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This paper reports the results of a comparison between two different methods of examining quality in outpatient services in a developing country. Data from rural and urban Tanzania are used to compare the measures of quality collected by direct clinician observation (DCO) (where clinicians are observed in the course of their normal consultations) and vignettes (unblind case studies with an actor). The vignettes are shown to exhibit a strong connection between the inputs provided during consultation (rational history taking, physical examination and health education) and the ability of the clinician to properly diagnose the presented illness. However, the inputs provided in vignettes are not well correlated with the inputs provided in DCO, suggesting that the inputs provided in the vignette are not well correlated with the inputs that would be provided in an actual consultation. We conclude that since vignettes do not appear to be measuring what would be provided in an actual consultation they are not a good measure of quality. Instead, we suggest that vignettes and DCO be used simultaneously. We show how the scores obtained using vignettes in conjunction with DCO can be used to improve the reliability of DCO and therefore our estimates of actual clinician quality. Keywords: Direct clinician observation; Vignettes; Health services quality; Tanzania

The complexity and cost of health systems requires innovative forms of organization to provide accessible health services of an acceptable quality and at an acceptable cost. Interorganizational collaboration (IoC) is an innovation to increase the availability of organizational resources, improve service effectiveness, and improve access to health care. In Pakistan, a weak health system and little collaboration limit access, especially of women and children, to health services. Many nongovernmental organizations (NGOs) provide primary health care to the very poor, and some appear to collaborate to varying degrees; however, this has not been systematically analyzed. The purpose of this qualitative research, the first scientific study of collaboration between NGOs providing health services in Pakistan, was to describe collaboration between three pairs of NGOs providing community-based health services to women in Karachi. A longterm goal is to build a basis for future research linking IoC to access to health care and health outcomes. Findings indicated that collaboration was strongest when there was willingness to cooperate, a need for expertise and funds, and adaptive efficiency. In Pakistan's complex social environment, collaboration tended to be stronger when there was fairly high organizational formalization. Broader IoC appears to be positively associated with women's access to health care. Recommendations are made for future research, education, and management. Keywords: Nongovernmental organizations (NGOs); Interorganizational collaboration; Health care access; Women's health; Health services; Karachi; Pakistan

A growing body of literature in geography and other social sciences considers the role of place in the provision of healthcare with particular interests emerging around the role of the psychological, social and cultural aspects of place in care provision. As healthcare stretches increasingly beyond the traditional four walls of the hospital, so questions of the role of place in practices of care become ever more pertinent. In this paper, we examine the relationship between place and practice in the care and rehabilitation of older people across a range of settings, using qualitative material obtained from interviews and focus groups with nursing, care and rehabilitation staff working in hospitals, clients' homes and other sites in England. By analysing their testimony on the characteristics of different settings, the aspects of place which facilitate or inhibit rehabilitation and the ways in which place mediates and is mediated by social interaction, we consider how various dimensions of place relate to the power-inscribed relationships between service users, informal carers and professionals as they negotiate the goals of the rehabilitation process. We seek to demonstrate how the physical, psychological and social meanings of place and the social processes engendered by the rehabilitation encounter interact to produce landscapes that are more or less therapeutic, considering in particular the structuring role of state policy and formal healthcare provision in this dynamic. Keywords: Intermediate care; Older people; Therapeutic landscape; Rehabilitation; Community care; UK

This paper presents results from a qualitative analysis of official documents dealing with the deregulation of the Danish medicine distribution system, 2001. In an attempt to clarify how consumerism within health care is manifested in policy, this study explores how central actors in the political process explicitly referred to the needs, interests and problems of the users of medicine. The results show that explicit references to the users of medicine by central actors in the political process were limited. Based on this we argue that in this case, although the debate centred on liberal ideas it seems as if chief values of classic liberalism were lost in the process of translating a political idea into political practice. Keywords: Medicine Distribution System; Consumer Participation; Health Policy; Health Care Reform; Denmark

In many countries health policy has been guided by a focus on the supply side factors of access to health care, a lot of attention being directed at the availability of services. This paper concentrates on the demand side of access and investigates relational factors that may limit people's subjective choice sets or their freedom to utilise health services, emphasising that relations between service providers and individuals are based on an interchange of information. It develops an argument for health communication strategies based on an interactive exchange of information as a means of improving access and is intended as a conceptual basis for further debate. Trust assumes a key position within this transactional process of information exchange or communicative interaction. Information may enlarge individual choice sets and increase the freedom to use health care; it serves as a stimulus for access. The paper argues that trust plays a role in the utilisation of provided information. Trust emerges as a prerequisite of the effectiveness of information with regard to access. A discussion of the origins of trust shows that, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place. Culturally diverse societies are often low-trust environments. The paper analyses the driving forces of trust and distrust in health care within these societies and delineates barriers for the individual and the community to the transfer of information. Specific characteristics of health communication turn out to be key determinants of access. In conclusion, principles for health policy on equity and information are derived which are rooted in a distinctive notion of democratic societal structure. Keywords: Access; Health communication; Information; Trust

