When Do We “Just Say No”? Policy Termination Decisions in Local Hospital Services

This paper develops a two‐stage decision‐making model of the public policy termination process, which integrates political and economic influences on local decision makers. We empirically explore the model using data on the provision of local public hospitals in California over 1981–95. The results provide support for the model as we find that triggering events as well as characteristics of the local decision‐making context affect the termination decision. For the case of public hospitals, we find that lower state and local revenue growth rates increase the likelihood of termination, while decision makers in communities with a larger local health budget, more unionized public employees, and a larger private hospital sector are less likely to terminate local public hospitals. The implications for public policy and for our understanding of the termination process are discussed.     

GRAVITY MODEL APPLICATIONS IN HEALTH PLANNING: ANALYSIS OF AN URBAN HOSPITAL MARKET*

ABSTRACT. In this paper a gravity model is formulated to model a hospital patient flow system. Both spatial and nonspatial measures of separation are used to estimate the model. Travel time was found to provide improved fits over linear distance in modeling patient flow behavior. Transformations of travel time (square root and log) were found to improve model performance further. Model diagnostics suggested additional spatial separation measurw, separation measure parameters demonstrated stability over time. The model is used to forecast the effects of health care financing reform and hospital closure on patient flows in an urban hospital market. Universal health coverage was found to dramatically improve access to hospital services for lower income patient populations. Hospitals at risk for closure were forecast to receive increased patient flows. Medical school hospitals are expected to lose patients after implementation of health reform, with important implications for graduate medical education. Hospital closures were shown to have negative effects on access to services in poor neighborhoods, but relatively little effect on access in the system as a whole.     

Entitled to Health? Social Protection in Chile's Plan AUGE

In theory everyone has the right to health. However, in reality many low income households are unable to fully access health services and therefore cannot fully claim their rights. Recently, in an attempt to overcome these limitations, health reforms in Chile under the Plan AUGE have proposed a series of legal entitlements to health care that are available to everyone regardless of income level. While this is an important starting point in ensuring more universal access to health, the process has raised a number of important issues, particularly on how these entitlements have been defined and how far they will be able to transform (gender) inequalities within the health system. Looking at this from a gender perspective enables us to see that despite the shift from a health care system based on redistributive rights towards one based on the right of recognition, certain sectors of the population remain excluded. Decision‐making processes have remained technocratic, and women's groups have been marginalized from the debate around the reform. Moreover, health policy makers continue to ignore the role of the unpaid care economy in health care provision. The current reform has served to reinforce the gender roles around health care.     

Voluntarism, municipalism and welfare: the geography of hospital utilization in England in 1938

This paper provides a comprehensive analysis of the pattern of hospital utilization (rather than provision) in England prior to the establishment of the NHS, showing the extent to which the probability of obtaining hospital treatment was a function of residence. Access to hospital care depended on the vigour of voluntarism and the political priorities of local governments. The pattern of voluntary hospital utilization is shown to have been markedly unequal, but the effect of municipal provision was to reduce disparities in access to services. The paper demonstrates variations in hospital utilization and discusses contemporary assessments of the situation. This work contributes to debates about the efficacy of non-profit forms of welfare delivery; it provides a novel British study to complement American work in this field. It also raises questions about the contemporary vogue for partnerships in health care delivery between the public and private sectors, arguing that such proposals rest on an optimistic view of history.     

A political economy approach to the allocation of health care resources: the case of remote areas of Queensland

This article describes and accounts for the existing distribution of medical services in remote areas. In contrast to traditional geographical approaches which have sought to explain problems associated with service provision in remote areas in terms of high costs of overcoming vast distances and low population thresholds, it is argued that such geographical and economic factors alone are an insufficient basis for explanation. Rather, it is necessary to view this issue in the broader context of existing ideology that underpins the procedures relating to the allocation of society's scarce resources, and the role of political and bureaucratic processes that are responsible for health care inequities. The adoption of apolitical economy framework recognises the problem of resource allocation as essentially a political matter requiring an analysis of power relations.     

