Universal health coverage and equal access in Sweden: a century-long perspective on macro-level policy.

BACKGROUND: When today's efforts to achieve universal health coverage are mainly directed towards low-income settings, it is perhaps easy to forget that countries considered to have universal, comprehensive and high-performing health systems have also undergone this journey. In this article, the aim is to provide a century-long perspective to illustrate Sweden's long and ongoing journey towards universal health coverage and equal access to healthcare. METHODS: The focus is on macro-level policy. A document analysis is divided into three broad eras (1919-1955; 1955-1989; 1989-) and synthesises seven points in time when policies relevant to overarching goals and regulation of universal health coverage and equal access were proposed and/or implemented. The development is analysed and concluded in relation to two egalitarian goals in the context of health: equality of access and equal treatment for equal need. RESULTS: Over the past century, macro-level policy evolved from the concept of creating access for the neediest and those reliant on wages for their survival to a mandatory insurance with equal right to healthcare for all. However, universal health coverage was not achieved until 1955, and individuals had to rely on their personal financial resources to cover the cost at the time of care utilization until the 1970s. It was not until 1983 that legislation explicitly stated that access to healthcare should be equal for the entire population (horizontal equity), while a vertical equity-principle was not added until 1997. Subsequently, ideas of free choice and privatization have gained significance. For instance, they aim to increase service access, addressing the Swedish health system's Achilles' heel in this regard. However, the principle of equal access for all is now being challenged by the emergence of private health insurance, which offers quicker access to services. It can be concluded that there is no perpetual Swedish healthcare model and various dimensions of access have been the focus of policy discussion. The discussion on access barriers has shifted from financial to personal and organizational ones. Today, Sweden still ranks high in terms of affordability and equity in international comparisons: although not as well as a decade ago. Whether this marks the beginning of a new trend intertwined with a decline in Sweden's welfare 'exceptionalism', or is a temporary decline remains to be assessed in the future.

The Need for Historical Fluency in Pandemic Law and Policy.

The primary claim of this essay is that historical fluency is required for effective work in crafting legal and policy interventions as a part of public health emergency preparedness and response (PHEPR). At a broad level, public health law is explicitly recognized as a key systems-level component of PHEPR practice.1 This essay therefore focuses on the extent to which historical fluency is necessary or at least useful to all aspects of PHEPR that draw on or deploy legal and policy mechanisms (e.g., design, planning, implementation, dissemination, monitoring and evaluation, etc.). The essay collectively refers to these legal and policy mechanisms as epidemic law and policy response (ELAPR). Part I explains the concept of historical fluency. Part II explores the foundations of public health law both as a way of highlighting key structural features of ELAPR and in supporting the claim that historical fluency is critical for ELAPR. Part III applies the previous arguments to a specific case study to highlight the promise and power of historical fluency - the outbreak of bubonic plague in San Francisco in 1900. Tracking this essay's pragmatic focus, part IV offers several recommendations for how specifically historical fluency in public health law and ethics can be operationalized in PHEPR practice and policy. Part V summarizes and concludes.

Whose experts? How federalism shaped psychiatry in the late Habsburg monarchy.

The late Habsburg period (1867-1918) created a constitutional dual monarchy of Austria-Hungary. This paper discusses the role of psychiatry in Cisleithania, both as a developing profession and as a distinct 'policy field'. Tension between psychiatry's academic professionalisation and the creation of public institutions as signature projects by individual crownlands created complex relationships between psychiatry and politics. In federalist Cisleithania, psychiatrists became very 'political': whether employed by the state or a crownland influenced their position on policy, despite claiming that their expert knowledge was 'scientific' and 'objective'. The conflicts between asylum-based and academic psychiatrists mirrored those between the central state and the crownlands. This led to intractable delays in mental health law reform, eventually resolved by Imperial decree in 1916.

Historical Origins of the Personal Belief Exemption to Vaccination Mandates: The View from California.

A number of states, starting with California, have recently removed all non-medical exemptions from their laws requiring vaccinations for schoolchildren. California was also one of the earliest states to include a broad non-medical, or personal, belief exemption in its modern immunization law, which it did with a 1961 law mandating polio vaccination for school enrollment, Assembly Bill 1940 (AB 1940). This paper examines the history of AB 1940's exemption clause as a case study for shedding light on the little-examined history of the personal belief exemption to vaccination in the United States. This history shows that secular belief exemptions date back further than scholars have allowed. It demonstrates that such exemptions resulted from political negotiation critical to ensuring compulsory vaccination's political success. It challenges a historiography in which antivaccination groups and their allies led late-nineteenth and early-twentieth century opposition to vaccination mandates while religious groups drove mid-twentieth century opposition. It also complicates the historiographic idea of a return to compulsion in the late 1960s, instead dating this return a decade earlier, to a time when belief exemptions in polio vaccination mandates helped reconcile the goal of a widely vaccinated population with the sacrosanct idea of health as a personal responsibility.

