On the validity of language: speaking, knowing and understanding in medical geography.

This essay examines methodological problems concerning the conceptualization and operationalization of phenomena central to medical geography. Its main argument is that qualitative research can be strengthened if the differences between instrumental and apparent validity are better understood than the current research in medical geography suggests. Its premise is that our definitions of key terms and concepts must be reinforced throughout the design of research should our knowledge and understanding be enhanced. In doing so, the paper aims to move the methodological debate beyond the simple dichotomies of quantitative vs qualitative approaches and logical positivism vs phenomenology. Instead, the argument is couched in a postmodernist hermeneutic sense which questions the validity of one discourse of investigation over another. The paper begins by discussing methods used in conceptualizing and operationalizing variables in quantitative and qualitative research design. Examples derive from concepts central to a geography of health-care behavior and well-being. The latter half of the essay shows the uses and misuses of validity studies in selected health services research and the current debate on national health insurance.

Help-seeking behavior, use, and satisfaction among frequent primary care users in Santiago de Chile.

PIP: A survey of 140 low-income, urban consumers of primary health care services provided by the public sector at Santiago, Chile's Villa O'Higgins Clinic suggested that organizational factors are more significant predictors of frequency of clinic use and patient satisfaction than demographic characteristics of the clinic population. 73% of respondents interviewed were female; the mean family size was 5, most were from families that fell well below the official poverty level, and 76% of household income went toward food. 29% of the households represented lacked adult men or had unemployed male workers. 66% were acute care patients; the remainder were receiving treatment for chronic conditions such as diabetes, high blood pressure, and alcoholism. 70% had been attending the clinic for the past few years; the mean number of visits per year was 6.4. 53% indicated a preference for a public rather than a private doctor, even if the latter were affordable. Only 51% expressed a dislike of any aspect of the clinic (long waits, 24%; discourteous staff, 19%; and lack of cleanliness, 5%). 84% perceived the quality of the care they received as good; this perception was strongly associated with satisfaction with the physician and receipt of prescription drugs. Multiple regression analysis indicated that 4 organizational variables (travel time to clinic, distance from home to clinic, waiting time at clinic, and travel time-travel distance) and 3 demographic factors (mother bringing child for care, presence of children under 5 years of age, and acute rather than chronic illness) were the best predictors of the frequency of clinic visits. Changes in clinic management by Chile's military government may jeopardize this pattern of high satisfaction with public health services by the poor.^ieng

DRG calculation and utilization patterns: a review of method and policy.

This paper examines methodological and policy issues of interest to medical geographers who use diagnosis-related groups (DRGs) in their research. Methodological issues are studied in terms of the calculation of DRGs and variation in the utilization of surgical and medical DRGs. It is argued that a shift to a single DRG price system should first address the (i) regional disparities that currently exist and the need for large-scale indices of medical wages and labor costs; (ii) severity of illness measurements other than the present nominal ones; and (iii) wide variation among medical versus surgical procedures. The Department of Commerce's Economic Analysis Area is recommended to remedy the problem of geographic scale. Policy issues of interest to medical geographers center around the shift to greater hospital specialization which is likely to continue across the country. Inner-city, rural and teaching hospitals may continue to be inadequately reimbursed by DRGs, treat more medically indigent, or both. Medical geographers should be aware of the policy and methodological issues involved not only in DRGs, but in proposed prospective payment systems for ambulatory and long-term care.

HMO promotion and the privatization of health care in Chile.

Since 1973 the Chilean junta has privatized sectors of the national economy. This paper analyzes the country's policy process of promoting private medical programs through HMO-like plans (ISAPREs, or Institutes of Provisional Health). These plans have captured less than half of their originally anticipated market share. It is argued that the future performance of ISAPREs will be undermined by their limited maternal benefits, their targeting to a small upper-income group which cannot sustain many private medical programs, and competition with less expensive yet equally competent public medical programs. The paper briefly compares privatization in Chile with the experiences of other countries, and specifically contrasts the restructuring of health services under military rule in Chile with those of Argentina and Uruguay. The paper concludes that the Chilean experience with HMOs epitomizes the perils of planning health care during short-term periods of economic prosperity as well as failing to consult medical care providers and consumers.

Restructuring health care financing in Chile.

The current Chilean government adopted a neoclassical model of development and subsequently introduced various incentives for the privatization of medical care. This paper analyzes health care financing in Chile during the last decade and evaluates government efforts to minimize state-financed medical care. In so doing, this paper provides a framework for analyzing private vs public medical care delivery systems in developing countries. For this reason, the first section discusses the major attributes and issues of public and private delivery systems followed by a case study examining the origins, effectiveness and impact of the restructured health system in Chile.

A methodological note on location-allocation models.

Three conditions render the use of standard methodologies inappropriate in solving location-allocation problems. This paper presents one alternative method for assigning an emergency aircraft to one of three hospitals in northern Chile when standard approaches are not suitable. Graph analyses and the demographic potential measures are used in the case presented. The main advantages of this alternative approach are its computational ease and the use of more than one method.