The effects of behavioral health reform on safety-net institutions: a mixed-method assessment in a rural state.

In July 2005, New Mexico initiated a major reform of publicly-funded behavioral healthcare to reduce cost and bureaucracy. We used a mixed-method approach to examine how this reform impacted the workplaces and employees of service agencies that care for low-income adults in rural and urban areas. Information technology problems and cumbersome processes to enroll patients, procure authorizations, and submit claims led to payment delays that affected the financial status of the agencies, their ability to deliver care, and employee morale. Rural employees experienced lower levels of job satisfaction and organizational commitment and higher levels of turnover intentions under the reform when compared to their urban counterparts.

Economic crisis, restrictive policies, and the population's health and health care: the Greek case.

The global economic crisis has affected the Greek economy with unprecedented severity, making Greece an important test of the relationship between socioeconomic determinants and a population's well-being. Suicide and homicide mortality rates among men increased by 22.7% and 27.6%, respectively, between 2007 and 2009, and mental disorders, substance abuse, and infectious disease morbidity showed deteriorating trends during 2010 and 2011. Utilization of public inpatient and primary care services rose by 6.2% and 21.9%, respectively, between 2010 and 2011, while the Ministry of Health's total expenditures fell by 23.7% between 2009 and 2011. In a time of economic turmoil, rising health care needs and increasing demand for public services collide with austerity and privatization policies, exposing Greece's population health to further risks.

"Post"-pandemic Capitalism: Reform or Transform? Comment on "Ensuring Global Health Equity in a Post-pandemic Economy".

This commentary expresses appreciation for Professor Labonté's work, along with some hopefully constructive suggestions. Professor Labonté's editorial shows ambivalence about reforms within capitalism. Such reforms remain contradictory and unlikely to prevail. Transformation to post-capitalist political economies is an exciting focus of moving beyond the hurtful effects of capitalism. Can "the state… mitigate capitalism's inherent inegalitarianism"? Problematically, government resides in the capitalist state, whose main purpose is to protect the capitalist economic system. The state's contradictory characteristics manifest in inadequate measures to protect health, as during the COVID-19 pandemic. "Social determination," referring to illness-generating structures of power and finance, is replacing "social determinants," referring mainly to demographic variables. Problems warranting attention include: capitalist industrial agriculture causing pandemics through destruction of protective natural habitat, structural racism, sexism and social reproduction, social class structure linked to inequality, and expropriation of nature to accumulate capital. Transformation to post-capitalism involves creative construction of new solidarity economies, while creative destructions block smooth functioning of the capitalist system.

Advancing the business creed? The framing of decisions about public sector managed care.

Relatively little research has clarified how executives of for-profit healthcare organisations frame their own motivations and behaviour, or how government officials frame their interactions with executives. Because managed care has provided an organisational structure for health services in many countries, we focused our study on executives and government officials who were administering public sector managed care services. Emphasising theoretically the economic versus non-economic motivations that guide economic behaviour, we extended a long-term research project on public sector Medicaid managed care (MMC) in the United States. Our method involved in-depth, structured interviews with chief executive officers of managed care organisations, as well as high-ranking officials of state government. Data analysis involved iterative interpretation of interview data. We found that the rate of profit, which proved relatively low in the MMC programme, occupied a limited place in executives' self-described motivations and in state officials' descriptions of corporation-government interactions. Non-economic motivations included a strong orientation toward corporate social responsibility and a creed in which market processes advanced human wellbeing. Such patterns contradict some of the given wisdom about how corporate executives and government officials construct their reality.

Universal health coverage as hegemonic health policy in low- and middle-income countries: A mixed-methods analysis.