COVID-19 and the reenactment of mass masking in South Korea.

How can we explain the divergence of social commitment to mass masking as public health measures in the global response to COVID-19? Rather than searching for deep-rooted cultural norms, this essay views the contemporary practice as a reenactment of multiple layers of accumulated socio-material conditions. This perspective will allow us to pursue a comparative study of the social history of mask-wearing around the world.

The history of mental health policy in Turkey: tradition, transition and transformation.

This article offers a brief history and the evolution of mental health policy in Turkey. It aims to analyse how mental health policies were transformed and why certain policies were introduced at specific times. The modern history of mental health policy is divided into three periods: the institutionalization of psychiatry and hospital-based mental health services; the introduction of community-based mental healthcare services; and lastly, the policy of deinstitutionalization after the 1980s. These periods have been categorized in a way that basically coincides with Turkey's modern political history.

The History of Saskatchewan's Public Health Association Policy Initiatives, 1954-86: A Regional Comparison for Preventative Health Policy Work in Canada.

After the Second World War, health prevention work in Canada shifted from a focus on sanitation and hygiene to illness prevention and health promotion. Canada became a significant global leader, beginning with the Lalonde Report of 1974. Yet less is known about the provincial public health associations and how their work differed from that of the national body. The purpose of this article is to examine the Saskatchewan Public Health Association's (SPHA) policy work from 1954 to 1986. Utilizing meeting minutes and newsletters, we found that while both national and provincial associations made efforts to prevent accidents, reduce tobacco use, and fluoridate water, the SPHA tended to advocate more for child health, and the cautious use of nuclear power. At the same time, the SPHA's resolutions tended to ignore emerging factors shaping health, including the social determinants of health, regional inequities, lack of public trust in experts, misinformation, and human psychology. Examining the SPHA's records revealed that region mattered in preventative policy work.

Oral rehydration therapies in Senegal, Mali, and Sierra Leone: a spatial analysis of changes over time and implications for policy.

BACKGROUND: Oral rehydration solution (ORS) is a simple intervention that can prevent childhood deaths from severe diarrhea and dehydration. In a previous study, we mapped the use of ORS treatment subnationally and found that ORS coverage increased over time, while the use of home-made alternatives or recommended home fluids (RHF) decreased, in many countries. These patterns were particularly striking within Senegal, Mali, and Sierra Leone. It was unclear, however, whether ORS replaced RHF in these locations or if children were left untreated, and if these patterns were associated with health policy changes. METHODS: We used a Bayesian geostatistical model and data from household surveys to map the percentage of children with diarrhea that received (1) any ORS, (2) only RHF, or (3) no oral rehydration treatment between 2000 and 2018. This approach allowed examination of whether RHF was replaced with ORS before and after interventions, policies, and external events that may have impacted healthcare access. RESULTS: We found that RHF was replaced with ORS in most Sierra Leone districts, except those most impacted by the Ebola outbreak. In addition, RHF was replaced in northern but not in southern Mali, and RHF was not replaced anywhere in Senegal. In Senegal, there was no statistical evidence that a national policy promoting ORS use was associated with increases in coverage. In Sierra Leone, ORS coverage increased following a national policy change that abolished health costs for children. CONCLUSIONS: Children in parts of Mali and Senegal have been left behind during ORS scale-up. Improved messaging on effective diarrhea treatment and/or increased ORS access such as through reducing treatment costs may be needed to prevent child deaths in these areas.

Beautiful Harmony of the Japanese Precious Healthcare Legacies for the New Imperial Era.

The new Imperial era, Reiwa, started in May, 2019. After World War II, Reiwa is the third Imperial era following Showa and Heisei. In each era, we had specific healthcare problems in cardiovascular medicine and implemented preventive strategies against them. Furthermore, nationwide healthcare policies such as a universal healthcare insurance system (kaihoken) and health check-up system largely contribute to overcoming these problems. Here, we summarize the specific issues in cardiovascular medicine and nationwide strategies policies against them in each era. We also describe what we should do in the new Imperial era from the cardiovascular viewpoint.

A historical perspective of how public policy shaped dialysis care delivery in the United States.

Broadly defined public policy has been said to be whatever "governments choose to do or not to do" As applied to healthcare, public policy can be traced back to the 4000-year-old Code of Hammurabi. As it applies to dialysis care its history is barely 50 years old since national coverage for end-stage renal disease (ESRD) was legislated as Public Law 92-603 in 1972. As with most healthcare policy changes, it was a result of medical progress which had changed renal function replacement by dialysis from its rudimentary beginnings during the Second World War into an experimental acute life-saving procedure in the 1950s and to an established life-sustaining treatment for the otherwise fatal disease of uremia in the 1960s that was limited by its costs. Since 1973, the Medicare ESRD Program has saved the lives of thousands of individuals, a compassionate achievement that has come at increasing costs which have exceeded all estimates and evaded containment. Apart from cost containment, policy changes in dialysis care have been directed at improving its safety and adequacy. Some of the results of these changes are evident as one compares the outcomes and complications of dialysis encountered in the 1970s to those in the present; others, particularly those related to vascular access and hospitalization rates have improved modestly. This article recounts the historical background in which national coverage for dialysis care was developed, legislated and has evolved over the past 50 years.

