Comparative federal health care policy: evidence of collaborative federalism in Pakistan and Venezuela.

Collaborative federalism has provided an effective analytical foundation for understanding how complex public policies are implemented in federal systems through intergovernmental and intersectoral alignments. This has particularly been the case in issue areas like public health policy where diseases are detected and treated at the local level. While past studies on collaborative federalism and health care policy have focused on federal systems that are largely democratic, little research has been conducted to examine the extent of collaboration in authoritarian structures. This article applies the collaborative federalism approach to the Islamic Republic of Pakistan and the Bolivarian Republic of Venezuela. Evidence suggests that while both nations have exhibited authoritarian governing structures, there have been discernible policy areas where collaborative federalism is embraced to facilitate the implementation process. Further, while not an innate aspect of their federal structures, Pakistan and Venezuela can potentially expand their use of the collaborative approach to successfully implement health care policy and the epidemiological surveillance and intervention functions. Yet, as argued, this would necessitate further development of their structures on a sustained basis to create an environment conducive for collaborative federalism to flourish, and possibly expand to other policy areas as well.

The clash of medical civilizations: experiencing "primary care" in a neoliberal culture.

An anthropologist describes how he found himself at the vortex of a "clash of medical civilizations:" neoliberalism and the international primary health care movement. His involvement in a $6 million social change initiative in medical education became a basis to unlock the hidden tensions, contradictions and movements within the "primary care" phenomenon. The essay is structured on five ethnographic stories, situated on a continuum from "natural" species-level primary care to "unnatural" neoliberal primary care. Food is an element of all tales. Taking the long view of history/prehistory permits us to better recognize ideological distortions in order to more capably transform medicine.

[Trade-off between formal and informal care in Europe]. / Trade-off entre cuidados formales e informales en Europa.

OBJECTIVE: To study the relationship between formal and informal care for the dependent population in a number of European countries. METHOD: Data from the Survey of Health, Aging and Retirement in Europe for 2004 were used and a bivariate probit model was estimated. Unlike other studies, the present analysis includes the institutional features of the various long-term care systems, in addition to the demographic, health and environmental characteristics of the individual receiving care. RESULTS: A significant correlation was found between the two options, which reveals that, conditional on receiving care, there was a preference for the combination of both types of care. The results show the importance of health status and living arrangements for defining the combination of formal and informal care. There were substantial differences in the likelihood of the two types of care among European countries. A notable finding was the importance of informal care in Spain in comparison with other countries. CONCLUSIONS: The probability of receiving formal or informal care is higher in countries where families have a legal obligation to look after dependent relatives and where institutionalization rates are higher. This finding should be considered in the design of long-term care policies. Therefore, to control growth of public expenditure and, at the same time, improve caregiver satisfaction, policies that combine distinct formal services should be promoted over the implementation of care allowances.

Trade-off entre cuidados formales e informales en Europa / Trade-off between formal and informal care in Europe

Objetivo: En este trabajo se estudia la relación entre cuidados personales formales e informales para la población dependiente en un conjunto de países europeos. Métodos: Se utilizan datos del Survey of Health, Ageing and Retirement in Europe (2004), y se estima un modelo probit bivariado. A diferencia de otros estudios, no sólo se tienen en cuenta características sociodemográficas, de salud y del entorno del receptor de los cuidados, sino que también se consideran las características institucionales de los sistemas de cuidados de largo plazo. Resultados: Se obtiene una correlación positiva y significativa entre ambas decisiones, es decir, condicional a recibir cuidados; hay una cierta preferencia por la combinación de ambos tipos de cuidados. Los resultados muestran la relevancia de las variables de salud y del régimen de convivencia a la hora de definir la combinación de cuidados formales e informales. Hay diferencias importantes en la probabilidad de utilización de ambos tipos de cuidados entre países europeos, y destaca la relevancia de los cuidados informales en España. Conclusiones: El diseño de políticas de cuidados de largo plazo debe tener en consideración que la probabilidad de recibir cuidados formales o informales aumenta más en los países donde hay obligación legal de atender a familiares dependientes o con una mayor tasa de institucionalización. Por tanto, la combinación de diferentes servicios formales, más que la implementación de prestaciones económicas para el cuidador, debiera considerarse como alternativa posible para controlar el gasto público y aumentar la satisfacción de los cuidadores (AU)

