Nonprofit and for-profit home care in Israel: clients' assessments

Clients' assessments of differences between nonprofit and for-profit organizations delivering home care services to Israel's frail elderly were studied. No significant differences were found between nonprofit and for-profit providers with respect to organizational efficiency; speed of placement and replacement of home care workers; responsiveness to clients' complaints; and supervision of care plans, schedules, and service delivery. Systematic differences were found, however, in clients' perceptions of workers employed by nonprofit versus for-profit service providers. The differences related to the home care workers' adaptation to clients' needs and wants; how well workers delivered services; and how satisfied clients were with the services received. Indications are that the relatively high efficiency of nonprofit organizations can largely be attributed to the performance of their home care workers.     

Aged care service delivery in Japan: preparing for the long-term care insurance scheme

The implementation of Japan's Long-Term Care Insurance Scheme in early 2000 presaged many changes in service delivery and much debate among service providers, different levels of government, academic analysts, and major media interests. The first part of this paper gives an account of the major changes in the organization of service delivery that have increased opportunities for private sector providers, including large corporations, and restructured contractual relationships between municipalities and providers in all sectors. New arrangements for client assessment, classification, care management, and extended service types are then outlined. An assessment is then made of the likelihood that the expected outcomes of the scheme will be realized, with the concerns of welfare professionals that the public welfare system is under threat juxtaposed with bureaucratic goals of liberalizing the provision of long-term.     

Conditional Cash Incentive and Use of Health Care Services: New Evidence from a Household Experiment

Studies have recently provided insights into the effects of incentive modalities in the health care sector. However, there is insufficient evidence on the underlying causes of the partial effectiveness of these strategies in the health systems of developing countries. This study presents results from a large-scale randomized experiment across 6848 households in Afghanistan that evaluates the impact of a conditional incentive pay scheme on health facilities. Supported by the target-income hypothesis framework and relaxing the compliance assumption in the empirical modeling, the estimated coefficients yield causal effects of the supply-side conditional incentive on the utilization for health care services. After 2 years, the conditional incentive increased the use of pre-targeted maternal and children health care services among the households at lower levels and at contracted-out health facilities. Additionally, the incentive scheme is associated with sizable efficiency gains at the facility level. These gains are realized at the expense of deterring service users’ satisfaction with physicians’ communication qualities. This study establishes that margins of improvement do exist in the supply-side performance conditioning on an organizational structure and the service contractual arrangements of health facilities. This work provides a framework for the plausible implementation of incentive policies in the health care sector.

     

The Impact of Caregiver-Care Recipient Relationship Quality on Family Caregivers of Women With Substance-Use Disorders or Co-Occurring Substance and Mental Disorders

This cross-sectional study utilized a stress-process model to examine the impact of caregivers' (N = 82) perceptions of their relationship quality with a female family member (i.e., care-recipient) with substance-use or co-occurring substance and mental disorders on caregivers' perceived burden. Regression findings indicate that relationship quality impacts both subjective and objective burden. Higher levels of emotional support given to the care recipient by the caregiver predicted lower levels of caregiver displeasure; whereas higher levels of undermining of the care recipient by the caregiver predicted higher levels of caregiver stigma. Higher levels of emotional support received by the caregiver from the care recipient were associated with lower levels of caregiver displeasure and lower objective burden; higher levels of undermining of the caregiver by the care recipient predicted higher objective burden. Implications for practice and service delivery are presented.     

Women in the Workplace:

This study examined the influence of employee sponsored child care service on employee stress level and job satisfaction. The findings revealed that women who used company sponsored child care services manifested significantly lower levels of stress and higher levels of job satisfaction than women who were not utilizing this service. In addition, a higher level of satisfaction with child care arrangements was associated with women involved in company sponsored child care service compared to women who had to make their own child care arrangements.     