江苏省城乡公共服务发展差距及其障碍因素分析

以江苏省13个省辖市为研究样本,通过构建评价教育、卫生、环境和基础设施等公共服务指标体系,运用熵值法、协调度模型和障碍度模型等方法,对江苏各省辖市的城乡公共服务发展水平进行综合评价。结果表明:①城乡公共服务发展水平区域分异明显;②不同类型公共服务发展水平城乡差距各不相同,基础教育服务城乡差距明显,医疗卫生服务乡村远落后于城市,生态环境服务城乡差距相对较小,基础设施服务城乡差距位居中等;③城乡公共服务协调发展水平可以划分为四种类型,城乡基础教育和医疗卫生等服务领域发展水平差距是影响多数省辖市城乡公共服务协调发展的最大障碍因素。     

Nearby,but Not Wanted? The Bypassing of Rural Hospitals and Policy Implications for Rural Health Care Systems

This study examines the underutilization of rural hospitals. The authors study hospital and patient characteristics to determine why and how rural patients bypass local rural hospitals despite the availability of comparable medical services. The general conditional logit analysis of data on patients and hospitals suggests that hospital characteristics (size, ownership, and distance) and patient characteristics (payment source, medical condition, age, and race) influence rural patients' decisions to bypass local rural hospitals. The study offers two suggestions (policy implications) to better utilize rural health care institutions: a market-centered approach, and more effective government intervention for horizontal and vertical hospital integration.     

Medical versus social work-places: constructing and compensating the personal support worker across health care settings in Ontario,Canada

This article explores the role of place in explaining variation in caregiver compensation. Using the labour category of Personal Support Worker (PSW) in Ontario, Canada, it contrasts wage rates across three health care settings: hospitals, long-term care facilities and private homes. An evaluation of current literature from disciplines spanning geography, gender studies, political science and sociology is combined with a critical analysis of policy documents and wage data to reveal that, despite holding similar qualifications and performing comparable job duties, hospital-based workers receive higher wages than home-based workers. I theorize that this wage disparity is partially attributable to the historical privileging of hospital settings in Canada, based on a medical-social continuum of health care valuation. Given that the hospital is constructed as a highly medical place, whereas the home is considered to be a social place, caregiving work enjoys greater financing protection in the former. I argue that these constructions stem from deeply gendered historical roots which view the marketplace as a male-dominated setting for productive waged labour, and the home as a female-dominated setting for unpaid social pursuits. Thus, when personal support services shift from public institutions into private homes, these activities become invisible to the state, and their provision beyond its purview. I conclude that the medical versus social nature of the duties performed by PSWs has become secondary to the medical versus social nature of the setting in which these activities take place. This has translated into lower wages for home-based PSWs, effectively resulting in wage discrimination.     

Health Care in Rural Texas

The purpose of this article is to assess the quality of health and health care services available to rural Texans. Specifically, we seek to answer two related questions. First, do people living in rural areas of Texas generally suffer from poorer health than people living in urban Texas? One undoubtedly would think so, given frequent references to the low quality of personal services in general for rural America. Moreover, the persistence of the congressional Rural Health Care Caucus over the past two decades points to a rural health care crisis. Second, to what extent are these differences in health conditions explained by differences in access to health care enjoyed by people living in the two different regions? Access certainly appears to be the problem alluded to above. Rural people apparently lack physician care. In addition to providing answers to these questions, we also examine the difference in the health conditions and access to care enjoyed by minority and non‐minority rural Texans. Is this a part of the rural health care problem given the high incidence of non‐whites in rural Texas? If so this may be minority rather than rural neglect. We briefly conclude the article with some recommendations for improving the problems we identify.     

EQUALITY OF SPATIAL ACCESS TO PRIMARY HEALTH SERVICES FOR SINGAPORE'S BABY BOOMERS

The ageing baby boomers in Singapore, which account for one-third of the total population in 2006, will have a profound impact on the economy, society and environment. The greatest demand is for health care services. Even though Singapore has generally been regarded as a country where primary health services are easily available to all residents, this paper identifies significant spatial variations across the island-state. In particular, accessibility in some areas with high concentration of boomers is relatively lower compared to other residential areas. This paper concludes that understanding the spatial variation in primary health service accessibility is critical to the success of future policies, which may lead to a review of the provision of such services across the island. The methodology developed in this paper is also applicable to the study of service inequalities in other Asian countries with large rural settings.     

An Analysis of Capitation for Mental Health Services

The major impetus for health care reform clearly seems to be the desire to contain the cost of health care. One of the major cost-containment methods proposed is capitation. Capitation poses specific problems when applied to mental health services delivery. This article discusses several of the major issues pertaining to the utility of capitation in mental health, discusses on-going capitation efforts, and provides an evaluation of capitation programs. Future directions for research on capitation in mental health are then suggested.     

