[Social inequality in home care: A scoping review on the impact of socio-economic resources on home care arrangements]. / Soziale Ungleichheit in der häuslichen Pflege: ein Scoping-Review zum Einfluss sozioökonomischer Ressourcen auf die Gestaltung häuslicher Pflegearrangements.

INTRODUCTION: Inequalities in long-term home care are still rarely considered in the discourse on health inequalities, although there is reason to assume that opportunities for a successful home care arrangement are not equally distributed among those in need of it. This paper pursues the question how socio-economic resources of people in need of care and their family caregivers are influencing the utilization of care services in Germany. METHODS: A scoping review has been conducted to analyse the current state of research. To identify relevant papers the online databases CINAHL including MEDLINE, PubMed, LIVIVO and Web of Science were searched and supplemented by internet research. According to Bourdieu, the research studies included were arranged in economic, educational and social resources. RESULTS: 29 qualitative and quantitative research papers were included in the analysis. 14 papers represent quantitative research results, nine papers are based on qualitative research. Six further papers are analyses based on an international data record. The utilization of care services increases with the level of income and wealth as well as education. On closer examination of individual care services, however, the evidence is inconsistent and only the so-called 24-hour care service is distinguishable as a care arrangement for high-status groups. A compensation of the lower utilization of professional care by informal support cannot be described in quantitative terms. Caregivers with low income and education levels seem to be more likely to not only provide care but also to provide higher-intensity care. DISCUSSION: Despite increasing research reflected in the literature, the evidence remains incomplete and shows inconsistencies so that a valid statement on the degree of inequalities in care provision is not possible. A conceptual basis for the definition of social inequality in the context of long-term home care is lacking as well as a common understanding of equity in care provision. The perspective of people in need of care and their caregivers has hardly been addressed. CONCLUSION: Home care is not only determined by individual need but seems to be decisively influenced by socio-economic restrictions. For a more targeted approach, further research on the use of care services depending on socio-economic resources is needed, explicitly taking into account the user perspective.

Physician extender services in family planning agencies: issues in Medicaid reimbursement.

PIP: The US Social Security Amendments of 1972 mandated the inclusion of family planning services in state Medicaid plans, authorized 90% of reimbursements for family planning care, and imposed financial penalties for failure to provide these services to Medicaid-eligible clients. On the other hand, many states have retrictive policies regarding Medicaid reimbursements to family planning agencies for services provided by physician extenders (e.g.s nurse practitioners and physician assistants). There is concern that such restrictions greatly reduce accessibility to family planning services. Reasons that hae been suggested as causes of such restrictive policies include physician concern over loss of income, the uncertain status of physician extenders in some states, a fear that this step will lead to a demand for reiimbursement for the services of other allied health care providers such as social workers, and concern that care for the indigent will lead to an expensive increase in state reimbursement for family planning services. However, a review of relevant federal law and regulations indicates that Medicaid reimbursement for services provided to eligible patients by physician extenders has never been prohibited or discouraged. Physician supervision is required in reimbursement cases, but this does not mean that a physician must be on the premises while services are delivered. The Medicaid program actually allows significant latitude in establishing administrative policies and procedures. Rather, problems faced by family planning agencies in receiving Medicaid reimbursements for physician extenders' services are due to restrictions in state laws and staff misinterpretations of policy. Research has demonstrated that physcian extenders can contribute significantly to cost effectiveness, while providing types of care in localities such as rural areas that physicians tend to avoid. Given the importance of family planning services to Medicaid-eligible clients, unwarranted policy restrictions contrary to congressional intent should be eliminated.^ieng

National community health worker programs: how can they be strengthened?

This article is based on a collaborative research study of policy and practice in national community health worker (CHW) programs in developing countries. The study involved a review of the relevant literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop where the future of such programs was discussed. The findings of this research are discussed under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining quality. It is clear that existing national community health worker programs have suffered from conceptual and implementation problems. However, given the interest and political will, governments can address these problems by adopting more flexible approaches within their CHW programs, by planning for them within the context of all health sector activities rather than as a separate activity, and by immediately addressing weaknesses in task allocation, training and supervision. CHWs represent an important health resource, whose potential in extending coverage and providing a reasonable level of care to otherwise underserved populations must be fully tapped.