Child care burden and the risk of child maltreatment among low-income working families

Studies suggest that a substantial proportion of low-income working mothers experience work disruptions and parental stress related to child care, which may lead to increases in the risk of physical and psychological abuse and neglect of children. However, little research has examined the relationship between child care burden and the risk of child maltreatment among low-income working families. Using the Fragile Families and Child Wellbeing Study 3-year data, this study explores how child care burden is associated with the risk of child maltreatment (physical aggression, psychological aggression, and neglectful behavior) among low-income working mothers. We find that instability in child care arrangements is likely to increase mothers' physical and psychological aggression, while not having someone reliable for emergency child care is likely to increase mothers' neglectful behaviors. Findings also show that the risk of child maltreatment related to child care burden measures is more significant for single mothers than married mothers. Potential policy implications are discussed.     

Organization and delivery of long-term care in Taiwan

Taiwan reached the World Health Organization (WHO) benchmark of 7% aged 65 and over for defining an aging population only as recently as 1993. With this proportion projected to double to 14% by 2020, Taiwan faces a rapid increase in need for long-term care. This article presents an account of the current service delivery system, which is divided between health and social affairs administrations, with a substantial role also taken by the Veteran Administration, and growing provision of facilities that operate outside the government-registered system. While a basic level of both institutional and community care services has developed, they are not organized into an integrated service system. Problems arising from the divisions and overlaps in responsibility are identified in relation to competition for resources, differences in regulation and eligibility, funding arrangements and misallocation of resources, and divergent views about the philosophical basis of long-term care. Other aspects of services fall under each jurisdiction, but there is also some overlap. A case study of Taiwan's second largest city, Kaohsiung City, reports the outcomes of these divisions as a thin spread of a range of services rather than a coordinated service network. Several planning exercises have been undertaken in recent years to address these problems, and although at an early stage of implementation, the outcomes of these plans are seen as shaping the future directions of long-term care in Taiwan.     

LESS ACCESS,WORSE QUALITY

High-quality child care is a boon for children and buffers some of the long-term negative effects of growing up in straitened circumstances. Yet, just one in seven Canadian children has access to regulated care. Within this, poor children have worse access and are over-represented in lower-quality care arrangements. Canada's policy architecture, as reviews of Winnipeg, Quebec, and Vancouver demonstrate, generates inequities of access and quality that reproduce neighborhood socioeconomic gradients of class and racialization. Poor children are systematically disadvantaged by a national approach that relies on privatized partnerships with the voluntary sector to implement public child care policy. Equalizing poor children's access to quality child care remains a pressing Canadian challenge, and will require policy and delivery redesign.     

Aged Care Service Delivery in Japan

Summary

The implementation of Japan's Long-Term Care Insurance Scheme in early 2000 presaged many changes in service delivery and much debate among service providers, different levels of government, academic analysts, and major media interests. The first part of this paper gives an account of the major changes in the organization of service delivery that have increased opportunities for private sector providers, including large corporations, and restructured contractual relationships between municipalities and providers in all sectors. New arrangements for client assessment, classification, care management, and extended service types are then outlined. An assessment is then made of the likelihood that the expected outcomes of the scheme will be realized, with the concerns of welfare professionals that the public welfare system is under threat juxtaposed with bureaucratic goals of liberalizing the provision of long-term care.     

Organization and Delivery of Long-Term Care in Taiwan

Summary

Taiwan reached the World Health Organization (WHO) benchmark of7%aged 65and over for defining an aging population only as recently as 1993. With this proportion projected to double to 14% by 2020, Taiwan faces a rapid increase in need for long-term care. This article presents an account of the current service delivery system, which is divided between health and social affairs administrations, with a substantial role also taken by the Veteran Administration, and growing provision of facilities that operate outside the government-registered system. While a basic level of both institutional and community care services has developed, they are not organized into an integrated service system. Problems arising from the divisions and overlaps in responsibility are identified in relation to competition for resources, differences in regulation and eligibility, funding arrangements and misallocation of resources, and divergent views about the philosophical basis of long-term care. Other aspects of services fall under each jurisdiction, but there is also some overlap. A case study of Taiwan's second largest city, Kaohsiung City, reports the outcomes of these divisions as a thin spread of a range of services rather than a coordinated service network. Several planning exercises have been undertaken in recent years to address these problems, and although at an early stage of implementation, the outcomes of these plans are seen as shaping the future directions of long-term care in Taiwan.     

