Twelve questions to ask about your outcomes monitoring system--Part I

Outcomes monitoring is an integral part of any decision maker's information resources--the cornerstone of a provider's commitment to quality improvement or of a purchaser's strategy for seeking value. In their eagerness to obtain useful information about provider performance, purchasers and consumers naively may accept flawed evaluations and thereby create perverse incentives for providers that undermine the very qualities they wish to foster. Inaccurate or misleading information about provider performance will lead managers to reward the wrong behavior and so induce more of it. Inaccurate information also can discourage better providers whose performances are not recognized and can lead all providers to distrust and denounce clinical monitoring in general. When these things happen, the great value of outcomes monitoring systems as a tool for quality improvement is lost.     

The ethics of health care system reform

The United States is now engaged in a momentous national debate about health care. How can we provide the best care possible while simultaneously containing cost (to promote the general economic integrity of society) and somehow maintain a semblance of a free health care marketplace. This is not just a political question; it is also a question of ethics. It is an ethical consideration because the current debate is not just about designing or promoting health care systems that can best address our concerns for costs, quality, and accessibility. It appears that at least some participants in the debate would not stop at arguing their beliefs as valid; they would make their beliefs law. Some urge the creation of the right to health care as a matter of law. There are significant differences between beliefs and rights, however, and they need to be considered carefully in the ongoing debate over the future of this country's health care delivery and financing system.     

Meeting the change challenge: managing growth in the nonprofit and public human services sectors

The current economic climate has been particularly hard on non-profit and public human services organizations, frequently resulting in managing organizational decline. The authors believe that the dominant concern should be with fostering organizational growth. To this end, they suggest that nonprofit board members and executives, as well as public sector leaders, need to concern themselves with the concurrent management of two agendas: Running the Shop and Meeting the Change Challenge. This can be done effectively through the use of strategic issue management, which is a set of techniques that represents a blend of traditional strategic management and change management approaches.     

Pluralism and ethnic conflict in Tanzania's arid lands: the case of the Maasai and the WaArusha

In Tanzania, the Maasai and Waarusha tribes are experiencing conflict because differences in their modes of productions and economic strategies undermine the peaceful coexistence that they have enjoyed since the 18th century. The Maasai are pastoralists, while the Waarusha are agricultural subsistence farmers who are encroaching on the best pasture lands. A sketch of the history of the two groups shows that the Maasai reached the peak of their land holding in 1880 before the arrival of European colonists who seized land and restricted the Maasai to a semi-arid reserve but allowed the Maasai to remain an autonomous and powerful group. The Waarusha began encroaching on Maasai land after independence due to land and population pressure. While closely tied, each group looks down on the other, and Maasai ascendancy has given way to Waarusha challenges. After independence, the tribal and ethnic rule that was protected by the colonial system was disrupted to allow for increased internal migration and new patterns of settlement. The rights of land ownership were transferred from tribes to the State, allowing privileged groups to benefit. The Waarusha began to engage in illegal land-grabbing and to encroach on the Maasai preserve using legal and illegal means. The Maasai view land as collective property and have had difficulty retaining title of traditional lands in the face of population pressure. This loss of grazing land has forced the Maasai into a mixed economy that depends upon agricultural production as well as livestock production. In the meantime, the Waarusha have deliberately sought political office to gain power to secure their holdings. Immediate action is needed to produce 1) a policy on spontaneous settlement, 2) an immediate adjustment of legal procedures for land acquisition, 3) a land tenure policy that equally emphasizes agricultural and livestock production, and 4) controls on undue expansion of subsistence agriculture into semi-arid rangelands.     

The new health care civilization: integration of physician land and manageria

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.     

IOM/UNFPA project on emigration dynamics in developing countries

The author briefly reviews a special section of papers in this issue of International Migration. The papers focus on aspects of a project on emigration dynamics in developing countries.     

Freud's “Anna O.”: Social work's Bertha Pappenheim

The story of Anna O. has loomed large in psychoanalytic history, but few social workers know that the young woman, who was so influential in the development of Freud's thinking, became a pioneer social worker in Germany. The story of the transformation of the troubled young woman, who was actually Joseph Breuer's patient, is the focus of this paper. In addition, some of the facts of the case are discussed as social constructions. Anna O./ Bertha Pappenheim participated in the creation of the talking cure and eventually went on to be a leading feminist, developer of social programs for women, and social reformer.