PIP: A collaborative research study of policy and practice in large, national community health worker (CHW) programs in developing countries was conducted. The report was based on a review of the literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop on the future of CHW programs. The objective of the study was to reexamine the implementation of national CHW programs, looking at policy, planning and management implications to suggest improvements. The chief findings were poor initial planning, unrealistic expectations of the workers, difficulties in maintaining quality and problems of sustainability. National CHW programs have suffered from conceptual and implementation problems. With political will, however, governments can adopt more flexible approaches by planning CHW programs within the context of overall health sector activities, rather than as a separate activity. Weaknesses in training, task allocation and supervision need to addressed immediately. CHWs represent an important health resource whose potential in providing and extending a reasonable level of health care to undeserved populations must be fully tapped.

Community health and the midwife.

PIP: As a member of the national medical team, the midwife has an important role to play in community health care. Traditional birth attendants still attend a large proportion of the Nigerian population but they are gradually being replaced by trained midwives who have taken an examination and registered with the Midwives' Board of Nigeria as a State Certified Midwife. Training includes working with a midwife for 2 years and oral and practical examinations. Professional nurses are also included in training programs for dual qualifications. The trained midwife handles normal pregnancy, labor and puerperium. She can work in rural areas under difficult conditions. Teaching and counseling are also her responsibility. She prepares the mother for analgesia when the need arises, introduces her to the modern approach to relaxation during childbirth and to physiologic feeding and care of the breasts. The midwife helps the patient to relate ill health to situations in her environment, e.g., unsanitary conditions, overcrowding, and superstitious beliefs. The community midwife tries to provide health guidance to all members of the family at home, in school, and wherever else she finds them, and to educate the people to make and carry out plans for improving their health problems. She will work with other voluntary organization, e.g., Red Cross, and the social welfare department.^ieng

Health manpower planning for primary care in Ghana.

PIP: In Ghana, a 3-tier system of health manpower is being planned in conformity with the country's primary health care strategy. Since independence, the total number of hospital beds and cots has increased from 5787 in 1960 to 12,973 in 1975, resulting in a population per hospital bed of 705 in 1975. Since 1975, health manpower planning has been mainly based on training various cadres of health to work in the existing health institutions. The acceptance of the primary health care strategy, the country's health problems, the relatively simple nature of the tasks to be performed, and sometimes the refusal to conventional health workers to work in rural areas led the Ministry of Health to critically examine the types and number of health services personnel required. A human resources project team was set up in 1976 to investigate the present and projected supply of selected categories of health personnel and to make recommendations as to the types of personnel that should be the front-line health workers. The 3-tier health system is made up of Level A, the community level; Level B, the local council subareas; and Level c, the district. Level A health workers, who form the base of the system, are selected and compensated by the community itself but trained by the Minsitry of Health for 6 weeks and subsequently for weekly refresher courses as needed. The functions of these front line workers include: pregnancy management; personal health improvement with emphasis on infant and child development; community mobilization and social development projects; health education; and simple 1st level curative measures. Level B health workers, who serve the people living within 8 km of every community, comprise 1 or more community nurses/midwives and health station environmental and development workers. Their responsibilities include support and technical supervision of Level A workers, diagnosis and treatment of simple cases or referral to a higher level; immunizing infants and children at level A; and identifying pregnant women at high risk of complicatons. The district is considered the key level. Functions of the district health management team include management of the district health services serving as the basic unit for planning and budgeting, training and supervising Level B health workers within the district, and evaluating health work within the district. In all cases the Village Development Committee is responsibile for selecting Level A halth workers for training. Training should be arranged in a way that trainees can continue their routine work without being separated from their families and communities for a long time. The teaching method involves the use of demonstration and story telling.^ieng

Cost analysis of a primary health centre in northern India.