This paper explores the lived experiences and the identity processes attached to attendance at free clinics. It draws on a qualitative study of 94 patients and 37 professionals who were interviewed at four free clinics in France. Since these facilities are for the poor and for people without health coverage, attendance reflects a medical experience as well as an experience of assistance, both of which have an impact on healthcare utilisation. Nevertheless, the meaning attached to the recourse to free clinics and the patients' lived experiences change over time and depend on interactions with clinic staff. This study proposes a typology of care recourse modes (occasional, regular and inconsistent attendance) crossed with different types of lived experiences. Occasional attendance and distant patient-professionals relationships, often due to the humiliation that some people feel when they have to ask for social assistance, characterise the first time people have recourse to care. Patients commit to regular follow-ups only when they have come to terms with their position in the medical and assistance system, doing so by rationalising and adjusting their identity. Our aim in discussing our findings is to gain greater insight into the utilisation of healthcare by different population groups and in different contexts. Keywords: Healthcare utilisation; Free clinics; Moral career; Doctor-patient relationship; Poverty; France

Based on anthropological field research (1997-2000) within the Department of Health and Community Services in the Northern Territory in Australia, this paper explores the lingering features of colonial logic in the pastoral work of public health workers in the Northern Territory of Australia. The public health professionals drawn to work in this space are determined to remedy what is wrong with culturally acceptable solutions. But viewed from an anthropological perspective, the way in which health professionals conceptualise the problems they need to solve ultimately serves to reinforce the reality of the need for their continued tutelary presence. This paper aims to draw out the complex ways in which this interventionary effect is secured, concentrating in particular on the role played by progressive ideologies of participatory development and information sharing. It argues that through a complex process of forgetting, the otherwise innocuous gestures of public health goodwill recreate a mandate for more public health intervention. This is not a simple moral tale where analysts can easily identify good and bad practices and thus distance themselves from the difficulties involved. Rather, by emphasising the honest commitments to improvement in situations of mass illness and preventable disease that health professionals bring to their work, and the burden they bear in being conscious of the recent colonial past, the paper aims to avoid the judgement that this sort of work is easy to get right. Keywords: Aborigines; Public health; Postcoloniality; Cross-cultural pedagogy; Australia

To better understand the distribution of resources and health care consumption patterns in different geo-ethnic and socio-economic settings, we sought to describe the patterns of illness, care-seeking behavior and health services utilization in Hong Kong compared to the US and UK. Data were derived from the 2002 Hong Kong Thematic Household Survey covering 31,762 non-institutional and institutional residents, representing 6,504,255 persons after applying population weights. Of 1000 individuals during a 1-month period, 567 reported symptoms, 512 of whom considered seeking health care. Four hundred and forty persons visited western allopathic medical practitioners, with 372 (84.5%) in primary care and 68 (15.5%) in specialty care. There were 54 visits to traditional Chinese medical practitioners and 16 emergency room episodes. Seven individuals were hospitalized in community hospitals and on average one in 1000 were admitted to a tertiary medical center. Ninety out of the 567 who experienced symptoms undertook self-management strategies, which included over-the-counter western allopathic medications (n = 54) or traditional Chinese remedies (n = 14) or both (n = 2), dietary modification (n = 1) and rest (n = 15). We have mapped the ecology of health care in Hong Kong. Monthly prevalence estimates were remarkably similar to US figures for hospital-based events, whereas there was evidence of apparent, substantial 'over-consumption' of ambulatory, community-based care. Our results also indicate that the local community's care-seeking orientation still very much favors western allopathic medicine over traditional Chinese therapy, at least for acute illness episodes. Keywords: Hong Kong; Health services utilization; Western allopathic medications; Traditional medicine

Epidemiological, demographic and environmental crises, transition to a new political regime and exceptionally severe economic crises were powerful stimuli to health sector reform in Russia. The Russian Federation responded by introducing medical insurance whilst decentralising public administration. Yet despite intense contextual pressures to do so and a new policy climate, Russian hospitals found it difficult to reprofile services and reallocate their resources. A case study analysing governance structures in Sverdlovsk oblast reveals that medical insurance created incentives to reduce costs by reducing bed-days, but if hospitals did so they would lose money under the formulae through which decentralised local government still allocated around three-quarters of hospital income. If instead hospitals tried to increase budgetary income by increasing numbers of bed-days, the insurance system would penalise them. This specific form of policy mess can be called 'governance in gridlock'. The juxtaposition of two overlapping but incompatible sets of governance structures practically immobilised official hospital management systems. It is as one-sided to blame residues of the Soviet system for this gridlock as it is to blame the medical insurance system. Gridlock resulted from the interaction of the two, a problem to which all health system reform is potentially vulnerable. Keywords: Decentralisation; Governance; Gridlock; Health insurance; Hospital management; Russia; Soviet Union

