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This article uses history to stimulate reflection on the present opportunities and challenges for public health practice in English local government. Its motivation is the paradox that despite Department of Health policy-makers' allusions to 'a long and proud history' and 'returning public health home' there has been no serious discussion of that past local government experience and what we might learn from it. The article begins with a short resumé of the achievements of Victorian public health in its municipal location, and then considers the extensive responsibilities that it developed for environmental, preventive and health services by the mid-twentieth century. The main section discusses the early NHS, explaining why historians see the era as one of decline for the speciality of public health, leading to the reform of 1974, which saw the removal from local government and the abolition of the Medical Officer of Health role. Our discussion focuses on challenges faced before 1974 which raise organizational and political issues relevant to local councils today as they embed new public health teams. These include the themes of leadership, funding, integrated service delivery, communication and above all the need for a coherent vision and rationale for public health action in local authorities., (© The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health.)

Given limited resources, priority setting or choice making will remain a reality at all levels of publicly funded healthcare across countries for many years to come. The pressures may well be even more acute as the impact of the economic crisis of 2008 continues to play out but, even as economies begin to turn around, resources within healthcare will be limited, thus some form of rationing will be required. Over the last few decades, research on healthcare priority setting has focused on methods of implementation as well as on the development of approaches related to fairness and legitimacy and on more technical aspects of decision making including the use of multi-criteria decision analysis. Recently, research has led to better understanding of evaluating priority setting activity including defining 'success' and articulating key elements for high performance. This body of research, however, often goes untapped by those charged with making challenging decisions and as such, in line with prevailing public sector incentives, decisions are often reliant on historical allocation patterns and/or political negotiation. These archaic and ineffective approaches not only lead to poor decisions in terms of value for money but further do not reflect basic ethical conditions that can lead to fairness in the decision-making process. The purpose of this paper is to outline a comprehensive approach to priority setting and resource allocation that has been used in different contexts across countries. This will provide decision makers with a single point of access for a basic understanding of relevant tools when faced with having to make difficult decisions about what healthcare services to fund and what not to fund. The paper also addresses several key issues related to priority setting including how health technology assessments can be used, how performance can be improved at a practical level, and what ongoing resource management practice should look like. In terms of future research, one of the most important areas of priority setting that needs further attention is how best to engage public members.

In this commentary, the authors summarize and discuss some of the concerns presented in the papers herein, including issues of funding, skill sets and education. They present two key steps we could take across this country to ensure the long-term viability of public health within our healthcare system and ensure that public health and population goals are shared widely across our health systems., (Copyright © 2013 Longwoods Publishing.)

In the United States, fiscal and functional federalism strongly shape public health policy and programs. Federalism has implications for public health practice: it molds financing and disbursement options, including funding formulas, which affect allocations and program goals, and shapes how funding decisions are operationalized in a political context. This article explores how American federalism, both fiscal and functional, structures public health funding, policy, and program options, investigating the effects of intergovernmental transfers on public health finance and programs.

This article explores how health inequalities are constructed as an object for policy intervention by considering four framings: politics, audit, evidence and treatment. A thematic analysis of 197 interviews conducted with local managers in England, Scotland and Wales is used to explore how these framings emerge from local narratives. The three different national policy regimes create contrasting contexts, especially regarding the different degrees of emphasis in these regimes on audit and performance management. We find that politics dominates how health inequalities are framed for intervention, affecting their prioritisation in practice and how audit, evidence and treatment are described as deployed in local strategies., (© 2011 The Authors. Sociology of Health & Illness © 2011 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.)

Background: During the 2001 election campaign, President Yoweri Museveni announced he was abolishing user fees for health services in Uganda. No analysis has been carried out to explain how he was able to initiate such an important policy decision without encountering any immediate barriers., Objective: To explain this outcome through in-depth policy analysis driven by the application of key analytical frameworks., Methods: An explanatory case study informed by analytical frameworks from the institutionalism literature was undertaken. Multiple data sources were used including: academic literature, key government documents, grey literature, and a variety of print media., Results: According to the analytical frameworks employed, several formal institutional constraints existed that would have reduced the prospects for the abolition of user fees. However, prevalent informal institutions such as "Big Man" presidentialism and clientelism that were both 'competing' and 'complementary' can be used to explain the policy outcome. The analysis suggests that these factors trumped the impact of more formal institutional structures in the Ugandan context., Conclusion: Consideration should be given to the interactions between formal and informal institutions in the analysis of health policy processes in Uganda, as they provide a more nuanced understanding of how each set of factors influence policy outcomes.