Israel’s Long-Term Care Social Insurance Scheme After a Quarter of a Century

Long-term care social insurance schemes exist in a number of countries, while the introduction of such schemes enjoys some support in others. Israel’s long-term care social insurance scheme has been operating since 1988. This article examines the emergence, goals, design, and impacts of this scheme and draws out some of the lessons that can be learned from Israel’s quarter century experience of long-term care social insurance.     

Changing health culture in rural Appalachia: Implications for serving the elderly

This article explores the dual themes of place and time as influences on health care service delivery to the rural elderly, through a case study of rural Appalachia. Traditional patterns of indigenous health care practice and values are contrasted with more “professional” formal models of health care service delivery that have entered the region. The result has been a clash of health care cultures. The continuing validity of this perspective is appraised in relation to apparent generational differences between the old-old and the young-old in the degree to which contemporary health care practices and values are adopted. It is concluded that traditional and contemporary health care cultures can be reconciled through an expanded vision of health care service delivery premised on: understanding health care within a total community context; redefining the role of the health practitioner; improving education of both the rural elderly and service providers; and enhancing communication in the rural health care environment.     

The effectiveness of health care cost management strategies: a review of the evidence

This Issue Brief discusses the evolution of the health care delivery and financing systems and its effects on health care cost management and describes the changes in the health care delivery system as they pertain to managed care. It presents empirical evidence on the effectiveness of managed care and concludes with an analysis of the potential of future health care reform to influence the evolution of the health care delivery system and affect health care costs. Between 1987 and 1993, total enrollment in health maintenance organizations (HMOs) increased from 28.6 million to 39.8 million, representing an additional 11.2 million individuals, or 4 percent of the U.S. population. At the same time, new forms of managed care organizations emerged. Enrollment in preferred provider organizations increased from 12.2 million individuals in 1987 to 58 million in 1992, and enrollment in point-of-service plans increased from virtually none in 1987 to 2.3 million individuals in 1992. In addition, the percentage of traditional fee-for-service plans with some form of utilization review increased to 95 percent in 1990 from 41 percent in 1987. Measuring the effects of the changing delivery system on the costs and quality of health care services has been a difficult task, resulting in considerable disagreement as to whether or not costs have been affected. In a recent report, the Congressional Budget Office recognizes two new major findings. First, managed care can provide cost-effective health care at a level of quality comparable with the care typically provided by a fee-for-service plan. Second, independent practice associations can be as effective as group- or staff-model HMOs under certain conditions. In the future, we are likely to see a continued movement of Americans into managed care arrangements, an increase in the number of physicians forming networks, a reduction in the number of insurers, an increase in the number of employers joining coalitions to purchase health care services for their employees, and a health care system that is generally more concentrated and vertically integrated.     

Exploring policy and financing options for long-term care in Taiwan

Policy and financing arrangements for long-term care are important themes in each country and/or region, and Taiwan, with its unique historic and politico-economic background, can be regarded as a bridge between well-developed and under-developed countries. Policy formulation about long-term care in Taiwan involves several agencies in the government, including Ministry of Health, Interior Affairs, Education, Insurance Bureau, and Economic Council, and formulation of policy objectives has progressed considerably in the last five years. Financing arrangements are less well-developed because the National Health Insurance Program began only in 1995, and most long-term care is not yet covered. As demand for long-term care exceeds supply, and this gap will grow in future, current resource allocation measures are concerned to facilitate the expansion of community care rather than allowing institutional care to absorb more resources. Developing future financing options is now a central task for policymaking, and government must continue to take a leading role in consolidating financial and integrating the service systems.     