The paper explores the attitudes of medical physicians towards adverse incident reporting in health care, with particular focus on the inhibiting factors or barriers to participation. It is recognised that there are major barriers to medical reporting, such as the 'culture of blame'. There are, however, few detailed qualitative accounts of medical culture as it relates to incident reporting. Drawing on a 2-year qualitative case study in the UK, this paper presents data gathered from 28 semi-structured interviews with specialist physicians. The findings suggest that blame certainly inhibits medical reporting, but other cultural issues were also significant. It was commonly accepted by doctors that errors are an 'inevitable' and potentially unmanageable feature of medical work and incident reporting was therefore 'pointless'. It was also found that reporting was discouraged by an anti-bureaucratic sentiment and rejection of excessive administrative duties. Doctors were also apprehensive about the increased potential for managers and non-physicians to engage in the regulation of medical quality through the use of incident data. The paper argues that the promotion of incident reporting must engage with more than the ubiquitous 'culture of blame' and instead address the 'culture of medicine', especially as it relates to the collegial and professional control of quality. Keywords: Patient safety; Incident reporting; Blame; UK

In November 2002 the World Bank published a report on the Argentine health sector. The report accurately portrays the complexity and severity of the problems facing the health care system. It stresses that these problems are not purely a product of the country's economic collapse, noting that the system has suffered from long-standing structural problems and inefficiencies. Curiously, the report makes no mention of the leading role played by the World Bank in health reform efforts during the 1990s. This paper demonstrates that these reforms did much to worsen pre-existing weaknesses of the sector. The paper criticises the content of the reform agenda and the manner in which it was produced, arguing that these were reforms in which considerations of public health were less significant than conformity to the wider model of neo-liberal social and economic development prevailing at the time. It also highlights problems of implementing the reform agenda, which reduced the coherency of the reforms. The paper goes on to examine the impact of the crisis, noting links with the preceding reforms. It identifies a number of insights and lessons of potential value to other countries which are pursuing similar policies. Keywords: Argentina: Health sector reform; World Bank

The area configuration of healthcare resources, such as the number of hospitals per hundred thousand population, has often been used in healthcare planning and policy making to estimate the global access (potential access) of health services to a local population. However, the actual utilization of the 'available' healthcare resources (revealed access) is usually much more limited. The objectives of this study were to examine the availability of healthcare resources by measuring the potential access and the revealed access for outpatients who need to access pharmacies to fill prescriptions of Schedule II (CII) opioids for pain management, and to explore the difference between rural and urban residents in these two types of access. About 191, 700 prescriptions for CII opioids dispensed in 1997 in the state of Michigan, USA were analyzed. Revealed accessibility was measured by the distance between the paired zip codes of the pharmacy and the patient listed on each prescription. Potential accessibility was measured by the distance from a patient's zip code to that of the nearest community pharmacy that could dispense the opioid prescriptions. The analyses on revealed access showed that 50% of the CII prescriptions were dispensed by pharmacies located within a 5-mile radius of patients' residences, 75% of prescriptions were dispensed within about a 10-mile radius, and 90% were within 20 miles. If patients were free to access the nearest pharmacy for dispensing (a hypothetical situation under potential access), the median, 75th percentile, and 90th percentile distances could reduce to 2, 3, and 5 miles, respectively. Similar differences between revealed and potential access were observed in both rural and urban areas and for every major opioid drug group. We conclude that policymakers should recognize the discrepancy between potential and revealed accessibility and move beyond only considering area configuration of healthcare resources to evaluating and improving access to care. Keywords: Opioids: Potential accessibility: Revealed accessibility: Geographic information system; Community pharmacy; USA

In New Zealand, health promotion is now expected to be an integral part of the work of a general practitioner, and in the recently implemented New Zealand Primary Health Organisation structure, specific funding is available to undertake health promotion activities in primary care. Eighteen general practitioners recruited to take part in two focus groups discussing men's health, talked extensively about health promotion. This talk was analysed through a discourse analysis. This study of the 'talk' of general practitioners suggests that there are problems in transferring the concept, which must be recognised and addressed if health promotion is going to be taken up effectively within general practice. The meaning given to health promotion in the consultation is unclear and general practitioners were unsure about its value in 'health checks' and screening. Lack of time and lack of confidence in the evidence appeared to be barriers to undertaking health promotion within general practice consultations. In the current climate general practitioners are uncertain, to the point of ambivalence, about health promotion in their work. Further work will be required to ensure this ambivalence does not result in covert resistance. Keywords: General practitioners; Health promotion; New Zealand

