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This paper examines the current health care reform issues in Canada. The provincial health insurance plans of the 1960s and 1970s had the untoward effects of limiting the federal government's clout for cost control and of promoting a system centered on inpatient and medical care. Recently, several provincial commissions reported that the current governance structures and management processes are outmoded in light of new knowledge, new fiscal realities and the evolution of power among stake-holders. They recommend decentralized governance and restructuring for better management and more citizen participation. Although Canada's health care system remains committed to safeguarding its guiding principles, the balance of power may be shifting from providers to citizens and "technocrats". Also, all provinces are likely to increase their pressure on physicians by means of salary caps, by exploring payment methods such as capitation, limiting access to costly technology, and by demanding practice changes based on evidence of cost-effectiveness. ; Este artículo examina los temas más recientes en las reformas del sistema de atención a la salud en Canadá. Los planes de seguridad en el sector salud durante los años sesenta y setenta tuvieron efectos inapropiados en cuanto a que limitaron el poder del gobierno federal para controlar costos y promover un sistema centrado en la atención médico-hospitalaria. Recientemente, varias comisiones provinciales reportaron que las actuales estructuras de gobierno y gestión de los procesos no están actualizadas en términos del nuevo conocimiento, las nuevas realidades fiscales y la evolución en las formas de poder entre los grupos de interés. Sus recomendaciones incluyen formas descentralizadas de gobierno y mayor participación ciudadana. A pesar de que el sistema de atención a la salud en Canadá permanece comprometido a garantizar sus principios centrales, el balance de poder estaría cambiando de los proveedores a los ciudadanos y "tecnócratas". Al mismo tiempo, es probable que todas ...

ResumenPrimary health care (PHC) is currently the most important health reform underway in the world today. In most countries, governments and services have taken the lead in PHC development as a result of the declaration of Alma Ata. Since the 1990s, a large amount of evidence has demonstrated the impact of a strong primary health care system on the health of the communities. 2,3 Improved health status of a community is directly related to a better or morebalanced ratio of primary care professionals to specialists and to increased individual access to primary care within a region. As co-morbidities increase as a population ages, access to comprehensive and coordinated primary care becomes an increasingly cost-effective approach. Accessibility to primary care reduces the adverse effects on health of social inequalities.

ResumenPrimary health care (PHC) is currently the most important health reform underway in the world today. In most countries, governments and services have taken the lead in PHC development as a result of the declaration of Alma Ata. Since the 1990s, a large amount of evidence has demonstrated the impact of a strong primary health care system on the health of the communities. 2,3 Improved health status of a community is directly related to a better or morebalanced ratio of primary care professionals to specialists and to increased individual access to primary care within a region. As co-morbidities increase as a population ages, access to comprehensive and coordinated primary care becomes an increasingly cost-effective approach. Accessibility to primary care reduces the adverse effects on health of social inequalities.