Universal health coverage (UHC) has become an influential global health policy. This study asked whether and to what extent UHC became a "hegemonic" health policy. The article consists of three parts: a historical timeline of UHC's rise, a bibliometric analysis of UHC in the literature, and a qualitative thematic analysis of how UHC is defined and the thematic content of those definitions. The roots of UHC can be traced to policies enacted by international financial institutions (IFIs) such as the World Bank and International Monetary Fund (IMF) during the latter half of the twentieth century. These policies caused the debt of low- and middle-income countries (LMICs) to rise precipitously and led the same IFIs and other institutions like the World Health Organization to become involved in the development and restructuring of health systems. UHC was presented as the leading method for financing development of health systems. As the bibliometric analysis shows, UHC has come to predominate in the literature around health system reforms. The thematic analysis based on a random selection of papers obtained in the bibliometric component of the study shows that often the term is not defined or only poorly defined. There is wide variation in the definitions, with many papers mentioning concepts such as quality, access, and equity without further clarification. Usually, papers define UHC to include tiering of benefits, with discussions of financing that focus on preventing "catastrophic [individual] expenditures" rather than discussing universal budgeting of a national health care system or national health insurance. We conclude that UHC has become hegemonic within global health policy, to the exclusion of discussions about other approaches to the transformation of health systems that are not predominately based on insurance coverage such as Health Care for All system, a system which provides equal services for the entire population.

How missing evidence-based medicine indicators can inform COVID-19 vaccine distribution policies: a scoping review and calculation of indicators from data in randomised controlled trials.

OBJECTIVE: Reports of efficacy, effectiveness and harms of COVID-19 vaccines have not used key indicators from evidence-based medicine (EBM) that can inform policies about vaccine distribution. This study aims to clarify EBM indicators that consider baseline risks when assessing vaccines' benefits versus harms: absolute risk reduction (ARR) and number needed to be vaccinated (NNV), versus absolute risk of the intervention (ARI) and number needed to harm (NNH). METHODS: We used a multimethod approach, including a scoping review of the literature; calculation of risk reductions and harms from data concerning five major vaccines; analysis of risk reductions in population subgroups with varying baseline risks; and comparisons with prior vaccines. FINDINGS: The scoping review showed few reports regarding ARR, NNV, ARI and NNH; comparisons of benefits versus harms using these EBM methods; or analyses of varying baseline risks. Calculated ARRs for symptomatic infection and hospitalisation were approximately 1% and 0.1%, respectively, as compared with relative risk reduction of 50%-95% and 58%-100%. NNV to prevent one symptomatic infection and one hospitalisation was in the range of 80-500 and 500-4000. Based on available data, ARI and NNH as measures of harm were difficult to calculate, and the balance between benefits and harms using EBM measures remained uncertain. The effectiveness of COVID-19 vaccines as measured by ARR and NNV was substantially higher in population subgroups with high versus low baseline risks. CONCLUSIONS: Priorities for vaccine distribution should target subpopulations with higher baseline risks. Similar analyses using ARR/NNV and ARI/NNH would strengthen evaluations of vaccines' benefits versus harms. An EBM perspective on vaccine distribution that emphasises baseline risks becomes especially important as the world's population continues to face major barriers to vaccine access-sometimes termed 'vaccine apartheid'.

Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression.

We assessed the role of promotoras--briefly trained community health workers--in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention's impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention's implementation, involving infrastructure at the health centers, boundaries of the promotoras' roles, and "turf" issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.

Confronting the Upstream Causes of COVID-19 and Other Epidemics to Follow.

The upstream causes of the COVID-19 pandemic have received little attention so far in public health and clinical medicine, as opposed to the downstream effects of mass morbidity and mortality. To resolve this pandemic and to prevent even more severe future pandemics, a focus on upstream causation is essential. Convincing evidence shows that this and every other important viral epidemic emerging in the recent past and predictably into the future comes from the same upstream causes: capitalist agriculture, its destruction of natural habitat, and the industrial production of meat. International and national health organizations have obscured the upstream causes of emerging viral epidemics. These organizations have suffered cutbacks in public funding but have received increased support from international financial institutions and private philanthropies that emphasize the downstream effects rather than upstream causes of infectious diseases. Conflicts of interest also have impacted public health policies. A worldwide shift has begun toward peasant agricultural practices: Research so far has shown that peasant agriculture is safer and more efficient than capitalist industrial agricultural practices. Without such a transformation of agriculture, even more devastating pandemics will result from the same upstream causes.

