Study tour examines health care systems in Germany, Holland--Part II: The German system

In October 1992, the American College of Physician Executives sponsored a study tour to Berlin, Germany, and Amsterdam, Holland. Meetings were held with government officials, third-party payers, and providers, and on-site visits were made at hospitals, clinics, and academic centers. The purpose was to study the health care delivery system in those countries and to share some insights with the countries' hosts on the U.S. system. In a series of reports that began in the July issue of the journal, 5 of the 10 study tour participants describe their impressions of the tour and of the health care systems in the countries that were visited. In the first report, the health care delivery systems of the United States, Germany, and Holland were compared. In this report, the German system is analyzed in greater detail.     

What will future historians say about the Clinton health reform act

In a series of articles that began in the March-April 1992 issue of Physician Executive, the author has provided historical background on the debate that currently rages on the nature and course of national health reform. In addition to tracing past efforts to expand access to health care for Americans, Dr. Goldfield has provided unique insights into the American political process and into the American psyche. In this final article in the series, Dr. Goldfield provides his personal assessment of what the chances for real reform of the health care delivery system are and his views on what that reform will ultimately look like. He calls himself a skeptic, not a cynic, saying that the likelihood of meaningful change is small, given the numerous proponents of the status quo.     

Poland's crisis and East European socialism

Conclusion We began this article by asking whether the Polish crisis is a socialist or a Polish disease. By citing the structural factors, we brought out the common difficulties affecting all East European societies in their political and economic development. These difficulties arose out of the transition from extensive to intensive economic growth and the consequent need to replace political mobilization of the population with their political integration. The structural contradictions occurred together with conjunctural developments in the world economy, the collapse of detente, the post-war demographic explosion, and natural calamities. Poland was least able to cope with these structural and conjunctural dynamics. The result was a society united on a national basis in its conflicts with the Party State apparatus. This conflict was never resolved by Solidarity nor by the subsequent military coup.While Poland and Romania had quite similar structural and conjunctural dynamics, it was only in Poland that the constellation of nation-specific factors yielded a societal reaction of system-threatening character. Looking at the rest of Eastern Europe, we do not see a similar constellation of factors. Rather, the combination of structural, conjunctural, and specific conditions has prevented the deeper contradictions from evolving into Solidarity-type mass movements of the Polish variety. Thus, we believe that the Polish developments will not be replicated in any of the other East European countries in the foreseeable future.Does this mean that the Polish experience is so unique that it is without relevance for the other East European states? On the contrary, the recognition of common structural problems points to fundamental conflicts in all the countries of actually existing socialism. The essence of these conflicts may be the same. It is the ability to identify and deal with them that distinguishes one East European regime from another. This ability varies with the specific and conjunctural factors as applied to each country. While there is little likelihood that the Polish disease will spread, this is partly because the other East European states are beginning to take preventive measures. In other words, they are learning from the Polish experience.There are several indicators that these regimes have learned from the Polish crisis. We can summarize them in the following predictions:First, we believe that state power and the repressive apparatus of the various East European countries will be reinforced and made more effective. This applies not so much to overt shows of force but to more sophisticated methods of social control and repression: e.g., limiting information channels, dispersing dissident groups, giving in to workers protests before they spread, taking practical measures to prevent consumer shortages from getting out of hand, and the like.Second, we can expect that oppositional forces, especially intellectuals, will be increasingly restricted in their ability to formulate and articulate system-threatening demands. The East European states will take any measures - jail, slander, internal deportation, cooptation, forced emigration - to make sure that intellectuals' contact with workers is weakened or at least strictly supervised.Third, we can expect the Eastern European states to take further measures to integrate potential system-threatening movements into the official system. We will see further attempts to improve the access possibilities for those social interests that have up to now been neglected, e.g. in physical and social infrastructures, neglected regions. Moreover, there will be renewed efforts to make the system of political socialization (education, propaganda, culture) more effective. Finally, we can expect anti-corruption campaigns within the State, Party, and industrial bureaucracies as the elites attempt to make these organs more legitimate in the eyes of the population.In recent months there seems to be considerable evidence that the East European regimes have taken all these measures. There have been attempts to re-invigorate the official trade unions. Yuri Andropov's succession was marked by a highly publicized anti-corruption campaign designed to win favor among rank-and-file workers. In Romania there have been exhortations towards more self-sufficiency and self-management, so that individual producers will be less dependent on State retail outlets, and the country less dependent on costly foreign imports. The reduction in East-West trade and decline of detente have also given more leeway for the East European repressive apparatus to crack down on dissidents and oppositional movements.With reduced trade, the economic benefits of detente no longer exist as a restraining factor on the authorities. The West now has reduced influence on domestic politics in East Europe. The combination of integration and repressive measures has so far prevented the structural contradictions from growing into true political crises of the Polish variety. Eastern Europe (and Poland) is remarkably quiet.With the broad enthusiasm fostered in the West by the rise of Solidarity, it is understandable that its brutal demise had generated parallel feelings of disillusionment. It would be erroneous to consider the Polish events as an archetype for Eastern Europe. The problems of East European regimes reflect a general system crisis (economic and political), each country's response depends on specific local conditions and fortuitous conjunctures. If the Polish events are to be understood, they must be explained as a variant in a larger East European context.Having concentrated on the crisis aspects in Poland and Romania should not blind us from the fact that these systems have an amazing ability to reproduce themselves - to muddle through. Actually existing socialism is more than simply brute force. Each of the East European societies exhibits a complex dialectic between the forces of functional stability and the forces of immanent contradictions. As such, in addition to their structural aspects, we must analyze each of these societies in their differing vulnerability to conjunctural events and in their specific political, social, and cultural characters.For those who seek to replace actually existing socialism with a more emancipatory socialism, the Polish crisis constitutes a key point of departure. It should be discussed both in terms of what it means for Poland, and for Eastern Europe. The Polish events provide further evidence that the tasks of social theory reside as much in explaining why societies muddle through as why they fall apart.     

Trends in marriage and divorce in Peninsular Malaysia

Summary Median age at marriage for women has risen sharply for each of the three major ethnic groups - Malays, Chinese and Indians, in Peninsular Malaysia since 1957. The sharpest rise has been recorded for Malays and Indians, whose median age at marriage was barely over 17 in 1957. A shortage of potential husbands in the traditionally sanctioned ages contributed to the rise for Malays and Indians, but was probably not the paramount reason; average age differences between the spouses narrowed, but median age at marriage for men actually rose. During the same period, the previously extremely high divorce rates amongst Malays have fallen sharply, though wide inter-state differences remain. The sharp changes in marriage patterns reflect, and in turn are partly responsible for, far-reaching social and economic changes. They have profoundly affected fertility levels and patterns, as well as intra-familial relationships.     

The certainty of judgments in health evaluations

Most evaluators seem to presume that all evaluative studies should result in conclusive evidence. Often, however, less than conclusive evidence may not only suffice, but be the only real alternative under conditions of limited evaluation resources. Three levels of evidence common to evaluation studies are discussed: suggestive evidence, preponderant evidence, and conclusive evidence. Ten factors are also presented which can be used to determine the level of certainty appropriate for a given evaluation study. Consideration of these factors enables the evaluator to specify when less than conclusive evidence is acceptable.