The primary determinants of public health are political. Comparisons among countries have shown that the importance of public health within public institutions and the priorities given by those institutions depend on the power relations in existence in that society. Authors who attribute the limited influence of public health in the United States to the public's limited understanding of the issues and/or to the supposed anti-government position of the American population miss the roots of the problem.

European policymakers have recently become increasingly committed to using Impact Assessment (IA) to inform policy decisions. Welcoming this development, the public health community has not yet paid sufficient attention to conceptual concerns about IA or to corporate efforts to shape the way in which IA is used. This essay is a thematic analysis of literature concerning IA and associated tools and a related assessment of the European Union's (EU) new 'integrated' IA tool. Eight key concerns regarding IA are identified from the literature, many of which relate to the potential for undue corporate influence. Assessment of the EU's IA tool suggests that many of these concerns are valid. The findings raise crucial questions about the role of IA in public policy. By focusing mainly on the impact on the economy and business environment, the EU's current approach to IA may undermine healthy public policy. Those interested in public health need to acknowledge and respond to the problems associated with IA and evaluate the effects of 'integrated' IA tools on policy decisions affecting public health.

Introduction: Delayed discharge from acute hospital has been a cause of concern for the last 10 years. Older people with complex health needs are particularly vulnerable to delayed discharge with negative consequences for their health and wellbeing., Source of Data: Review of the literature on the impact of the Community Care (Delayed Discharge) Act (2003) and subsequent policy initiatives on delayed discharges. Areas of agreement A number of cross-institutional complexities contribute to delayed discharges. Policy measures have contributed positively to reducing delayed discharges. Investment in intermediate care services has provided a range of services to promote maximum independence for older people after acute hospital admission. Joint working between health and social services is necessary to prevent delayed discharges., Areas of Controversy: Pressure to achieve rapid hospital throughput may be contributing to older people leaving hospital too soon and to recent increases in hospital re-admission rates. Policy measures are extending to older people with mental health problems., Areas Timely for Developing Research: Patient and carer experiences of delayed or premature discharge. Quality and equity of access to intermediate care for older people.

This article presents two approaches that have dominated International Relations in their approach to the international politics of health. The statist approach, which is primarily security-focused, seeks to link health initiatives to a foreign or defence policy remit. The globalist approach, in contrast, seeks to advance health not because of its intrinsic security value but because it advances the well-being and rights of individuals. This article charts the evolution of these approaches and demonstrates why both have the potential to shape our understanding of the evolving global health agenda. It examines how the statist and globalist perspectives have helped shape contemporary initiatives in global health governance and suggests that there is evidence of an emerging convergence between the two perspectives. This convergence is particularly clear in the articulation of a number of UN initiatives in this area - especially the One World, One Health Strategic Framework and the Oslo Ministerial Declaration (2007) which inspired the first UN General Assembly resolution on global health and foreign policy in 2009 and the UN Secretary-General's note "Global health and foreign policy: strategic opportunities and challenges". What remains to be seen is whether this convergence will deliver on securing states' interest long enough to promote the interests of the individuals who require global efforts to deliver local health improvements.

This synthesis seeks to assess and explain the effectiveness of policy interventions to reduce elective wait times or lists. PubMed, EMBASE, EconLit, and grey literature were systematically searched for relevant studies and reviews. Strategies with the strongest evidence base include paying for activity, buying capacity locally and setting targets with strong incentives. There is also evidence for improving the use of existing capacity. Limiting demand through rationing can reduce waits, but is ethically problematic. Short-term injections of funding, cross-border treatment schemes, unenforced targets and promotion of private health insurance had the weakest evidence. Available evidence favours options that act fairly directly on supply, demand or local organizations' behaviour, over indirect strategies that depend on a 'domino effect'. Further research is needed to determine how to achieve major, system-wide improvements in the use of capacity.

The health of the individuals and whole population is determined by many interrelated factors. Primary by socio-economic distal determinants which are essential for health inequalities. In the article health linkages with wealth and economic prosperity in developed countries are presented. The concept of investment for health is described. Principles of healthy public policy and prospects of health in all policies, Impact Assessment methodology and Health Impact Assessment are marked out.