BACKGROUND: Cost data are useful in health planning, budgeting and for assessing the efficiency of services. However, such data are not easily available from developing countries. We therefore estimated the cost incurred for the year 1991-92 on a primary health centre in northern India, which is affiliated to an academic institution. METHODS: The total costs incurred included the capital costs for land, building, furniture, vehicles and equipment as well as the recurrent costs for salaries, drugs and vaccines, diesel and maintenance. Except for land, where the 'opportunity cost' was calculated, the current market rates were considered for all other factors. A discount rate of 10% was used in the study. RESULTS: A total of Rs 777,015 (US $24,282) was incurred on the primary health centre in the study year, 80% being recurrent costs. Salaries constituted 62% of the total costs. A sum of Rs 30 (US $0.94) per head per year on primary health care was being incurred. CONCLUSION: Salaries constitute the bulk of the cost incurred on health. Approximately Rs 28 (40%) of the Rs 69 spent per head per year on health services by the Government of India is incurred on providing primary health care services.

PIP: Primary health care in India is provided by a chain of primary health centers (PHC) which are staffed by a medical officer and para-professional health workers. The multipurpose workers (MPW) deliver health services such as immunization and antenatal care. Each male and female worker team serves a population of approximately 5000, while the PHC serves a population of approximately 30,000. The MPWs are supervised by two health assistants, one male and one female, while the medical officer supervises the workers and provides curative services. The authors report findings from their study of the cost of providing health care through the Chhainsa PHC of the Comprehensive Rural Health Services Project in Ballabgarh, Haryana, during 1991-92. Such data are useful in health planning, budgeting, and assessing the efficiency of services. The authors note that Chhainsa PHC caters to a population of 25,762 and that it is not a prototype of others in the country as it is run by a medical college, the All India Institute of Medical Sciences. Capital costs were assessed for land, building, furniture, vehicles, and equipment, as well as the recurrent costs for salaries, drugs, and vaccine, diesel, and maintenance. Current market costs were considered for all factors except land for which the opportunity cost was calculated. A 10% discount rate was used in the study. The analysis found that Rs 777,015 was incurred on the primary health center in the study year, 80% being recurrent costs. Salaries constituted 62% of total costs, drugs and equipment 10% of recurrent costs, and vaccines and other family welfare items 4% of the total annual costs. Salaries therefore consume the bulk of expenditures for health. It costs Rs 30 per head per year to run the PHC. This per head estimate is probably high compared to other PHCs in India. So, out of Rs 69 per capita currently spent on health in India, approximately 44% appears to be spent on primary health care.

Population uncertainty, social insurance, and actuarial bias.

PIP: The authors examine the relation between changes in the size of the working population and the value of a social insurance contract between unborn workers and future retirees. They develop a model suggesting that such a contract will benefit both of the generations concerned. The implied geographical focus is on developed countries.^ieng

Self-selection and intermunicipal migration in Canada.

"This paper investigates individual intermunicipal migration behaviour in Canada within the context of a human capital model that adjusts for the migrant's selectivity in computing expected income gains. In addition to the typical regional determinants of migration, housing and labour market characteristics are found to influence intermunicipal migration significantly, the effects differing with age. Structural coefficients remained more or less stable during the decade 1971-1981. It is shown that the failure to adjust income gains for selectivity bias results in an underestimation of the migration-impacts of income gains and municipal-specific factors."

Health personnel training in the Nicaraguan health system.

The "Unified National Health System" of Nicaragua was established in 1979, in an attempt to transform some of Latin America's worst health indices. This system, based on the stated principles of planning, regionalization, public participation, and primary care, has prioritized the development of health professions training programs appropriate to its special needs and principles. Public Health and Epidemiology training was inaugurated in 1982. A new campus of the School of Medicine was opened in 1981, increasing the number of medical students by a factor of five. Formal residency training (never before available within the country) in primary care specialties has been established. Training for allied health personnel has been formalized in several fields, with the establishment of the Polytechnical Institute of Health. The rapid increase in number and size of training programs has created a tremendous need for educational resources both human and material. This article reviews the status of health personnel training in Nicaragua today, the integration of these programs into planning for the health system, and problems arising from their rapid appearance.