Health policy impacts on malaria transmission in Costa Rica.

Costa Rica is near malaria elimination. This achievement has followed shifts in malaria health policy. Here, we evaluate the impacts that different health policies have had on malaria transmission in Costa Rica from 1913 to 2018. We identified regime shifts and used regression models to measure the impact of different health policies on malaria transmission in Costa Rica using annual case records. We found that vector control and prophylactic treatments were associated with a 50% malaria case reduction in 1929-1931 compared with 1913-1928. DDT introduction in 1946 was associated with an increase in annual malaria case reduction from 7.6% (1942-1946) to 26.4% (1947-1952). The 2006 introduction of 7-day supervised chloroquine and primaquine treatments was the most effective health policy between 1957 and 2018, reducing annual malaria cases by 98% (2009-2018) when compared with 1957-1968. We also found that effective malaria reduction policies have been sensitive to natural catastrophes and extreme climatic events, both of which have increased malaria transmission in Costa Rica. Currently, outbreaks follow malaria importation into vulnerable areas of Costa Rica. This highlights the need to timely diagnose and treat malaria, while improving living standards, in the affected areas.

Botswana's HIV response: Policies, context, and future directions.

This brief report describes key periods in the history of the national public health response to the human immunodeficiency virus (HIV) epidemic in Botswana. It reveals the context leading to the development of HIV policies presently in place and current challenges that remain. The report concludes with opportunities for future directions, initiatives, and policy changes to reduce the high rates of HIV.

Beyond the asylum and before the 'care in the community' model: exploring an overlooked early NHS mental health facility.

This article discusses the Admission and Treatment Unit at Fair Mile Hospital, in Cholsey, near Wallingford, Berkshire (now Oxfordshire). This was the first new hospital to be completed in England following the launch of the National Health Service. The building was designed by Powell and Moya, one of the most important post-war English architectural practices, and was completed in 1956, but demolished in 2003. The article relates the commission of the building to landmark policy changes and argues for its historic significance in the context of the NHS and of the evolution of mental health care models and policies. It also argues for the need for further study of those early NHS facilities in view of current developments in mental health provision.

Incertitude diagnostique et action politique : une association de parents face aux politiques de l'autisme, 1982-2017.

The definition of diagnostic categories, such as autism, is not always consensual. It can be the cause of political struggles between various actors, including professionals, public administrations or patient associations. However, little is known about the situation of patient or parent associations in these "diagnostic politics." We assert here that these associations are more sensitive to the politics of definition than is suggested by the current historiography. Through an analysis of discourses and strategies of the Quebec Autism Society from 1982 to 2017, we document the role that this association intended to play in the politics of autism and we show how the adoption by the state of diagnostic-based policies intensify definitional debates in civil society, including among parents.

La définition de catégories diagnostiques comme l'autisme ne fait pas toujours l'unanimité. Elle peut faire l'objet de luttes politiques entre divers acteurs, notamment les professionnel.le.s, les administrations publiques ou les associations de patients. On en sait toutefois peu sur la situation des associations de patients ou de parents dans ces « politiques du diagnostic ¼. Nous affirmons ici que ces associations sont plus sensibles aux politiques de la définition que l'historiographie actuelle ne le laisse paraître. En analysant le discours et les stratégies de la Société québécoise de l'autisme de 1982 à 2017, nous illustrons le rôle que cette association entendait jouer dans les politiques de l'autisme et nous démontrons que l'adoption par l'État de politiques axées sur le diagnostic a eu pour effet d'intensifier les débats définitionnels chez divers acteurs, y compris les parents.

Building Community and Transforming Knowledge: Histories of Women's Health Practitioners and Community-Based Health Services in 20th-Century Alberta, Canada.

As new government health policy was created and implemented in the late 1910s and the late 1960s, women patients and health practitioners recognized gaps in the new health services and worked together to create better programs. This article brings the histories of the district nursing program (1919-43) and local birth control centres (1970-79) together to recognize women's health provision (as trained nurses or lay practitioners) as community-based and collaborative endeavours in the province of Alberta. The district nursing and birth control centre programs operated under different health policies, were influenced by different feminisms, and were situated in different Indigenous-settler relations. But the two programs, occurring half a century apart, provided space for health workers and their patients to implement change at a community level. Health practitioners in the early and late twentieth century took women's experiential knowledge seriously, and, therefore, these communities formed a new field of women's health expertise.