Women and tobacco in Indonesia.

OBJECTIVES: To present a broad exploration of the relationship of women and tobacco in Indonesia and to describe action on tobacco and health specific to women taken by government and non-government agencies. DATA SOURCES: Published and unpublished prevalence surveys, official documents, vernacular newspapers, secondary sources, unstructured interviews, and personal observations. STUDY SELECTION: Data on smoking prevalence among women was primarily sought from official household surveys but several smaller scale local surveys were also examined. The only representative national household data on smoking prevalence from 1995 suggested a national prevalence for occasional and regular smoking of 2.6% for women aged 20 years or older. Smaller, local level surveys had reported rates varying from 4% for junior high school girls, and 2.9% for women undergraduates at a provincial university, to 6.4% of women in a representative sample in Jakarta. Claims that the incidence of female smoking is increasing cannot be confirmed due to an absence of comparable national longitudinal data. CONCLUSION: Although Indonesian women are conspicuous in growing and processing tobacco, their rates of smoking are low in comparison with their male compatriots and internationally. Anecdotal evidence suggests that their disinclination to smoke is commonly attributed to cultural values, which stigmatise women smokers as morally flawed, while at the same time sanctioning smoking by men. Although there is little evidence of tobacco advertising directly targeting women, Indonesian health activists interviewed by the author felt that women are increasingly taking up smoking due to a weakening of stigma and to Western cultural influences. Cultural factors in the low rates of smoking among Indonesian women deserve closer investigation as they have proved to be a major source of health protection, albeit within a stigmatising context. More also needs to be known about the dynamics of female tobacco use in Indonesia and the factors contributing to marked geographical variations in smoking prevalence.

Constraints on the retreat from a welfare-orientated approach to public health care in Malaysia.

Both in its articulation of values and through incremental changes, the Malaysian government has signalled a change in attitude towards the welfare approach which had hitherto characterized public health care policy. This change envisions an end to reliance upon the state for the provision and financing of health services and the fostering of a system of family-based welfare. In the future citizens should finance their own health care through savings, insurance or as part of their terms of employment. While the state will still accept a degree of responsibility for those unable to pay for their health care, it wishes to share this burden with the corporate sector and non-government organizations as part of a national policy of the 'Caring Society'. In this article the retreat from a commitment to a welfare model of public health care is documented and some of the serious obstacles to such a policy are discussed. It is concluded that the government's aspirations for reforming the welfare model will need to be tempered by both practical and political considerations. Moreover, the socio-economic consequences of the Asian currency crisis of 1997 are likely to increase the need for government welfare action.

The Asian currency crisis and the Australian health industry.

This article identifies linkages between the Australian health industry and the global economy. It discusses some of the consequences of the Asian currency crisis of 1997-98 for the Australian economy and health industry, with special emphasis upon exports. Devaluation of the Australian dollar will increase the cost of most pharmaceutical and medical imports, but may offer competitive advantages to some Australian exporters. The nascent engagement with Asia of many health industry enterprises is likely to be stifled. It is therefore important for Australian governments, as well as the Australian health industry, to provide intelligence and encouragement to those enterprises that wish to continue their engagement with Asia or resume it when economic equilibrium returns. Markets throughout the world must also be further developed. The crisis may therefore provide the stimulus for re-thinking and re-stating Australian health export policy.

The growth of corporate private hospitals in Malaysia: policy contradictions in health system pluralism.

The rapid growth of corporate investment in the Malaysian private hospital sector has had a considerable impact on the health care system. Sustained economic growth, the development of new urban areas, an enlarged middle class, and the inclusion of hospital insurance in salary packages have all contributed to a financially lucrative investment environment for hospital entrepreneurs. Many of Malaysia's most technologically advanced hospitals employing leading specialists are owned and operated as corporate business ventures. Corporate hospital investment has been actively encouraged by the government, which regards an expanded private sector as a vital complement to the public hospital system. Yet this rapid growth of corporately owned private hospitals has posed serious contradictions for health care policy in terms of issues such as equity, cost and quality, the effect on the wider health system, and the very role of the state in health care provision. This article describes the growth of corporate investment in Malaysia's private hospital sector and explores some of the attendant policy contradictions.