PIP: This article explores the policies and early experiences of the extensive changes in the preparation of health personnel in Nicaragua; massive changes in the health care system were launched after the victory of the Sandinista Revolution in 1979. It reviews the status of health personnel training in the country today, the integration of these programs into planning for the health system, and problems arising their rapid appearance. The Unified National Health System was established in 1979 in an attempt to transform some of Latin America's worst health indices. This system is based on the stated principles of planning, regionalization, public participation, and primary care. To implement these policies, high priority has been given to the development of health professions training programs appropriate to the system's special needs and principles. Public Health and Epidemiology training was inaugurated in 1982. A new campus of the School of Medicine was opened in 1981, increasing the number of meidcal students by a factor of 5. Formal residency training in primary care specialties has been established. Training for allied health professions has been formalized in several fields, with the establishment of the Polytechnical Institute of Health. The rapid increase in number and size of training programs has created a trmendous need for educational resources, both human and material. The greatest constraint in expanding medical education was the lack of qualified teachers. As a solution, the new health system has made public sector employment much more available and attractive; most Nicaraguan physicians today divide their time between public and private practice, and the pressures on voluntary teaching time are heavy. The Health Ministry has developed strategies for making clinical teaching more attractive and prestigious in compensation. Medical curriculum reform since 1979 is designed to turn out doctors capable along 4 lines: clinical service, teaching, administration and research. Special importance is placed on integrated teaching and service. These multiple objectives are built into the teaching program from the very beginning. To date there are 6 schools of nursing in the country (4 before 1979), with 5 times the pre-1979 enrollment. Nicaragua has made a deliberate decision not to train mid-level medical workers. However, volunteer health personnel, the Brigadistas, have played a definite role in Nicaraguan communities. They concentrate on public education and mobilize the people for immunization and sanitation campaigns. Additionally, traditional birth attendants in rural areas have been recognised by the Health Ministry and been given training to upgrade their performance. Much in the new System has emulated policies of Cuba, especially the emphasis on public education, models for personnel training and community-oriented primary care.

The underemployment of American rural women: prevalence, trends and spatial inequality.

PIP: The growing numerical significance of women in the US nonmetropolitan labor force has not been matched by parallel efforts to document the changing quality of their employment. In this paper. Lichter uses the labor utilization framework of Clogg and Sullivan to examine the prevalence and spatial convergence of various forms of female underemployment during 1970-1985. Data from the March annual demographic files of the Current Population Survey reveal that underemployment has been a significant aspect of the employment experiences of nonmetropolitan women during this period. There has been little evidence of spatial or sex convergence in labor market outcomes. Roughly 1 of every 3 rural female workers today is a discouraged worker, jobless, employed part-time involuntarily, or working for poverty-level wages. Moreover, rural women continue to suffer substantially higher levels of economic underemployment than urban women and rural men. This study reinforces the view that rural women remain a seriously underutilized labor resource in the US.^ieng

Afro-Caribbean migrants in France: employment, state policy and the migration process.

"Afro-Caribbean labour in France plays a distinctive role relative to the French population as a whole and the foreign immigrant population. Using a variety of qualitative and quantitative sources, this paper demonstrates that the role of the state in the process of migration from the French Caribbean islands of Martinique and Guadeloupe from the early 1960s onwards was crucial.... Aggregate sources are used to describe detailed occupational distributions while records of individual migrants illustrate the process of migration and the influences on employment. At a time usually characterized by lack of direct involvement in migration by the French state, for Afro-Caribbeans state intervention in recruitment, training and settlement is shown to be very substantial."

International migration and real wages: a resolution note.

PIP: The authors examine the impact of international labor migration on wages in country of origin. Two types of emigration are distinguished: bundled emigration, which can result in a reduction of real wages; and pure labor emigration, which results in an increase in real wages.^ieng

Urbanization in a developing country: city size and population composition.

Reasons for the high correlation between city size and educational attainment in developing countries are explored. "Two explanations are examined. First, the types of goods produced in larger cities require relatively high skill labor inputs. Second, public and perhaps private services demanded by higher skill people are only offered in larger cities. The paper econometrically tests these hypotheses for Brazil, estimating the elasticities of substitution (or typically complementarity) between high and low skill labor and the 'bright lights' effect for high versus low skill labor."