Objective: To study the relationship between formal and informal care for the dependent population in a number of European countries. Method: Data from the Survey of Health, Aging and Retirement in Europe for 2004 were used and a bivariate probit model was estimated. Unlike other studies, the present analysis includes the institutional features of the various long-term care systems, in addition to the demographic, health and environmental characteristics of the individual receiving care. Results: A significant correlation was found between the two options, which reveals that, conditional on receiving care, there was a preference for the combination of both types of care. The results show the importance of health status and living arrangements for defining the combination of formal and informal care. There were substantial differences in the likelihood of the two types of care among European countries. A notable finding was the importance of informal care in Spain in comparison with other countries. Conclusions: The probability of receiving formal or informal care is higher in countries where families have a legal obligation to look after dependent relatives and where institutionalization rates are higher. This finding should be considered in the design of long-term care policies. Therefore, to control growth of public expenditure and, at the same time, improve caregiver satisfaction, policies that combine distinct formal services should be promoted over the implementation of care allowances (AU)

Social inequalities in 'sickness': European welfare states and non-employment among the chronically ill.

The aim of this paper is to examine educational inequalities in the risk of non-employment among people with illnesses and how they vary between European countries with different welfare state characteristics. In doing so, the paper adds to the growing literature on welfare states and social inequalities in health by studying the often overlooked 'sickness'-dimension of health, namely employment behaviour among people with illnesses. We use European Union Statistics on Income and Living Conditions (EU-SILC) data from 2005 covering 26 European countries linked to country characteristics derived from Eurostat and OECD that include spending on active labour market policies, benefit generosity, income inequality, and employment protection. Using multilevel techniques we find that comprehensive welfare states have lower absolute and relative social inequalities in sickness, as well as more favourable general rates of non-employment. Hence, regarding sickness, welfare resources appear to trump welfare disincentives.

Health inequalities and welfare state regimes: theoretical insights on a public health 'puzzle'.

Welfare states are important determinants of health. Comparative social epidemiology has almost invariably concluded that population health is enhanced by the relatively generous and universal welfare provision of the Scandinavian countries. However, most international studies of socioeconomic inequalities in health have thrown up something of a public health 'puzzle' as the Scandinavian welfare states do not, as would generally be expected, have the smallest health inequalities. This essay outlines and interrogates this puzzle by drawing upon existing theories of health inequalities--artefact, selection, cultural--behavioural, materialist, psychosocial and life course--to generate some theoretical insights. It discusses the limits of these theories in respect to cross-national research; it questions the focus and normative paradigm underpinning contemporary comparative health inequalities research; and it considers the future of comparative social epidemiology.

Socioeconomic inequalities in old-age mortality: a comparison of Denmark and the USA.

Previous studies have reported important variations in the magnitude of health inequalities between countries that belong to different welfare systems. This suggests that there is scope for reducing health inequalities by means of country-level interventions. The present study adds to this literature by exploring whether the magnitude of socioeconomic inequalities in mortality is associated with social inequality levels. Denmark and the USA belong to fundamentally different welfare systems (social democratic and liberal) and our study thereby contributes to the ongoing debate on whether welfare systems are linked to health inequalities. We analyze Denmark and the USA in terms of socioeconomic differences in mortality above age 58. The data sources were Danish register data from 1980 to 2002 (n = 2,029,324), and survey data from the US Health and Retirement Study (HRS) from 1992 to 2006 (n = 9374). Survival analysis was used to study the impact of socioeconomic status on mortality and the magnitude of mortality differences between the two countries was compared. The results showed surprisingly that mortality differentials were larger in Denmark than in the USA even after controlling for a number of covariates: The poorest 10 percent of the Danish elderly population have a mortality rate ratio of 3.32 (men) and 3.70 (women) compared to the richest 25 percent. In the USA the corresponding rate ratios are 1.67 and 1.56. Low income seems to be a more powerful risk factor for mortality than low education. A number of possible explanations for higher mortality differences in Denmark are discussed: unintended positive correlation between generous health services and health inequality, early life influences, mortality selection, and relative deprivation.

Work, worklessness and the political economy of health inequalities.

This essay argues that work, and the socioeconomic class polarities it creates, plays a fundamental role in determining inequalities in the distribution of morbidity and mortality. This is by means of uneven exposure to physical hazards and psychosocial risks in the workplace, as well as by inequalities in exclusion from the labour market and the absence of paid work. Furthermore, this essay shows that the relationships between work, worklessness and health inequalities are influenced by the broader political and economic context in the form of welfare state regimes. This leads to the development of a model of the political economy of health inequalities, and how different types of public policy interventions can mitigate these relationships. This model is then applied to the case of work and worklessness. The essay concludes by arguing that politics matters in the aetiology of health inequalities.

Social complexity and linguistic diversity in the Austronesian and Bantu population expansions.