Although the public health community has developed several typologies for classifying public health services into programmatic categories, to date little attention has been paid to the legislative perspective on these program designations. Using programs in the state of Georgia's public health budget as a case study, this article describes the considerations that were important to legislators and legislative budget staff when assessing the Georgia Division of Public Health's program structure. The case study illustrates how legislative concerns over accountability and control as well as practical, political, and strategic choices influence the program structure. These different considerations led to a structure that differed from the Ten Essential Services as well as the National Association of State Budget Officers program categories.

The ability of public health to meet its functional mandates of assessment, assurance, and policy development footline is driven by the system's capacity to meet basic financing needs. To do so, state and local public health leaders must be able to articulate financing needs in terms that are understandable to policy makers and that link funding to anticipated community impact, benefit, and performance. "Rational" budgeting demands imposed by performance-centered budgeting in the states have proved particularly challenging for public health programs. This Georgia-based case study explores one approach for program budgeting in state and regional public health systems and finds the framework to be normatively sound and appropriately descriptive of the "core functions" of public health. The structure clearly distinguishes between personal health services and population health and allows for the future establishment of measurable program targets, an essential feature of a performance-centered budgeting system.

Objective: We examined heptavalent pneumococcal conjugate vaccine (PCV7) uptake among children aged 19 to 35 months in the United States and determined how uptake rates differed by state vaccine financing policy., Methods: We analyzed data from the 2001-2003 National Immunization Survey. States that changed their vaccine financing policy between 2001 and 2003 (n=17) were excluded from analysis. Logistic regression was performed to identify the association between state vaccine financing policy and receipt of 3 or more doses of PCV7 after control for demographic characteristics., Results: The proportion of children receiving 3 or more doses increased from 6.7% in 2001 to 69.0% in 2003. After controlling for demographic characteristics, children residing in states that provided all vaccines except PCV7 to all children had lower odds of receiving 3 or more doses compared to children residing in states that provided PCV7 only to children eligible for the Vaccines for Children program (odds ratio=0.58; 95% confidence interval=0.51, 0.66)., Conclusion: It is essential that we continue to monitor the effect that state vaccine financing policy has on the delivery of PCV7 and future vaccines, which are likely to be increasingly expensive.

Focusing mainly on the United States and Latin America, we aimed to identify the constructions of social reality held by the major stakeholders participating in policy debates about global trade, public health, and health services. In a multi-method, qualitative design, we used three sources of data: research and archival literature, 1980-2004; interviews with key informants who represented major organizations participating in these debates, 2002-2004; and organizational reports, 1980-2004. We targeted several types of organizations: government agencies, international financial institutions (IFIs) and trade organizations, international health organizations, multinational corporations, and advocacy groups. Many governments in Latin America define health as a right and health services as a public good. Thus, the government bears responsibility for that right. In contrast, the US government's philosophy of free trade and promoting a market economy assumes that by expanding the private sector, improved economic conditions will improve overall health with a minimum government provision of health care. US government agencies also view promotion of global health as a means to serve US interests. IFIs have emphasized reforms that include reduction and privatization of public sector services. International health organizations have tended to adopt the policy perspectives of IFIs and trade organizations. Advocacy groups have emphasized the deleterious effects of international trade agreements on public health and health services. Organizational stakeholders hold widely divergent constructions of reality regarding trade, public health, and health services. Social constructions concerning trade and health reflect broad ideologies concerning the impacts of market processes. Such constructions manifest features of "creed," regarding the role of the market in advancing human purposes and meeting human needs. Differences in constructions of trade and health constrain policies to address the profound changes generated by global trade.

Medicines that are vital for the saving and preserving of life in conditions of public health emergency or endemic serious disease are known as essential medicines. In many developing world settings such medicines may be unavailable, or unaffordably expensive for the majority of those in need of them. Furthermore, for many serious diseases (such as HIV/AIDS and tuberculosis) these essential medicines are protected by patents that permit the patent-holder to operate a monopoly on their manufacture and supply, and to price these medicines well above marginal cost. Recent international legal doctrine has placed great stress on the need to globalise intellectual property rights protections, and on the rights of intellectual property rights holders to have their property rights enforced. Although international intellectual property rights law does permit compulsory licensing of protected inventions in the interests of public health, the use of this right by sovereign states has proved highly controversial. In this paper I give an argument in support of states' sovereign right to expropriate private intellectual property in conditions of public health emergency. This argument turns on a social contract argument for the legitimacy of states. The argument shows, further, that under some circumstances states are not merely permitted compulsory to license inventions, but are actually obliged to do so, on pain of failure of their legitimacy as sovereign states. The argument draws freely on a loose interpretation of Thomas Hobbes's arguments in his Leviathan, and on an analogy between his state of War and the situation of public health disasters.