In spite of all the good news about the economy and the swift confirmation of Sonia Sotomayor to the Supreme Court, the headlines this stormy week have been dominated by town hall brawls. As congressional representatives went home to their districts for their August recess, they were greeted by a volatile mixture of high temperatures, monsoon-like storms and furious mobs who stormed town hall meetings to protest against health reform. Several politicians, terrorized by the voters, suspended the meetings and ran past the mobs and into their getaway cars. They later announced they would take phone calls or meet voters individually in scheduled appointments. Journalists and TV talk show personalities were left wondering as to the origin of this new movement of storm troopers: were they real people, from the grassroots, fed up with the way Washington is dealing with health care reform, or was this manufactured, "Astroturf" mobilization, organized by the health insurance and drug companies, scared of losing a large share of their profits if a government-run plan is included on the final bill? Most likely it is a mixture of both. But whether fabricated or not, the tone of the debate and the images of scuffles and fist fights shocked the nation and left many asking what happened to American civility. More importantly, where was the President's leadership?Granted, it is difficult to defend a bill that is not even ready, and Obama has avoided giving bottom lines that may come back to haunt him: his larger political purpose is to pass some kind of health care reform, even if serious compromises have to be made. Having taken the 1994 Clinton-care defeat lesson to heart, President Obama decided from the beginning that he could not dictate to Congress and therefore stated the general principles of health care reform (universal coverage and cost control) and then gave Congress leeway in writing the detailed legislation. But from the beginning, there was a deep chasm between progressives, who insist that a public-plan option is the best way to meet both goals, and conservatives, who adamantly oppose the government-run plan claiming it would bankrupt private insurance companies, and see this and the mandate of universal coverage as "socialized medicine". The Blue Dog Democrats, fiscally conservative, have joined ranks with the opposition and effectively killed the public option in some versions of the bill, replacing it with a vague alternative of co-ops (mutual care).The result so far has been a confusion of bills and versions that no regular voter can understand. Indeed, not even those that are following the debate closely can tell with clarity what each version entails. But because health care is close and personal, it is easy to whip up a frenzy over it just by letting out a few misleading judgments, half truths and exaggerations, and hammering at them until they have the ring of truth. Corporate interest groups from the health insurance and pharmaceutical industries are fiercely organizing fringe elements on the right, mainly instructing them to be disruptive of town hall meetings and to interrupt any serious discourse. And most of the average, less-educated voters use "easy" sources of information such as radio talk commentators (read: Rush Limbaugh) or TV news shows which are anything but "fair and balanced", instead of hard sources (newspaper editorials, op-ed and factual news articles). In the end, when topics are complex and conflicting information saturates the media, people believe what they want to believe, what confirms their feelings and their ideological bent, what reassures them they are correct in their assumptions and emotions.It is this state of confusion that has allowed the crazy mobs, aided and abetted by the likes of Rush Limbaugh and Sarah Palin, to make the most outlandish claims, from accusing the government of Socialism and Nazism in one voice, to vociferously asserting the Democrats' plan includes euthanasia (of course it does not; it includes a voluntary option for terminal patients to get "counseling on end-of-life options"). But these are the same kind of people that kill abortion-clinic doctors and nurses in their crusade to "save innocent lives". And exactly of the same kind as the "birthers", those who do not believe President Obama was born in the United States, a fact very easily verifiable, since the White House has made his birth certificate available!The point is, extremists are taking over that national scene and are attacking a bill that is not yet ready, based on false claims and preposterous characterizations. The left is now mobilizing union representatives to counteract the right wing crazies. Perhaps it would be better to cancel all town hall meetings, since it is expected that a bill will be passed by the end of the month. It will be most likely be a watered down version of what Obama initially wanted, but it will allow him to claim yet another victory, another check mark on his campaign promises.The debate over health care has accomplished something that seemed unfathomable only a month ago: it has united Republicans. Economic conservatives, libertarians and extreme right social conservatives are all against the public plan option. However, even if they were successful in defeating this bill, as long as they continue on this course of adamant opposition, they will not be well-positioned for the 2010 elections. They will have no other policy initiatives or legislative accomplishments to boast of and they will still be easily characterized as the "party of no." Their political calculations made them oppose a highly qualified Supreme Court nominee in a futile exercise that has put them on the wrong side of history and set them back at least for a decade in getting electoral support from the Latino community, the largest and fastest- growing minority group in the country. The void of Republican political leadership has been filled by extremist groups and irresponsible radio talk commentators, reducing the party's appeal to moderates and independents.This dramatic realization is one incentive to get Republicans to work harder in passing health care reform in some bipartisan shape or form. But this is not likely, since their preference so far has been to deny Obama any chance of bipartisanship. Another motivation to bring them to the table should be the awareness that, if the rising cost curve of health care is not brought under control, the economic recovery that is starting to show will only be temporary, the deficit will continue to grow and other countries will not be so accommodating in holding US debt. But political expedience on their part may overtake even this fundamental concern about the future economic stability of the country.On his part, Obama will have the problem of dealing with the liberal wing of his party: the left will be furious if, with a majority in both Houses, their version of health care reform does not pass, and the President settles for a weaker, watered down version. Indeed, in general terms, the biggest and most immediate test for Obama will be how far he allows the left in Congress to go before he decides to rein them in. In order to regain control of the health care debate, the President held his own town hall meeting in New Hampshire this past Tuesday. His message was clearer and more focused as he answered genuine concerns and questions from the audience. But to what extent he was able to calm down the prevailing anxiety in the country at large still remains to be seen. Outside the town hall, two groups of irate citizens on the opposite ends of the political spectrum confronted each other, yelled and shook their fists, but the police were able to restrain them without much effort.In spite of the turbulent TV images that have inundated the airways this week, the majority of the electorate in this country is still moderate, rational and centrist. They want health care reform and they want it to include a government-run option, which they may or may not buy into, but which they see as an important way to spur competition, in the understanding that it is competition and not monopolies that help control costs. They also want reform of the way private insurance companies ration care, for example, by denying coverage to those with pre-existing conditions. They are appalled at the crazies on the right, with their false claims about a bill they have not read, and their outrageous claims of Socialism and Nazism, which they merge into one demonic ideology. They are tired of their pseudo-religious zeal and self-righteousness, their insistence on rejecting Darwin's theory of evolution along with global warming, climate change and stem cell research, their violent outbursts, and their tendency to speak in terms of Good (themselves) and Evil (the rest). And they are embarrassed at the subtext of racism that underlies most of the extremists' demented claims, and which becomes crystal clear in their assertion that President Obama is not an American citizen.On the other hand, most citizens are also wary of ultra-liberals on the left, who want to use the Democrats' prevalence to entrench new vast social programs, over-regulate the financial system and corporate pay, and raise taxes to levels that would choke growth and productivity; they are afraid they will forever bankrupt the government and the country.Six months into his presidency, Obama faces sinking approval numbers and the possibility of a major defeat. After a string of solid successes that included, among others, passing an 800 billion dollar economic stimulus plan, expanding children's health insurance, and rescuing the banking system, his agenda may get bogged down in the politics- as- usual Washington culture he promised to change. It will take all his will power and discipline to stay focused, get back on message and resist the blows. His ambition will have to be tempered by patience, caution and political skill. As his aura wears off, the coming battles will be the final test of his courage and determination to succeed. Senior Lecturer, Department of Political Science and Geography Director, ODU Model United Nations Program Old Dominion University, Norfolk, Virginia