Reconstructing the rise and fall of social complexity in human societies through time is fundamental for understanding some of the most important transformations in human history. Phylogenetic methods based on language diversity provide a means to reconstruct pre-historic events and model the transition rates of cultural change through time. We model and compare the evolution of social complexity in Austronesian (n = 88) and Bantu (n = 89) societies, two of the world's largest language families with societies representing a wide spectrum of social complexity. Our results show that in both language families, social complexity tends to build and decline in an incremental fashion, while the Austronesian phylogeny provides evidence for additional severe demographic bottlenecks. We suggest that the greater linguistic diversity of the Austronesian language family than Bantu likely follows the different biogeographic structure of the two regions. Cultural evolution in both the Bantu and Austronesian cases was not a simple linear process, but more of a wave-like process closely tied to the demography of expanding populations and the spatial structure of the colonized regions.

Welfare regimes, labour policies and unhealthy psychosocial working conditions: a comparative study with 9917 older employees from 12 European countries.

BACKGROUND: Recent analyses explored associations of welfare state regimes with population health, with particular interest in differences between social protection-oriented versus more liberal regimes. Little is known about such associations with work-related health. The aims of this contribution are (1) to study variations of quality of work according to type of welfare regime and (2) to analyse differences in the size of effects of quality of work on workers' health according to type of welfare regime. METHODS: The authors use cross-sectional and longitudinal data from two studies ('Survey of Health, Ageing and Retirement in Europe' and the 'English Longitudinal Study on Ageing') with 9917 employed men and women (aged 50 to 64) in 12 European countries. Psychosocial quality of work is measured by low control and effort-reward imbalance at work. Depressive symptoms are introduced as a health indicator. Linear multilevel models and logistic regression analyses are performed to test the hypotheses. In addition to the welfare regime typology, the authors introduce labour policy and economy-related macro indicators. RESULTS: Between-country variations in quality of work are largely explained by macro indicators and welfare regimes, with poorer quality of work in countries with less emphasis on older workers' protection. Moreover, in the Liberal and Southern welfare regime, effects of quality of work on depressive symptoms are relatively strongest (adjusted ORs varying from 1.45 to 2.64). CONCLUSION: Active labour policies and reliable social protection measures (eg, Scandinavian welfare regime) exert beneficial effects on the health and well-being of older workers. More emphasis on improving quality of work among this group is warranted.

Opening the queen's closet: Henrietta Maria, Elizabeth Cromwell, and the politics of cookery.

The essay shows how two royalist recipe books- The queens closet opened (1655) and The court & kitchin (sic) of Elizabeth (1664)- fashioned Henrietta Maria (1609-69) and Elizabeth Cromwell (1598-1665) as very different housewives to the English nation. By portraying the much-disliked French Catholic Henrietta Maria as engaged in English domestic practices, The queens closet opened implicitly responded to the scandalous private revelations of The kings cabinet opened (1645); while, in contrast, the satiric cookery book attributed to Elizabeth Cromwell stigmatized her as both a country bumpkin and a foreigner. Yet the cookery books also had unintended republicanizing effects, as consumers appropriated the contents of the queen's closet for their own cabinets and kitchens.

Is democracy good for health?

Studies of health have recognized the influence of socioeconomic position on health outcomes. People with higher socioeconomic ranking, in general, tend to be healthier than those with lower socioeconomic rankings. The effect of political environment on population health has not been adequately researched, however. This study investigates the effect of democracy (or lack thereof) along with socioeconomic factors on population health. It is maintained that democracy may have an impact on health independent of the effects of socioeconomic factors. Such impact is considered as the direct effect of democracy on health. Democracy may also affect population health indirectly by affecting socioeconomic position. To investigate these theoretical links, some broad measures of population health (e.g., mortality rates and life expectancies) are empirically examined across a spectrum of countries categorized as autocratic, incoherent, and democratic polities. The regression findings support the positive influence of democracy on population health. Incoherent polities, however, do not seem to have any significant health advantage over autocratic polities as the reference category. More rigorous tests of the links between democracy and health should await data from multi-country population health surveys that include specific measures of mental and physical morbidity.

Cómo y dónde se encuentra la profesión médica. Visión de un médico especialista en formación / No disponible

No disponible

Medicalizacion del malestar. Alegato por una aproximacion compleja para un minimalismo terapeutico / Discomfort medicalization. Allegation for a complex approach to a therapeutic minimalism

Reflexiono acerca de las luces y las sombras observadas por Rendueles en mi trabajo sobre la fibromialgia. Debato alguno de sus argumentos, matizo mi postura ante la medicalización del malestar y concreto mi propuesta para una respuesta por parte del clínico de a pie (AU)

I reflect on the lights and shades noticed by Rendueles in my article about fibromyalgia. I debate some of his arguments, I make more precise my position about discomfort medicalization and I concrete my proposal for an answer of the part of the clinician (AU)