In this article, we investigate developments in Danish health care policy. After a short presentation of its historical roots, we focus on the decades after the administrative reform of 1970, which shaped the current decentralized public health care system. Theories of path dependency and institutional inertia are used to explain the relative stability in the overall structure, and theories of policy process and reform are used to discuss gradual changes within the overall framework. Although comprehensive reforms have not taken place in Denmark, many gradual changes may pave the way for more radical changes in the future. The political climate currently seems to be more favorable toward structural reform than in the past.

Estimating the economic value to societies of health research is a complex but essential step in establishing and justifying appropriate levels of investment in research. The practical difficulties encountered include: identifying and valuing the relevant research inputs (when many pieces of research may contribute to a clinical advance); accurately ascribing the impact of the research; and appropriately valuing the attributed economic impact. In this review, relevant studies identified from the literature were grouped into four categories on the basis of the methods used to value the benefits of research. The first category consists of studies that value the direct cost savings that could arise from research leading either to new, less-costly treatments or to developments such as vaccines that reduce the number of patients needing treatment. The second category comprises studies that consider the value to the economy of a healthy workforce. According to this "human capital" approach, indirect cost savings arise when better health leads to the avoidance of lost production. The third category includes studies that examine gains to the economy in terms of product development, consequent employment and sales. The studies placed in the fourth category measure the intrinsic value to society of the health gain, by placing a monetary value on a life. The review did not identify any consistency of methodology, but the fourth approach has most promise as a measure of social value. Many of the studies reviewed come from industrialized nations and a proposal is made by the present reviewers for an international initiative, covering developed and developing countries, to undertake further methodological analysis and testing.

Since the following days of independences, the Senegalese army mission has mainly consisted in defending the national territory integrity and in ensuring the protection of the populations and their goods. In the public health system, thanks to the quality of its human resources the army intervenes specifically at every level of the health care structure. The mission assigned to the Senegalese army health unit is therefore multidimensional. In 2001, the operational budget of the army health services is estimated at 177 millions CFA F (265500 euros), its medical consumption at 212 millions CFA F (323 000 Euros) and its health expenditure at 385 millions CFA F (585 000 euros). The army supports the government health policies in different ways: on the one hand, availability of the ministry of health staff, on the other hand, the direct involvement in health care and the implementation of the national and international health programmes.

Objective: This study sought to describe the New Hampshire incentive financing policy and report on its results over the first seven years., Methods: The description of the policy was based on reviewing state documents and interviews with state officials. The data were obtained from state records., Results: On the targeted outcomes of employment and psychiatric hospitalization the statewide improvement was dramatic. The service system concurrently became more efficient., Conclusion: The results suggest the incentive financing based on client outcomes may be a potent state strategy for improving service system performance.

Protecting the public's health historically has been a state and local responsibility. However, the growing threat of bioterrorism has highlighted the importance of a strong public health infrastructure to the nation's homeland security and has focused increased attention on the preparedness of the public health system. As a result, federal public health funding has increased exponentially since the anthrax attacks of late 2001, and Congress has passed sweeping new federal legislation intended to strengthen the nation's public health system. This heightened level of federal interest and support should yield important public health benefits. Most recognize that after years of neglect the public health infrastructure cannot be rebuilt overnight. As we implement a comprehensive strategy to increase the capabilities and capacity of our nation's public health system, it is essential to address a series of important policy questions, including the appropriate level of ongoing public health investments from local, state, and federal sources.

Thirteen years after the Unified National Health System was implemented in Brazil, the Federal government increased the use of norms and regulations aimed at rationalizing resources and prioritizing basic care within the system. In other words, although actions and services are the responsibility of Municipal governments, the Federal government used financing to reinforce its role in determining the policy to be adopted. The first part of this article analyzes trends in health care expenditures and financing in the country and priorities and strategies for financing. The second part relates the 1996 Basic Operational Norm to the Federal government policy of transferring resources to the Municipalities, discussing the importance of the Family Health Program as part of the financing logic and the role of the Health Care Operational Norm in reinforcing rationalization and emphasizing basic care.