Analysis of health care systems, especially hospitals, could benefit from Foucault's description of the medical gaze and the panopticon. Foucault's perspective sheds new light on the South African transformation from an oppressive to a more democratic State and is played out in particular ways in hospital settings. Analyses of the South African health care system and its interface with patients in hospitals seldom draw on the work of Foucault, despite its pertinent description of the diffuse and insidious forms of social surveillance (the 'gaze') and processes of 'normalization' brought about in panoptical settings. The gaze has become a metaphor for the processes whereby disciplinary 'technologies', together with the emergence of a normative social science, discipline both the mind and body of the individual, as in my example of a medicalised institutional setting. Transformation from an oppressive State system to a democratic South Africa has impacted in particular ways on the hospital setting. Instead of being subject to the constant surveillance of the gaze of the State or of medicine, there are numerous instances where patients to all intents become 'invisible', and end up beyond its perimeters. In the hospital as in the heterogeneous South African community, there is a continuous process of adjustment, with patients, services and staff being rotated in an attempt to provide redress and equal access to health services for all. A large, long-standing lack of funds forces the medical staff to make decisions as to who should get access to beds and to optimal care, and this permeates the everyday experience of institutionalisation and care-giving. It also militates against neutral policy objectives, consistent surveillance or a homogenised system of care. Keywords: Equity; Hospital; Resources; Medical gaze; South Africa

Difficult health care encounters often do not translate into expressions of dissatisfaction with care. This paper focuses on the 'non-expression' of dissatisfaction with care in the accounts of 12 people in Canada who provided care to a relative or friend who died of breast cancer. The analysis foregrounded in this paper began from the observation that as difficult health care experiences were elaborated, speakers located health professionals' actions in relation to various situational factors, including the fact of a (cancer) death and conditions of constraint in the health system. Set alongside these two realities, expressions of dissatisfaction tended to be disarmed. Results of this study suggest that the cost of articulating dissatisfaction with care is high where the cared-for person has died, and the perceived value of focusing on difficult experiences is low. Further, respondents in this study took the specificity of the situation and the setting into account in formulating beliefs about the care outcomes for which health professionals could be held responsible. When conditions in the health system and the disease process of advanced cancer were positioned in talk as 'ultimate limits' on health professionals' actions, perceived lapses in care were excused. Keywords: Satisfaction; Terminal care; Breast cancer; Canada

The publication of the Patient's Charter in Britain enabled patients to have access to a series of documented standards relating to health care provision in a variety of situations. However since its introduction much discussion has taken place as to its application in clinical practice. An initial interest in the accomplishment of routine accident and emergency (A & E) nursing work led to the identification of issues associated with the use of the Patient's Charter standards; particularly those associated with immediate assessment in the A & E department. Data were collected from 60 nurses in five A & E departments and analysed using a multidisciplinary multistage approach. Findings suggest that nurses are expected to juggle the daily tensions produced by the Charter standards, associated with initial assessment, alongside the accomplishment of other aspects of the work dedicated to the safe movement of patients through the system. Tensions are rooted in two particular issues. Firstly, the meanings of immediate assessment continue to remain open to interpretation and therefore difficult to capture and manage. Secondly, the Patient's Charter standards, associated with immediate assessment, deal with one aspect of the work only and yet the accomplishment of A & E work is dependent upon maintaining a perception of order and shape throughout the whole department. Ultimately both issues have an impact on nurses' recognition and management of what they know to be the normal appearances and shape of routine work. Keywords: Accident and emergency; Nursing; Patient's Charter; Assessment; Shape of work; United Kingdom

The integration of midwifery into the health care systems in the U.S. and Canada has invoked scholars to speak of a 'rise of midwifery'. Despite the gains that the profession of midwifery has made in both countries, there are some interesting differences in how midwifery is organized and practised in these two settings. Briefly, in the U.S. midwifery currently exists as a profession divided between nurse- and non-nurse-midwives, or 'lay' midwives, with greater acceptance and legitimacy garnered by the former, whereas midwifery in some jurisdictions in Canada has gained legitimacy as a unified profession separate from nursing. An analysis of the differences in the development and organization of lay and nurse-midwifery in Canada and the U.S. highlights the importance of differences in the system of health professions in these two countries, the role of the state in this system, and the relationship between feminism, midwifery and the state on the outcome of efforts to integrate midwifery. Key words - nurse-midwifery, lay midwifery, development, organization