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Managed health care has recently generated a great deal of distrust, even anger, in the public mind. To be sure, much of this public reaction is based on anecdotal evidence and one-dimensional thinking. But many unbiased experts observing managed care today are themselves unhappy with the health care industry's performance. While these observers find little justification for the current political backlash against managed care, they are also disappointed that today's health plans have not made a more positive difference. Indeed, informed observers commonly regret that the new arrangements for the financing and delivery of care have done so little to get physicians to adopt truly efficient practices, achieving not only cost reductions but also substantial improvements in health status and patient outcomes— that is, in the quality of care. Although managed care has not demonstrably harmed the overall quality of health care in the United States, it has done little to improve it.
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All the 32 member states in the World Health Organization European Region adopted a common health policy in 1980), followed by unanimous agreement on 38 regional targets in 1984. The first of these targets is concerned with equity. Target 1: “By the year 2000, the actual differences in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level of health of disadvantaged nations and groups” (WHO, 1985a). In addition, equity is an underlying concept in many of the other targets. At present, the targets are being reassessed and revised, in particular moving away from a focus on physical health status as measured by mortality to encompass, wherever possible, many other dimensions of health and well-being. But still the underlying concept of equity in health has been judged to be just as important for the 1990s as it was when the programme began (WHO, 1985b). However, it has not always been clear what is meant by equity and health and this paper sets out to clarify the concepts and principles. This is not meant to be a technical document, but one aimed at raising awareness and stimulating debate in a wide general audience, including all those whose policies have an influence on health, both within and outside the health sector.
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The investigation of socio-economic differences in mortality in Russia was effectively prohibited in the Soviet period. The extent and nature of any such differences is of considerable interest given the very different principles upon which Russian society has been organised for most of this century compared to the West where socio-economic differences in health have been extensively documented. Using cross-sectional data on mortality in Russia around the 1979 and 1989 Censuses, we have analysed mortality gradients according to length of education. Our results show that educational differences in mortality are at least as big as seen in Western countries, and are most similar to the recently reported differences observed for other former communist countries such as the Czech Republic, Estonia and Hungary. As observed in many other countries the strength of association of mortality with education declines with age, varies by cause of death and is generally stronger among men than women. Differentials are particularly large for accidents and violence, where for men and women the mortality rate among those with primary or basic secondary education is over twice that of people with higher education. Even larger effects are seen for causes directly related to alcohol (including alcoholic cirrhosis and accidental poisoning by alcohol), and for infectious and parasitic diseases and respiratory diseases. These educational differences may in part be related to educational differences in alcohol consumption. Of particular significance is the fact that there are indications that socio-economic differences in mortality have widened considerably in the 1990s, a period during which there was a huge increase in the national burden of alcohol-related deaths. This widening of socio-economic differences at this time suggest that these increases in consumption were especially acute among those with less education. At a more general level the fact that large educational differences in mortality were seen in Russia in 1979 and 1989, prior to the collapse of the Soviet Union, is very striking and informative. In this period there was a far weaker association between income and education than is seen in the West, suggesting that the education effects are unlikely to be driven by underlying differences in financial resources. The protective effect of education, in the Russian context at least, has been driven by more subtle and mechanisms. The apparent widening of socio-economic mortality differences since the collapse of the Soviet Union suggests that the transformation underway in Russian society requires a strengthening of the public health function.
Development as Freedom
  • A Sen
Commentary presented at the meeting Globalization and Human Development
  • P Streeten