User-Centred Time Geography for Location-Based Services

Location‐based services assist people in their decision‐making during the performance of tasks in space. They do not consider the user's individual preferences, time constraints and possible subtasks to be performed. In order to account for these important aspects, a user‐centred spatio‐temporal theory of location‐based services is required. We propose such a theory by combining classical time geography with an extended theory of affordances. It assumes that affordances belong to three realms: physical, social‐institutional, and mental. In addition to covering the capability, coupling and authority constraints from time geography, this allows for a user‐centred perspective because affordances describe action possibilities with regard to a specific person. Furthermore, the integration of mental affordances offers the possibility to account for cognitive time constraints due to the duration of decision‐making processes. This new theory for location‐based services is closer to the individual user and more plausible with respect to their daily lives. A business traveller scenario is used as a case study to demonstrate this.     

The Environmental Performance of Participatory and Collaborative Governance: A Framework of Causal Mechanisms

Many have advocated for collaborative governance and the participation of citizens and stakeholders on the basis that it can improve the environmental outcomes of public decision making, as compared to traditional, top‐down decision making. Others, however, point to the potential negative effects of participation and collaboration on environmental outcomes. This article draws on several literatures to identify five clusters of causal mechanisms describing the relationship between participation and environmental outcomes. We distinguish (i) mechanisms that describe how participation impacts on the environmental standard of outputs, from (ii) mechanisms relating to the implementation of outputs. Three mechanism clusters focus on the role of representation of environmental concerns, participants' environmental knowledge, and dialogical interaction in decision making. Two further clusters elaborate on the role of acceptance, conflict resolution, and collaborative networks for the implementation of decisions. In addition to the mechanisms, linking independent with dependent variables, we identify the conditions under which participation may lead to better (or worse) environmental outcomes. This helps to resolve apparent contradictions in the literature. We conclude by outlining avenues for research that builds on this framework for analysis.     

Human conflict and ecosystem services: finding the environmental price of warfare

Environmental degradation resulting from warfare is a growing concern, particularly with increasing recognition of humanity's dependence on healthy ecosystems. Though environmental legislation does exist that seeks to prevent or mitigate environmental harm before, during and after conflict, it has limited scope and effectiveness. This may be one reason why the environmental laws of war are so rarely applied in attempts to bring parties responsible for environmental harm to justice. Enforcement of such legal instruments also requires appropriate quantification of environmental damage, which is particularly difficult in a warfare context. A focus on the loss of environmental resources, habitats or ecosystems is only part of the story—the real cost of environmental damage is in the loss of ecosystem services that such resources provide, both now and in the future, and which regional and global human societies depend upon. The ecosystem services framework, wherein the costs of damage to ecosystem services are quantified in economic terms, may prove a more effective way of highlighting the environmental damage resulting from warfare. Moreover, quantification along monetary lines is potentially more likely to establish a solid case for justifiable reparations than criteria relating to loss of biodiversity or ecosystem health, which are more difficult for society and governmental agencies to place specific values on. This article discusses the ecosystem services framework in the context of warfare, and highlights both the potential and the challenges that may accompany adoption of such a framework by the international community.     

Equity in Regional Service Provision

Most transportation agencies stipulate that an important planning goal is to provide equitable and just public transport services. However, who is to be served and the type of service that should be provided has been ambiguous. This paper develops a methodology for examining equity in the provision of public transportation services. An approach for identifying areas in need of public transport is developed based upon the use of socio-demographic and economic information. Public transport need is then related to levels of access to service. This approach makes it possible to establish the degree to which public transport services may be considered equitable in relation to need and suitable access. A detailed analysis of the southeast Queensland region of Australia illustrates how this approach may be used to inform public transport decision making.     

‘It’s a very isolating world’: the journey to HIV care for women living with HIV in British Columbia,Canada

HIV health services research conventionally defines place in terms of proximity to care. However, understandings of place must also include the social spaces that women living with HIV (WLWH) occupy which shape their experience of health and access to care. Drawing on focus group data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study, we explored how 28 WLWH navigate geographic place and social space in attempting to access HIV-related healthcare within and across a range of urban to rural localities in British Columbia (BC), Canada. We describe how existing services, even if physically close, can be socially marginalizing as women confront HIV stigma, racism, and classism, which operate to exclude women from the places and spaces they must access for care. We also emphasize how women enact ‘geographies of resistance’ and succeed in carving out their own safe options for care and support. Finally, we share recommendations identified by women themselves towards developing local and community-driven ‘geographies of change’ that support the health and healing of diverse communities of WLWH. Our findings stress the urgent need to acknowledge and redress socio-spatial barriers to care and to work with WLWH to co-create a therapeutic landscape that reflects women’s diverse identities, localities, emotions, and experiences.     

