Need for primary health care: an objective indicator.

The allocation of resources for primary health care should be based on the community''s needs and not only on the workload of general practitioners. I therefore present an objective indicator that may be used to assess the need for primary health care.     

Business leaders begin to rally in support of public health care system

There appears to be growing concern among Canada''s business leaders about the future of Canada''s health care system. At a recent meeting in Montebello, Que., that was cosponsored by the CMA and several Canadian corporations, some business representatives said Canada''s publicly funded system gives them a competitive edge in an increasingly global market.     

Future role of neurologists.

Clinical neurologists in the health care system of the future should have a multifaceted role. Advances in the basic understanding of the nervous system and therapeutics of neurologic disease have created, for the first time in human history, an ethical imperative to correctly diagnose neurologic disease. In many situations, the neurologists may function as a consultant and principal physician for patients with primary nervous system disorders including Parkinson''s disease, multiple sclerosis, Alzheimer''s disease, epilepsy, migraine, cerebrovascular disease, movement disorders, and neuromuscular disease. Other important roles for neurologists include the training of future physicians, both neurologists and primary care physicians, the application of cost-effective approaches to care, and the support of health care delivery research and academic programs that link basic research efforts to the development of new therapy. To be successful, future residency training programs should include joint certification opportunities in both neurology and general medicine, and training programs for clinical investigators should be expanded. Despite its threats to specialists, managed care should also provide opportunities for new alliances among neurologists, other specialists, and primary care physicians that will both improve patient care and increase efficiency and cost-effectiveness.     

Should living wills be legalized?

Living wills allow patients to state their wish to die and not be kept alive through the use of medications, artificial means or "heroic" measures. They have been made legal documents in 38 states in the United States. Living wills permit advance expression of a patient''s wishes, promote effective communication and demonstrate respect for the patient as a person. Problems with legal recognition of such wills include the need for agreement on fundamental terms, possible restriction of patients'' rights, limitation of options in decision-making and possible negative effects on the physician-patient relationship. Before legislation is enacted, public and professional attitudes toward the care of terminally ill patients should be assessed. All health care professionals should receive better education in this area, and palliative care services should be made more widely available. Only if these measures fail should living wills be made legal documents in Canada.     

Key issues in managed competition.

All managed competition proposals for health system reform must confront several key issues. The premiums paid to health care purchasing cooperatives will need to be subsidized for those who cannot pay full fare; the amount and sources of the subsidies are controversial political issues. The payments passed on by purchasing cooperatives to health plans must be risk adjusted to account for differences in the health care needs of their enrolled populations. This is essential to create a level playing field for competition and to eliminate incentives for plans to use risk assessment for attracting enrollees. The data and methods needed for risk adjustment, however, are not adequate at present. The Clinton Administration''s plan to limit expenditure increases raises a host of thorny issues. Maintaining quality of care will require health plan quality report cards to be supplemented by external quality assurance systems. Assuring quality will be particularly problematic for traditional indemnity plans. The structure and governance of the system, administration simplification, and other issues need to be addressed. The size and voluntariness of the purchasing cooperatives greatly influence all of these considerations. Physicians should inform their political representatives on how these issues should be resolved as compromise bills are drafted by the United States Congress this year.     

Firm-level perspectives on public sector engagement with private healthcare providers: survey evidence from Ghana and Kenya

Background

Health systems in Sub-Saharan Africa (SSA) are in urgent need of improvement. The private health sector is a major provider of care in the region and it will remain a significant actor in the future. Any efforts by SSA governments to improve health systems performance therefore has to account for the private health sector. Regional and international actors increasingly recognize importance of effectively engaging with the private health sector, and initiatives to improve engagement are underway in several countries. However, there is little systematic analysis of private health providers'' view and experience with engagement.

Methodology/Principal Findings

In this study we surveyed private health facilities in Kenya and Ghana to understand the extent to which and how governments interact and engage with these facilities. The results suggest that government engagement with private health facilities is quite limited. The primary focus of this engagement is “command-and-control” type regulations to improve the quality of care. There is little attention paid to building the capacity of health care businesses through either technical or financial assistance. The vast majority of these facilities also receive no government assistance in meeting public health and social goals. Finally, government engagement with private pharmacies is often neglected and clinics receive a disproportionate share of government assistance.

Conclusions/Significance

Overall, our findings suggest that there may be considerable untapped potential for greater engagement with private health facilities—particularly pharmacies. Improving engagement will likely help governments with limited resources to better take advantage of the private sector capacity to meet access and equity objectives and to accelerate the achievement of the Millennium Development Goals.     

Resource allocation and physician liability

Lawyer Karen Capen says funding cutbacks that have affected the services physicians can provide may cause legal problems for Canada''s doctors. If cutbacks affect the care that is being provided, they should be discussed with the patient and noted on the chart. She says physicians have "good reason to be concerned" about increasing pressures that create an imbalance between health care resources and the demand and need for services. For some doctors, these have resulted in court cases.     