Objective: This paper aims to describe waste management in primary health care centers located in the municipality of Xalapa, Veracruz, Mexico, as a model case for developing countries. Material and methods: A observational, descriptive and cross-sectional study was conducted. The sample was made up of the seven primary healthcare centers located in the municipality of Xalapa, Veracruz, México. Data collection was carried out with a checklist designed according to the current legislation for the primary health care centers. Results: The global percentage of compliance was 55%, with variation between 47% and 63%. The stage of identification, separation and packaging recorded the highest percentage of compliance, while the temporary storage showed a lower percentage. Conclusion: The waste management in primary health care centers resulted in a level of compliance ranging from low to medium, which suggests the need for specific actions in order to improve waste management in health centers. ; Objective: This paper aims to describe waste management in primary health care centers of the Secretary of Health in the municipality of Xalapa, Veracruz, Mexico, as a model case for developing countries. Material and methods: A observational, descriptive and cross-sectional study was conducted. The sample was made up of the seven primary healthcare centers of the Secretary of Health located in the municipality of Xalapa, Veracruz, México. Data collection was carried out with a checklist designed according to the current legislation for the primary health care centers. Results: The global percentage of compliance was 55%, with variation between 47% and 63%. The stage of identification, separation and packaging recorded the highest percentage of compliance, while the temporary storage showed a lower percentage. Conclusion: The waste management in primary health care centers resulted in a level of compliance ranging from low to medium, which suggests the need for specific actions in order to improve waste management in health centers. Keywords: waste management; primary health care; medical waste; Public Health; Mexico

This book presents some of the results from the international research project "Impact on equity of access and efficiency of Integrated Health care Networks in Colombia and Brazil (Equity-LA)". Equity-LA was funded by the European Union and had the participation of six institutions from Spain, Belgium, Colombia and Brazil. The project's main objective was to understand the impact of implementing integrated health care networks on access, coordination, efficiency, and equity of access in different Latin American contexts. This study provided results, but also generated new questions that led to Equity LA II project (www.equity-la.eu). Currently undergoing and funded by the European Union, Equity LA II will include data from four additional countries in Latin America (Argentina, Chile, Mexico, and Uruguay) with the objective of broadening this understanding. The analyses described in this work refer exclusively to questions of access, coordination, continuity, and quality of care in health service networks, which are analyzed through a cases study, based on qualitative and quantitative data collected between 2009 and 2012. En este libro se presenta una parte de los resultados del proyecto internacional de investigación "Impacto en la equidad de acceso y la eficiencia de las redes integradas de servicios de salud en Colombia y Brasil (Equity-LA)", financiado por la Unión Europea y en el que participaron seis instituciones de cuatro países, dos europeos (España y Bélgica) y dos latinoamericanos (Colombia y Brasil). La investigación se diseñó con el propósito de mejorar la comprensión sobre el impacto de la implementación de las redes integradas de servicios de salud en el acceso, la coordinación, la eficiencia y la equidad de acceso, en diferentes contextos de Latinoamérica. El estudio además de evidencia, generó nuevas preguntas, que dieron lugar al proyecto Equity LA II (www.equity-la.eu), actualmente en desarrollo, también financiado por la Unión Europea, que profundiza en sus resultados y amplía el análisis a ...