Personal Assistance Services: The Hub of the Policy Wheel for Community Integration of People with Severe Physical Disabilities

The success of persons with severe physical disabilities in living independently in the community, engaging in self-directed productive activities, and staying healthy depends, in part, on getting and maintaining adequate personal assistance with basic tasks such as getting out of bed and tending to personal hygiene. Although few policymakers would disagree with the contention that many people with disabilities need assistance with daily tasks, there is considerable debate about who should provide assistance, what services should be included, who should pay, who should be entitled to publicly provided and paid services, how much assistance should be provided, and who should control its administration. The prevailing model for delivery of personal assistance services has been primarily medical, with control of services by health care professionals, rather than independent living, with control by consumers receiving services. Traditionally there has been an institutional bias of funding for disability-related service, despite its much higher expense than community-based personal assistance services and its violation of basic human rights. Proponents of various solutions to health care reform have given little consideration to the provision of support services for people with disabilities. The advantages of implementing a uniform national system for the delivery of personal assistance services based on consumer control are discussed.     

Spatial optimisation of fire service coverage: a case study of Brisbane,Australia

In the context of changing demand for fire services, spatial optimisation of fire coverage has attracted little scholarly attention despite its potential to improve emergency response and to inform future service planning for fire stations. Drawing on small area population forecasts, this paper extends the application of the Maximum Coverage Location Model to compute and delineate the spatial coverage of current and proposed new fire stations to align with population growth estimates for Brisbane, Australia. Our results reveal important gaps in fire cover that are likely to emerge as a result of predicted population growth, the spatial patterns of which varies across the Brisbane metropolitan area. We draw on these results to delineate a series of new potential sites for fire stations to ameliorate the reduction in spatial coverage as a consequence of predicted population growth demonstrating the utility of our analytic approach for decision‐making and operational planning in the fire services.     

Social and Spiritual Capital: Building ‘Emotional Resilience’ In Communities and Individuals

Abstract

The article examines the relationship between mental health, mental health promotion, religious communities and general issues of public health. It begins with an exploration of what is meant by mental health drawing a distinction between it, mental illness and mental health promotion, and argues that mental health can have a profound impact on physical health. The relationship between religious communities and the mentally ill is analysed next. Despite the attitudes of many in mental health provision, religious communities can offer a supportive environment for the mentally ill. The article avoids a ‘faith communities—good’, ‘mental health services—bad’ dichotomy, recognizing that religious communities can be excluding and discriminatory. The ambiguity of some experiences is recognized: are they forms of religious experience or symptoms of psychosis? The article highlights the inceasing advocacy of the user/survivor movement. In the final section, the relationship between mental health and public health is explored. It is suggested that religious communities can be places for the promotion of mental health. Mental health promotion is understood as aiming to strengthen both individuals and communities; its value is explored in relation to public health issues. It is suggested that those who are socially excluded are at a greater risk of some form of mental illness and that this may well impact on their physical health. Related to this are the beneficial effects of opportunities for participation in decision making, be it in the workplace or the local community. The article ends by arguing that service providers and service users need to be involved in decisions and planning. Further, some elements of mental health promotion will need to involve those outside the statutory sector.     

Narratives of emotion and anxiety in medical tourism: on State of the Heart and Larry's Kidney

This paper explores the emotional geographies of State of the Heart and Larry's Kidney—two nonfiction narratives about medical tourism wherein American patients and their caregiver companions travel abroad for life-saving surgeries. The paper has two main goals: first, to illustrate the importance of emotional geographies in medical tourists' lived experiences of travel and tourism, as well as the giving and receiving of transnational health care and second, to generate empirical, theoretical, and methodological discussions between geographical, travel, tourism, and health studies on the relevance of emotional geographies. Medical tourists' experiences of travel and health care have been usually examined as spatially distinct rather than as entwined phenomena. We address the above goals by discussing how the narratives of traveling thousands of miles to a radically different socio-cultural milieu in order to receive essential medical care produce two interrelated emotional geographies: first, they demonstrate the existence of ‘emotional amplification’ (increase in the intensity of emotions) and ‘emotional extensivity’ (increase in the range of emotions) and second, they show how anxiety is underpinned by proximity to Otherness, uncertain boundaries, and isolated decision making. We conclude by briefly addressing how our examination of these narratives can be usefully expanded.