Future of health care system tops agenda as CMA Board of Directors meets

The first part of the CMA''s efforts to spark a public debate on the future of Canada''s health care system is a “visioning exercise” in which the Board of Directors will attempt to spell out the association''s views on how the system should develop. The board also discussed CMA initiatives concerning two major public-health issues — smoking and blood transfusions.     

Physicians in health care management: 1. Physicians as managers: roles and future challenges.

Physicians are increasingly expected to assume responsibility for the management of human and financial resources in health care, particularly in hospitals. Juggling their new management responsibilities with clinical care, teaching and research can lead to conflicting roles. However, their presence in management is crucial to shaping the future health care system. They bring to management positions important skills and values such as observation, problem-solving, analysis and ethical judgement. To improve their management skills physicians can benefit from management education programs such as those offered by the Physician-Manager Institute and several Canadian universities. To manage in the future environment they must increase their knowledge and skills in policy and political processes, financial strategies and management, human resources management, systems and program quality improvement and organizational design.     

Medical Education and Research: The Foundations of Quality Health Care

In May 1964 the Royal Commission on Health Services declared that “health research is essential to health progress”. However, since that time the means of providing adequate health care have received far less attention than have methods of payment for physicians'' services. Because medical education and research is the source from which all other health benefits flow, urgent attention must be paid to the adequate support of teacher-scientists, as set forth in the Woods, Gordon (Gundy) report. It is the numbers and quality of these men and women, more than any other factor, that will determine the shape of medical science and, hence, medical practice in Canada in the future. Expensive as it is, Canadian medicine and Canadian medical scientists must have generous support if medical care in this country is to be of high quality.     

中国人工林经营发展战略与对策:从追求木材产量的单一目标经营转向提升生态系统服务质量和效益的多目标经营

人工林是全球森林资源的重要组成部分,在木材生产、环境改善、景观建设和减缓气候变化等方面扮演着愈来愈重要的角色。尽管我国人工林面积和蓄积不断增长,但是,人工林存在质量较差、结构不尽合理、生产力不高、生态功能较弱和生态稳定性下降等问题。人工林生态系统服务功能难以满足经济社会日益增长和新时期人们对美好生活向往的多方面需求。面对未来人工林面积继续增加受到适宜发展空间的严重制约和气候变化带来的现实和潜在的影响,亟需改变和调整我国人工林经营的发展战略和对策,将从人工林面积扩张、蓄积增加转变为人工林生态系统服务的质量和效益提升。如何提高人工林生态系统服务的质量和效益,创建健康稳定、高生产力和高碳汇的人工林生态系统,既能提供高产优质木材,又能够发挥固碳减排、生物多样性保护、水源涵养和水土保持等多种生态功能,以满足经济社会发展对森林的多种新需求和林业应对气候变化的新任务,亟需探索适合我国新时期人工林生态系统可持续经营的理论和多目标经营范式。在深入分析国际和我国人工林发展历程、变化趋势、面临问题的基础上,充分汲取和借鉴国际人工林经营的理念、经验和实践成果,并结合我国现阶段人工林发展实际情况,探索人工林生态系统服务质量与效益提升的发展思路和实践途径,从多层次、多尺度定位面向生态系统服务的人工林经营对策,倡导并实施人工林生态系统适应性经营,实现人工林生态系统服务的多目标权衡与协同,为我国人工林经营的战略转变和对策创新提供决策参考与未来展望。     

Primary care for AIDS and chemical dependence.

Primary care clinicians are acquiring an increasingly important role in preventing, diagnosing, and treating both chemical dependence and human immunodeficiency virus (HIV) illness. Towards this end they need to know the epidemiology of HIV infection in chemically dependent persons and methods of educating persons at high risk for these problems. It is critical that physicians screen for alcohol and drug addiction. Health care providers should understand the risks and benefits of HIV antibody testing and include in their practices the basic components of counseling before and after testing and informed consent. Both HIV illness and addiction are chronic diseases with long-term health implications. A knowledge of patient characteristics, intensity of treatments, and treatment modalities is important in making recommendations for individualized therapy. Combining service delivery is a future challenge necessitated by today''s joint epidemics of the acquired immunodeficiency syndrome and chemical dependence.     

Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child''s family and with other health care practitioners to determine the child''s role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child''s developing capacity for decision-making.     

Women's health. The childbearing years and after.

Health and development planners have tended to see women primarily in context of their reproductive role. As a result, solutions to women''s health needs have been restricted to expanding and improving maternal and child health systems. There has recently been a major shift in direction, largely because of the influence of the world conference on population and development held in Cairo in 1994. Dr Guiseppe Benagiano, director of the special programme of research, development and research training in human reproduction based at the WHO, says, "We need to remind ourselves constantly that reproductive health is not simply a biomedical issue but one with serious implications for our general health and by extension, for all our efforts in human social and economic development." The 1993 world development report on health identified the lack of a clear strategy for engaging women in health care and suggested that child health services, prenatal care, treatment of sexually transmitted diseases, and family planning services should be provided jointly at convenient times. In an example of this, the Chilean Institute of Reproductive Medicine now offers integrated family planning services at the same time as child health services, and Thailand is experimenting with mobile health clinics to reach women in their homes. As the proportion of elderly women increases, old age is increasingly being seen as a female issue. With the impact of urbanisation and industrialisation, more of these women are living isolated lives, often suffering from chronic debilitating diseases. In his opening statement to the global commission on women''s health in April 1995 which focused on health conditions of women in old age, Dr Hiroshi Nakajima, the WHO''s director general, said: "Our goal should not be solely to extend lives in the physical sense, but to ensure that the added years are worth living."     