Developments in health are easily among the best known human development indicators. Comparisons of life expectancy, infant mortality, access to safe water and similar data indicate the positions of individual countries. The political and economic processes which these indices reflect, or which inform the nature of health policy, are often not as clear or visible. These structural factors are either frequently ignored or mentioned only in passing, as illustrated in a recent paper published in this journal on the private medical enterprise in Nigeria (Ogunbekun et al. 1999). According to the authors, the generally low quality of public health services and high user fees have combined to make private medicine the 'unavoidable choice' of Nigerians. They identify benefits of private medicine as higher technical efficiency and contributing to fill the gap created by inadequate public sector services and to medical training. This paper argues that these claims are exaggerated, and that the authors seem to ignore Nigeria's political and economic processes, the health seeking behaviour of Nigerians, as well as the prevailing causes of morbidity and mortality. It is suggested that whereas the contributions of private medicine are significant, there are also several limitations, some of which originate from its for-profit raison d'être. The ultimate aim of health development must include improved access to services and better health status for the majority of the people. Without any form of public supported programme of payments in Nigeria, these objectives are circumscribed, especially with high fees in the private system. It is concluded that while private medicine will continue to be available for those who can afford it, it is unlikely to provide solutions to Nigeria's morbidity and mortality problems, particularly in relation to epidemics such as the growing burden of HIV/AIDS.

In the late 1980s, many developing countries were forced to adopt structural adjustment policies as a condition for securing loans from the International Monetary Fund (IMF) and the World Bank. One of the World Bank's recommended policies was to change the mix of private and public health facilities. This study, based on fieldwork done in Tanzania in 1993, examines the impact of this policy on health-care accessibility in two northern Tanzanian districts, one rural and one urban. Accessibility was measured in terms of equality and equity of coverage. The placement of the very few government clinics opened during the years 1985-1993 did much more to improve coverage than the haphazard location of many new private clinics. Equity was not improved as very few clinics were placed in demographically needy areas.

This article considers three examples of the use of quantitative policy analysis in setting public health policy: (1) benefit:cost and cost-effectiveness studies of influenza immunization and their role in achieving Medicare reimbursement for influenza immunization; (2) the 1993 World Bank World Development Report, which compared the burden of various health problems in different regions of the world and the cost-effectiveness of interventions for these problems, recommending a core set of public health and primary care services as being the most cost-effective; and (3) the role of the Agency for Health Care Policy and Research and how it might change if health care reform legislation such as President Clinton's original proposal were to be enacted. Finally, I describe the use of quantitative policy analysis to guide policy in one government agency--the Centers for Disease control and Prevention (CDC).

A Canadian plan for pandemic influenza was completed by the National Advisory Committee on Immunization in 1988. Its development took several years and involved consultation with provincial public health and laboratory authorities, the licensing body, manufacturers of influenza vaccine and antiviral agents, and representatives in the USA and UK. Key decisions in creating the pandemic plan include: (1) aiming for federal-provincial consensus on use of vaccine and antiviral drugs, (2) a selective vaccination approach (high-risk persons plus essential workers), (3) bulk purchasing and distribution of vaccine through the public sector, (4) leaving antiviral drugs on the open market, (5) careful planning of the communications strategy, and (6) increasing inter-pandemic use of flu vaccine in target groups. The plan addresses recognition of a pandemic; activation of a Pandemic Influenza Committee whose membership and responsibilities are spelled out; the federal-provincial decision making process; influenza vaccine considerations; amantadine and other antiviral agents; estimates of target group size, vaccine uptake, manufacturing capabilities and time frames; and communication considerations. Since 1988, influenza vaccine use has increased considerably in Canada and experience has been gained with amantadine. Manufacturing capability within Canada for influenza vaccine has also been enhanced. It is now time to update the plan, especially the targets, and to make sure that everyone involved remains aware of the assigned roles.

The Kenyan Government has recently introduced a new strategy for health financing. The roles of the World Bank and US-AID in developing this strategy are reviewed in this article. Particular attention is paid to the fact that the government--under heavy pressure from the World Bank-partly had to accept a strategy generating less revenue and greater inequities than alternative strategies considered. At the same time the policy options assessed illustrate how the Kenyan Government managed to avoid public health services being transformed into semi private services primarily for middle and high income groups.