Migration, remittances, and inequality: estimating the net effects of migration on income distribution.

"This paper examines the net effects of migration and remittances on income distribution. Potential home earnings of migrants are imputed, as are the earnings of non-migrants in migrant households, in order to construct no-migration counterfactuals to compare with the observed income distribution including remittances. The earnings functions used to impute migrant home earnings are estimated from observations on non-migrants in a selection-corrected estimation framework which incorporates migration choice and labor-force participation decisions. For a sample of households in Bluefields, Nicaragua, migration and remittances increase income inequality when compared with the no-migration counterfactual."

The earnings of Mexican immigrants in the United States.

"This paper documents the trends in the earnings of Mexican immigrants during the 1970-1990 period. The empirical evidence indicates that there has been a decline in the relative wage of successive Mexican immigrant waves in the past three decades and that little wage convergence occurs between the typical Mexican immigrant and the typical native worker. The data also suggest that the increasing importance of Mexican immigration is partly responsible for the deterioration in relative skills observed in the aggregate immigrant population, but that there has also been a decline in relative skills even among non-Mexican immigrants."

Primary school teacher as a primary health care worker.

School children (1608) were examined for three items (nails, scalp hairs and teeth) relating to personal hygiene and relevant infective conditions from two sets of villages i.e. one set where primary school teacher was working as primary health care worker (Group I) and the other set where Community Health Volunteer (CHV) was delivering primary health care (Group II). The objective was to evaluate the efficiency of school teachers' role vis-a-vis CHVs' in imparting health education to school children. Out of 1608 school children, 801 belonged to Group I villages and the remaining 807 to Group II villages. From the results, it was evident that children of Group I villages were better with respect to all the items related to personal hygiene and infective conditions excepting scalp infections, where difference was not statistically significant, indicating teachers' superiority over the CHVs' in imparting health education to school children.

Population pressure, intensification of agriculture, and rural-urban migration.

"In this paper I provide an analytical basis for why labor absorption [in agriculture] may improve with higher population density. My argument is in two parts. First, analysing agriculture in isolation, I use the Boserup insight to show that higher population density is associated with more intensive techniques of land use. Second, using a two-sector model, I show that the rate of labor absorption (defined as the rate of natural population growth minus the rate of rural-urban migration) increases with the intensity of land use." Cross-sectional data for Iran are used to illustrate the model.

PIP: This paper considers the Malthusian implication that population density leads to the inability of agriculture to absorb labor. The argument is presented that higher population density is associated with more intensive techniques of land use, based on the Boserup model, and that the rate of labor absorption (natural population growth minus the rate of rural-to-urban migration) increases with the intensity of land use. The model reveals that the availability of jobs in urban areas slows agricultural intensification and increases migration. The Asian model is different in that urbanization and intensification occur simultaneously. The model is empirically tested with Iranian data. Results indicate negative signs for the intensity coefficients (irrigation ratio and cropping intensity), which means a negative influence on rural out-migration. Population density has a positive coefficient. The effect of the percentage of land tilled by tractors is positive, while the number of diesel pumps in operation reduces out-migration. The contrasting results of Annable, Bilsborrow, and Winegarden are considered plausible, since an intensification factor is not included and population density is picking up the negative effect of the intensity of cultivation. High rates of out-migration from low population density areas usually are explained by the poor natural resources available. It is argued that poor soil quality is related to cultivation intensity, and thus, soil fertility is exogenous. The results are intended not as a definitive proof of the direct effect of population density on agricultural employment, but as an alternative explanation for out-migration from low density areas. Population increases clearly cause declines in wages in the proposed model and may not lead to intensification but to out-migration. Increases in agricultural prices or lowering the cost of inputs can promote intensification. Population density will always reduce the potential of a region to absorb population. Government has the ability to influence public investment in agriculture and trading through its regulations, which can speed up intensification and the capacity to provide agricultural employment. Government can also indirectly encourage out-migration through the promotion of attractive urban labor markets.

Migration to the United States and Mexican rural development: a case study.