WHO fellowships--what do they achieve?

Training health professionals is one of WHO''s major strategies for improving health care in the developing world. The aim, to strengthen a country''s own capacity rather than injecting expertise from outside, is in the best tradition of sustainable development. But how effective is this so called "capacity building in human resources"? Since it accounted for $43m of WHO''s budget in 1992-3 and is considered by WHO to be a major contribution to health in individual countries, it deserves detailed examination.     

Electronic health records: the European scene.

Caring for patients'' health problems relies increasingly on sharing information between clinical departments and disciplines and with managers. The medical record of the future will need to provide a flexible and shareable framework for recording and analysing the consultation process. The advanced informatics in medicine (AIM) programme seeks to encourage research and development in telemedicine in areas that are beyond the scope of any one country. It includes many European projects attempting to define the best storage and transmission formats for such diverse data types as laboratory results, biosignals, x ray images, and photographs, and in clinical specialties varying from intensive care to medicine for elderly people. One example, the good European health record project, is developing a model architecture for computerised health records across Europe that is capable of operating on a wide variety of computer hardwares and will also be able to communicate with many different information systems. The ultimate European health record will be comprehensive and medicolegally acceptable across clinical domains, hold all data types, and be automatically translated between languages.     

Toronto centre hopes to cash in on growing demand for private health services

When the CMA held its 1996 annual meeting, part of the debate on the future of health care involved the "appropriate balance of the roles of the public and private sectors" in delivering health care. The King''s Health Centre in Toronto is now doing its own balancing act: providing publicly funded care to Canadians, and private care to non-Canadians and Canadians who can afford it. This article discusses some of the niche markets King''s is attempting to develop.     

X-Ray Survey Results and Costs—A Health Officer's Viewpoint,A Preliminary Report

The obvious results of a mass chest x-ray survey from a health officer''s viewpoint are:1. The early discovery of unknown cases of pathologic conditions of the chest—tuberculosis, neoplasms, heart abnormalities.2. Increase in the community''s awareness of its tuberculosis problem.3. Opportunity to work closely with the medical society and the individual private physicians.4. Stimulation of all agencies in a community, health and non-health, to work together on a health project for the good of all of the people.5. Increased cooperation between the local department of public health and other health agencies in a community.6. Opportunity to underline to a staff of a local department of public health the importance of thinking in terms of the department as a whole, rather than in terms of respective divisions or bureaus.7. Opportunity to focus the awareness of the community on its public health services.In relation to costs, there are three aspects from a health officer''s viewpoint:1. The planning, together with other agencies, of an adequate budget with full recognition of community resources.2. The planning for estimated expansion of tuberculosis control services both in terms of increased expense for maintenance and operation, and of assignment of personnel to survey staff with resulting curtailment or postponement of other programs.3. The planning for completion of the follow-up program of the x-ray survey and of future continued extension of the total tuberculosis control program as the result of increased community awareness of the tuberculosis problem.     

面向生态系统服务的森林生态系统经营:现状、挑战与展望

森林生态系统是地球陆地生态系统的主体,它具有很高的生物生产力和生物量以及丰富的生物多样性,对全球生态系统和人类经济社会发展起着至关重要和无可替代的作用。伴随着人口的不断增长和经济社会的迅猛发展,对森林资源和森林生态系统服务的需求不断高涨,而且人类对森林资源价值的认识也发生了很大程度的改变。推进森林资源可持续经营,增加森林总量、提高森林质量、增强生态功能,已成为中国林业可持续发展乃至推进中国生态文明建设和建设美丽中国的战略任务。本文全面综述了森林生态系统经营发展历程,分析了森林生态系统经营的现状和存在问题,在此基础上,提出整合基于生态系统管理与满足现代人类福祉对森林多重需求的新的森林生态系统经营理念,面向生态系统服务的森林生态系统经营理念是未来的发展趋势。森林经营发展战略表现为:1)从单纯的森林面积数量扩张,转变到提高单位面积的森林生产力和森林质量;2)从单一追求木材生产逐步转变为多目标经营,将森林林产品单一的经营目标转变为广泛的生态、经济和社会等多目标经营;3)森林经营重点从林分水平转变为森林景观的经营,强调森林景观的时空异质性和动态变化,权衡和协同多种生态系统的服务功能,倡导森林景观的多样性和连通性,提高森林与其它土地利用模式镶嵌构成的复合景观的可持续性和稳定性,增强森林生态系统对气候变化影响的适应能力;4)森林生态系统经营将从依赖传统经验的主观决策转变为信息化、数字化和智能化的决策,发展森林生态系统经营决策支持系统和森林景观恢复与空间经营规划系统。