Home Health Care (HHC) services are based on a delivery network in which patients are hospitalized at their homes and health care providers must deliver coordinated medical care to patients. Demand for HHC services is rapidly growing and governments and health care providers face the challenge to make a set of complex decisions in a medical service business that has an important component of logistics problems. The objective of this paper is to provide a critical review of models and methods used to support logistics decisions in HHC. For this purpose, a reference framework is proposed first in order to identify research perspectives in the field. Based on this framework, a literature review is presented and research gaps are identified. In particular, the literature review reveals that more emphasizes is needed to develop and implement more integrated methodologies to support decisions at tactical and strategic planning levels and to consider key features from real systems.

The increased demand for health services and the inclusion of new aspects in what is culturally considered "health and health care" represent a significant challenge for the current health care system and health care practice model in Catalonia. Determining health care needs and providing the right responses to them should not only be the job of experts. Rather, it should involve the participation of all the agents who live with and in the health care system every day. The aim of this article is to point out the importance of the perceptions of the agents involved in health care for planning and decision-making in health policies. A summary of the integrated perspectives of the public, professionals, and managers from the Catalan health care system is presented. Such perspectives can reveal the agreements and disagreements concerning the dimensions of health care participants define as important: health resources, health care processes, and the relationship between professionals and users.

After the Second World War, many Western countries implemented mental health care reforms that included legislative changes, measures to modernise psychiatric hospitals, and policies to deinstitutionalise mental health care, shifting its locus from residential hospitalsto community services. In Greece, psychiatric reform began in the late 1970s and was linked to the fall of the military dictatorship in 1974, the general reorganisation of health care, accession to the European Economic Community and international outcry at the inhuman treatment of the Leros psychiatric hospital inmates. The 1950s, 1960s and most of the 1970s had been an ambivalent period in relation to psychiatric reform. On the one hand, a dynamic group of experts, some long established and some newly emergent, including psychiatrists, hygienists, psychologists and social workers, strove to introduce institutional and legislative changes. On the other hand, the state, while officially inviting expert opinion on mental health care more than once, did not initiate any substantial reform until the late 1970s and the early 1980s. Within this framework, we ask whether the story of psychiatric modernisation in Greece before the late 1970s could be summarised as a futile encounter between progressive scientists and indifferent state authorities. By assessing the early attempts to restructure mental health care in Greece, examining both the expert proposals and the state policies between the end of the civil war in 1949 and the fall of the dictatorship in 1974, this paper proposes a more nuanced view, which brings out the tensions between state and expert discourses as well as the discrepancies between the discourses and the implemented programmes.

Objective To propose an antenatal care classification for measuring the continuum of health care based on the concept of adequacy: timeliness of entry into antenatal care, number of antenatal care visits key processes of care. Methods In a cross sectional, retrospective study we used data from the Mexican National Health Nutrition Survey (ENSANUT) in 2012. This contained self reported information about antenatal care use by 6494 women during their last pregnancy ending in live birth. Antenatal care was considered to be adequate if a woman attended her first visit during the first trimester of pregnancy, made a minimum of four antenatal care visits underwent at least seven of the eight recommended procedures during visits. We used multivariate ordinal logistic regression to identify correlates of adequate antenatal care predicted coverage. Findings Based on a population weighted sample of 9 052 044, 98.4% of women received antenatal care during their last pregnancy, but only 71.5% (95% confidence interval, CI: 69.7 to 73.2) received maternal health care classified as adequate. Significant geographic differences in coverage of care were identified among states. The probability of receiving adequate antenatal care was higher among women of higher socioeconomic status, with more years of schooling with health insurance. Conclusion While basic antenatal care coverage is high in Mexico, adequate care remains low. Efforts by health systems, governments researchers to measure improve antenatal care should adopt a more rigorous definition of care to include important elements of quality such as continuity processes of care.