A Critical Response to the Keys Young Report: Ending Domestic Violence? Programs for Perpetrators

This paper questions some of the continuing effects of the dominant theoretical construction of domestic violence in the light of the recent Keys Young report to National Crime Prevention. A re‐examination is made of patriarchy as the dominant theoretical underpinning and some of the consequences for service delivery and policy development are explored. Is it necessarily the case that we have now got our understanding and subsequent intervention strategies right and that all that is needed is a consolidation of the ideas and the tightening of funding arrangements?     

CHILD CARE USE BY LOW‐INCOME FAMILIES IN RURAL AREAS

Using data from interviews with 323 low‐income women living in rural counties in 11 states, child care arrangements for 672 children under 13 are described in relation to women's employment status, partner availability, and child age. As found in previous studies of rural areas, informal care is frequently used, regardless of full‐ or part‐time work or partner availability. Single mothers rely more on regulated care arrangements than mothers with partners and are more likely to pay for informal care than other mothers. Work in part‐time and service jobs suggests the need for flexible arrangements. Public data on child care availability and access in rural areas, the cost of care, and state subsidy programs suggest reasons for rural women's child care decisions. Policy implications of the study findings are shared.     

Physician Resistance to Innovations: The Case of Contract Medicine

Abstract

Physicians' assessments of contract medicine arrangements such as health maintenance organizations (HMOs) are considered in light of innovation diffusion theory and changing professional relations in medical care. Data from a national sample of physicians reveal that physicians practicing in HMOs differed from others in that they were more likely to be primary-care practitioners and politically liberal; they were also more likely to have thought that a physician surplus was emerging and that HMOs offered better working conditions. They did not differ from other physicians in job satisfaction. After considering differences between the two groups, the research examines how physicians, who did not practice in HMOs, viewed such contract medicine arrangements. Findings indicate that physicians in fee-for-service (FFS) practices felt that working conditions and service quality in HMOs are highly related and are better in FFS practices than in HMOs. In addition, physicians who anticipated heightened competition from HMO development were more likely to favorably evaluate HMO service delivery. The findings suggest accommodation to an organizational innovation if it is seen as preserving practice autonomy, but limited acceptance otherwise.     

Changing Needs and Changing Service Delivery for Long-Term Care in Hong Kong

Summary

Both the need for and delivery of long-term care in Hong Kong are shaped by the interaction of the traditional and modern. Rapid social change is affecting traditional family structures and roles in care of the elderly, resulting in increased demand for formal care, which to date has been provided mainly by way of residential care. This growth of demand will escalate with rapid population aging in coming decades. In response to this burgeoning demand, current planning is seeking to reshape the established service system and tackle problems in service delivery in ways that will address the bias towards residential care and improve quality of care.     

Exploring Policy and Financing Options for Long-Term Care in Taiwan

Summary

Policy and financing arrangements for long-term care are important themes in each country and/or region, and Taiwan, with its unique historic and politico-economic background, can be regarded as a bridge between well-developed and under-developed countries. Policy formulation about long-term care in Taiwan involves several agencies in the government, including Ministry of Health, Interior Affairs, Education, Insurance Bureau, and Economic Council, and formulation of policy objectives has progressed considerably in the last five years. Financing arrangements are less well-developed because the National Health Insurance Program began only in 1995, and most long-term care is not yet covered. As demand for long-term care exceeds supply, and this gap will grow in future, current resource allocation measures are concerned to facilitate the expansion of community care rather than allowing institutional care to absorb more resources. Developing future financing options is now a central task for policymaking, and government must continue to take a leading role in consolidating financing and integrating the service systems.     

Public‐Service Provision in Clientelist Political Settlements: Lessons from Ghana's Urban Water Sector

The politics of public‐service delivery continues to be neglected under the supposedly more context‐sensitive post‐Washington Consensus. Using interviews and documentary evidence from Ghana, this article provides an account of the networks of political interference and informal practices in Ghana's public water utility. It argues that, in order to understand why private‐sector participation succeeds or fails and why similar arrangements have different outcomes across developing countries, we need to examine the effects of the informal institutional context, particularly the country‐specific political settlement in which public‐service provision operates.