Saving for hospital care costs in Singapore: are there lessons for Australia? [corrected].

Australian political leaders and policy analysts have increasingly sought to learn from Singapore, a nation which, despite its small size and lack of natural resources, has enjoyed rapid economic growth. Of particular interest to Australian policymakers has been Singapore's compulsory superannuation system, which has provided high levels of domestic savings and high levels of home ownership; it has also incorporated a scheme to enable Singaporeans to save for the costs of health care. In this article, Singapore's Medisave policy is described within its broader socioeconomic context. Saving for health care costs has been a largely neglected option in recent policy debate about reforming funding arrangements for hospital care in Australia. The potential for a formalised scheme for medical savings in Australia, subsidised by taxation concessions, is explored in terms of its socioeconomic policy implications, its congruence with Australian values, and the logistical ramifications of such a scheme.

Change of government and health services policy in Victoria, 1992-93 [see comment].

Although constrained by Federal financial dominance, State governments can, nevertheless, significantly shape a number of aspects of health policy within their own jurisdiction. New governments often seek to implement both substantive and symbolic policy changes. This is often also accompanied by alterations to organisational structures and personnel with a view to making implementation more effective. This article chronicles the continuities and changes in health services policy in the first year of the Liberal-National Coalition State Government in Victoria. These include institutional changes, key ministerial and bureaucratic appointments, health workforce issues, health services funding decisions, public and community health, and relations with the Federal Government. The decision-making style of the new government is also discussed. The authors regard the economic imperatives of Victoria's severe deficit as the dominant influence in all areas of public policy, including health services policy, although certain ideological predilections have also been evident. They further argue that the new government has primarily sought legitimacy by appealing to what it regards as its mandate to rectify Victoria's 'economic crisis' by reducing public expenditure and reforming managerial practices in the public sector.

The National Health Service reforms as an electoral issue in the United Kingdom.

The implementation of National Health Service (NHS) reforms left the Conservative Government with a major electoral problem. As Britain approached the 1992 general election, opinion polls revealed a popular perception that the Conservatives were planning to privatise the NHS. This perception was both fuelled and acted upon by the Labour Opposition which, at its 1991 annual conference, signalled its intention to make the health service a major item on the electoral agenda. In this article several issues associated with popular perceptions of the health reforms are explored including increased levels of copayment, the language of commerce, entrepreneurial activities within the NHS, and 'opting out'. The ways in which the Labour Party sought to place health on the electoral agenda are examined, together with the response of the government. Labour sought to portray the reforms as creeping privatisation while the Conservatives dismissed this as a crude propaganda ploy and have stressed their commitment to a more effective NHS. It is argued that the British experience exemplifies the perennial problems for any government seeking to introduce substantive changes to a national health system in a partisan political environment: the need to explain changes and legitimize them, and the danger that reforms will be politicized by an opposition eager for issues with immediate popular impact.

The NHS Patient's Charter: consumer, policy and partisan political functions.

The contents of The Patient's Charter, a recent initiative of Britain's Conservative government, with its origins in the broader Citizen's Charter policy, are summarised and discussed. The Charter details ten Rights which patients are to enjoy and introduces nine national standards relating to patient care practices and maximum waiting times for emergency services and outpatient clinics. The Charter also foreshadows future plans for national and local standards. New rights granted to patients include being given detailed information on local health services, including quality standards and waiting times, guaranteed admission for treatment within two years of going on a waiting list, and the right to a prompt written reply from the chief executive or general manager to any complaint about the NHS. The functions of the Patient's Charter are analysed in terms of their consumer, policy implementation and partisan political significance.

Reciprocal health care agreements and Australian health policy.

Shortly after the introduction of Medicare, following the return of the Australian Labor Party to government in 1983, the Federal Cabinet decided to extend basic health care coverage to the international level by seeking reciprocal health care agreements with other countries. This policy has resulted in the gradual establishment of a series of treaties providing Australian travellers with coverage in a number of countries and the process is continuing. This article examines the origins and nature of Australian government policy in this area, chronicles the development of treaty links and discusses some of the international and domestic policy issues associated with reciprocal health care agreements.