An analysis of the impact of migration to the United States on the sending community and on the labor market in the receiving country is presented based on a case study of Las Animas, Mexico. "As the community becomes increasingly involved in migration, tendencies can be identified regarding changing migration patterns, class differentiation among villagers, impact of migration on village economy, and the changing role of Mexican workers in California labor markets. Results indicate the importance of social networks in determining the outcome of migration; while migration is individually rational, it is a factor of stagnation for village economy, and it helps reproduce segmented California labor markets."

Integrated health programmes.

PIP: Over a period of 10 years, a hospital in rural Africa slowly built an integrated primary and secondary health care program to the point where it has more than 40 elements. In its initial stage (1982-84), hospital staff and community participants were trained, the number of mobile clinics was increased, community participation was sought, and health education was emphasized. During 1985-86, 92 village health committees were organized with 70 trained Village Health Workers (VHWs). This led to a rapid increase in vaccination rates, the use of oral rehydration therapy, and training of traditional birth attendants. In 1987-88, 14 VHW were trained to use basic medical kits and distribute medicines. By 1990, 18,000 of the 72,000 outpatient treatments were administered by VHWs. In 1987, the hospital made a community diagnosis and increased the size of its advisory board (which became 60% female). Because the community identified food, water, and poverty as its priorities, the hospital took steps to improve the food supply, the water supply, and the financial position of the women. In 1989-90, the primary health care (PHC) project added the components of family planning, a weaning food production unit, food coupons, food for work, grain banks, a trust fund, literacy classes, health stamps, a mobile malnutrition clinic, subsidized fertilizer and seed, low-cost care for victims of AIDS, new malaria treatment schedules, and a housing association. The PHC program has resulted in a reduction in under-five deaths from the national average of 330/1000 to 145/1000 (other areas have reduced deaths to 270-300/1000. The program is also becoming increasingly cost-effective, costing about 6 pounds per capita over 10 years for a population of 50,000. Country-wide implementation of the PHC program would require only 30% of the present health budget.^ieng

Realistic manpower planning for primary health care: practical considerations.

PIP: Adequate objective data for health manpower planning are often lacking, as are commonly accepted assumptions about the quantity or mix of health professionals and distribution patterns that will assure adequate and accessible care. Several methods can be used to estimate need and demand for health manpower, including: techniques using provider/population ratios, approaches based on professionally defined criteria, methods based on current, population specific utilization rates, and economic methods. A more efficient approach would be based on task analysis of needed jobs, where the provision of health care services is focused on utilizing the most appropriate health personnel. Although no single model for planning primary health care (PHC) programs has universal application, an approach which addresses common health care delivery problems would be beneficial. Problems face health planners in much of the developing world: lack of clear national health policy; shortages and maldistribution of manpower, facilities, equipment, supplies and finances; inadequate coverage; underutilization of services; inappropriate use of health education; insufficient community participation; inappropriate training systems; and inadequate attention to environmental sanitation. A service delivery model that has been effective in developing countries is based on new manpower configurations, relying on the services of mid-level and community health workers to increase the availability of care. New methods and technology for training these personnel are being developed. In planning the strengthening of a PHC program, adequate attention must be given to: analysis and projection of health needs and demand for services; enumeration of existing health workers and task analyses; estimation of future manpower needs and expected supply; assessment and strengthening of the manpower infrastructure; and regional utilization of resources. Based on the experiences of several PHC programs using a multitiered health manpower infrastructure, several suggestions are offered to facilitate the development and enhance the effectiveness of this type of program. Broad based support and national commitment is necessary to assure the program's significant and lasting impact. A positive operating framework must be created where workers are adequately compensated and accepted in the medical and local community. Community selection of workers is advised. Special attention must be given to management capability, including supervision and support. Doctors must be involved in developing training curricula, direct training, and supervision to secure their support for the program. Training programs must be problem oriented, reflecting task analyses and competency based. A modular program can allow curricular flexibility and be modified to address country specific needs. An additional advantage of a modular program, such as MEDEX, is the creation of a training and supervision interlock between the manpower levels and the multiplier effect of 1 person training several on the next tier, maximizing service expansion.^ieng