furthermore, ethical challenges related to communication and decision making were common. The participants welcomed ethics support responding to their challenges and being integrated in their daily practices. (shrink)

As policy makers place great hope in health information technology as a means to lower costs and achieve improvements in health care quality, safety, and efficiency, organizations at the forefront of building health information exchange networks attempt to weave the concept and function of informed consent into an evolving information-driven health care system. The vast amount of information that will become available to both health professionals and patients in the new HIT-driven environment (...) can reasonably be expected to affect the relationship between them in many ways, particularly in the area of informed consent. During this early stage of HIT adoption, it is critical that we engage in discussions regarding informed consent’s proper role in a heretofore unknown health care environment — one in which electronic information sharing holds primary importance. The central and largely unexamined question of whether and how the legal and ethical underpinnings of informed consent will fit into the context of HITenabled treatment is critical to both public policy and clinical practice. (shrink)

The role of nurses in leading the design and delivery of primary health care services to address health inequities is growing in prominence, specifically in rural Australia. However, limited evidence exists to inform nurse‐led primary health care in this context. Based on a focus group with nursing executives and semi‐structured interviews with registered nurses we describe nurse experiences of leading the design of a primary health care service in rural Australia (...) and nurse transition to and practice in this service. Nurse experiences were analysed using reflexive thematic analysis. The study reveals the centrality of relational integration in service design and nurse acquisition of relational practice as it relates to nurse to care recipient and nurse to nurse relationships. Tensions between primary health care nurses and their peers, and resultant de‐valuing of primary health care practice, are described. The acquisition of nurse professional agency draws attention to investments required to position nurses to lead and sustain care innovations external to hospital settings. The authors propose that relational approaches may provide nurses with the opportunity to reframe their leadership and service contributions towards community literate primary health care provision and provide a pathway to professional emancipation from constrained practice expectations. (shrink)

Book reviewed in this article: Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. By Lynn Payer. Health Care Systems: Moral Conflicts in European and American Public Policy. Edited by Hans‐Martin Sass and Robert U. Massey.

Professional autonomy interferes at a structural level with the various aspects of the health care system. The health care systems that can be distinguished all feature a specific design of professional autonomy, but experience their own governance problems. Empirical health care systems in the West are a nationally coloured blend of ideal type healthcare systems. From a normative perspective, the optimal health care system should consist of elements of all the (...) ideal types. A workable optimum taking national values into account could be attained by governance structures that also introduce elements from other ideal type systems. Thus a normative approach to medical practice guaranteeing an essential degree of professional autonomy for a relationship of trust between the patient and the physician, could be combined with an efficient and equitable allocation of health care resources. (shrink)

Despite being the primary homeland of Quebec's Inuit people, Nunavik's health care is typically planned and provided by non-Inuit newcomers. This retrospective case study investigates the effects of ethical leadership on the Westernized local Nunavik health care system's cultural sensitivity to its disproportionately Inuit populations. An integrative framework is developed that considers the dimensions of ethical leadership and the omnibus and discrete dimensions of context. This study shows that some Nunavik health care (...) managers seek to improve and adapt the system to the needs of their Inuit populations, while others do not. Unfortunately, the context restricts the former managers' ability to act consistently with their moral responsibilities and beliefs. Specifically, the findings show various institutional barriers to providing respectful and sensitive health care to Inuit. This study contributes to the scientific literature on ethical leadership by proposing an integrative conceptual framework. This framework illustrates how ethical leadership is inseparable from organizational context, identifying 16 contextual factors influencing managers' ethical behavior. Finally, three practical recommendations are proposed to highlight the omnibus and discrete context elements. (shrink)

An ‘ideal’ health care system would be unencumbered by economic considerations and provide an ample supply of well-paid health care professionals who would supply culturally appropriate optimal health care to the level desired by patients. An ‘ideal’ health care system presupposes an ‘ideal’ society in which resources for all social goods are unlimited. Changes within health care systems occur both because of changes within the system and because (...) of changes or demands in and by the ‘exterior environment’. Social systems must be in a homeostatic balance. If one component fails to accommodate itself to other forces, needs and interests within the system, the system is imperiled. It is difficult to create a just health care system in an unjust society, just as it is difficult to practise truly ethical medicine in an ethically corrupt system. (shrink)

This study aims to compare and contrast how specific information health technologies (IHTs) have been debated, how they have proliferated, and what they have enabled in Germany’s and England’s healthcare systems. For this a discourse analysis was undertaken that specifically focussed on future-scenarios articulated in policy documents and strategy papers released by relevant actors from both healthcare systems. The study reveals that the way IHTs have been debated and how they have proliferated depends on country-specific regulatory structures, their respective (...) values, actors’ and institutions’ organized interests, and the status of health professionals. These conditions have enabled IHTs to promote a new and similar concept of patienthood in both countries, although they tend to affect practitioners’ practices more dramatically in England. The conclusion is drawn that with the usage of IHTs, healthcare systems reproduced existing patterns of health provision while also enabling a sort of convergence. Future research should investigate whether the new concept of patienthood emerging in both welfare states actually suits patients’ and professionals’ needs and requirements. (shrink)