In the European Union, Spain is seen as a "nation of services"; therefore, the whole of society, both in Spain and in Europe, must prepare for plural cohabitation. Health and sickness are daily occurrences for people and groups, and have become a part of everyday life for various social and cultural groups. The Spanish healthcare system, and more specifically the Alicante system (both public and private), are accustomed to catering for patients/customers from different cultural backgrounds. Regarding Nursing Management, the need has been observed to create schemes for the management of clinical practice, identifiyng and understanding the specific characteristics of our patients, in order to make decisions and intervene in health planning (Andrews, 2003). This requires a consideration of cultural care, beliefs, references and ways of living of people from both similar and different cultures; this will yield profitable and satisfactory results concerning the general quality of healthcare, as perceived by patients/customers. From June 2001, an intereuropean social and health project has been carried out for the reduction of waiting time for surgical procedures, by the Dutch Healthcare System and the Clinica Vistahermosa in Alicante, Spain. What kind of care management has been implemented in clinical practice? An attempt has been made to avoid ethnocentrism, i.e. believing that our Spanish standards are the suitable and relevant ones, but also no attempt has been made to transfer a "hospital from the Netherlands" into Spain. A negotiation-management process has been designed. ; En la Unión Europea, España se presenta como nación de servicios, tanto la sociedad española como la europea deben preparase para una convivencia plural. La salud y la enfermedad son realidades cotidianas de las personas y los colectivos. El cuidado de la salud y la enfermedad forman parte de la vida de las personas en los diferentes grupos socioculturales. El sistema sanitario español y en concreto el sistema sanitario alicantino, tanto ...

En la Unión Europea, España se presenta como nación de servicios, tanto la sociedad española como la europea deben preparase para una convivencia plural. La salud y la enfermedad son realidades cotidianas de las personas y los colectivos. El cuidado de la salud y la enfermedad forman parte de la vida de las personas en los diferentes grupos socioculturales. El sistema sanitario español y en concreto el sistema sanitario alicantino, tanto público como privado, se encuentra acostumbrado a trabajar con pacientes-clientes procedentes de diversas culturas. Desde la Gestión de Enfermería se ve la necesidad de crear programas de gestión de la práctica clínica, identificando y comprendiendo las peculiaridades de los pacientes con los que se trabaja, siendo capaces de tomar decisiones e intervenir en la planificación sanitaria (Andrews, 2003) tomando en cuenta los valores de los cuidados culturales , las creencias, las referencias y formas de vida de la gente de culturas similares y diversas, para obtener resultados beneficiosos y satisfactorios en cuanto a la calidad asistencial global, percibida por el paciente-cliente. Desde junio de 2001, se esta llevando a cabo un Proyecto Socio sanitario Intereuropeo de disminución de listas de espera quirúrgicas entre el Sistema de Salud holandés y la Clínica Vistahermosa de Alicante, España. En la práctica clínica ¿qué Gestión de Cuidados se ha realizado? Se ha intentado no caer en el etnocentrismo, de pensar que sólo lo nuestro es lo adecuado y pertinente, tampoco intentar trasladar "un hospital de su país" a España… Se trata de realizar una NEGOCIACIÓN - GESTIÓN. ; In the European Union, Spain is seen as a "nation of services"; therefore, the whole of society, both in Spain and in Europe, must prepare for plural cohabitation. Health and sickness are daily occurrences for people and groups, and have become a part of everyday life for various social and cultural groups. The Spanish healthcare system, and more specifically the Alicante system (both public and private), are accustomed to catering for patients/customers from different cultural backgrounds. Regarding Nursing Management, the need has been observed to create schemes for the management of clinical practice, identifiyng and understanding the specific characteristics of our patients, in order to make decisions and intervene in health planning (Andrews, 2003). This requires a consideration of cultural care, beliefs, references and ways of living of people from both similar and different cultures; this will yield profitable and satisfactory results concerning the general quality of healthcare, as perceived by patients/customers. From June 2001, an intereuropean social and health project has been carried out for the reduction of waiting time for surgical procedures, by the Dutch Healthcare System and the Clinica Vistahermosa in Alicante, Spain. What kind of care management has been implemented in clinical practice? An attempt has been made to avoid ethnocentrism, i.e. believing that our Spanish standards are the suitable and relevant ones, but also no attempt has been made to transfer a "hospital from the Netherlands" into Spain. A negotiation-management process has been designed.