COVID-19 as Cause versus Trigger for the Collapse of Capitalism.

According to the official narrative of COVID-19, the pandemic has caused the global capitalist economy to collapse, or at least to enter a deep recession and possibly a great depression. Assigning blame to a virus takes attention away from the structural contradictions and instabilities of capitalism that would have led to a crash in any case. This narrative also helps justify non-evidence-based public health policies, including lockdowns, travel bans, closed schools and factories, and forced quarantines of large populations rather than individuals and clustered groups who harbor the infection. Advantages of such drastic measures happen primarily in countries that did not prepare adequately, that did not respond quickly enough with more focused measures to test and isolate people infected with the virus, and that have health care systems either organized by capitalist principles or suffering cutbacks and privatization as a result of capitalist economic ideologies, such as austerity. Authoritarian tactics purportedly intended to protect public health pave the way to antidemocratic rule, militarism, and fascism. These harsh policies also exert their most adverse effects on poor, minority, incarcerated, immigrant, and otherwise marginalized populations, who already suffer from the worsening economic inequality that global, financialized capitalism has fostered.

Moving Beyond Capitalism for Our Health.

Deepening crises now affect not only the capitalist health system in the United States, but also the national health programs of countries that have achieved universal access to services. In our recent collaborative book, Health Care Under the Knife: Moving Beyond Capitalism for Our Health, we analyze these changing structural conditions and argue that the struggle toward viable national health programs now must become part of a struggle to move beyond capitalism. Privatization, cutbacks in public-sector services and institutions, and public subsidization of private profit-making through transfer of tax revenues into private insurance corporations have worsened under neoliberal policies. Financialization of capitalist economies includes the increasingly oligopolistic and financialized character of health insurance, both public and private. Those struggling for just and accessible health systems now need to confront the shifting social class position of health professionals. Due to loss of control over the work process and a reduced ability to generate high incomes compared to other professional workers, the medical profession has become proletarianized. To achieve national health programs that will remain viable over a long term, a much more fundamental transformation needs to reshape not just health care, but also the capitalist state and capitalist society.

Transforming administrative and clinical practice in a public behavioral health system: an ethnographic assessment of the context of change.

In July 2005, New Mexico placed all publicly funded behavioral health services under the management of one private corporation. This reform emphasized the provision of evidence-based, culturally competent services. Methods. Participant observation and semi-structured interviews with 189 administrators, staff, and providers were carried out in 14 behavioral health safety-net institutions (SNIs) during the transition period. Results. New administrative requirements led to substantial paperwork demands, payment problems, and financial stress within SNIs. Personnel at the SNIs often lacked knowledge about and training in evidence-based practices and culturally competent care, and viewed the costs of delivering such services as prohibitive. Discussion. Policymakers must account for the challenges that SNIs face as the reform continues to unfold. The financial stability of SNIs is of critical importance. Efforts are needed to increase training and development opportunities in evidence-based care and cultural competency; SNIs typically lack resources to pursue these opportunities on their own.

Social capital and health care experiences among low-income individuals.

OBJECTIVES: We examined relationships between social capital and health service measures among low-income individuals and assessed the psychometric properties of a theory-based measure of social capital. METHODS: We conducted a statewide telephone survey of 1216 low-income New Mexico residents. Respondents reported on barriers to health care access, use of health care services, satisfaction with care, and quality of provider communication and answered questions focusing on social capital. RESULTS: The social capital measure demonstrated strong psychometric properties. Regression analyses showed that some but not all components of social capital were related to measures of health services; for example, social support was inversely related to barriers to care (odds ratio=0.73; 95% confidence interval=0.59, 0.92). CONCLUSIONS: Social capital is a complex concept, with some elements appearing to be related to individuals' experiences with health services. More research is needed to refine social capital theory and to clarify the contributions of social capital versus structural factors (e.g., insurance coverage and income) to health care experiences.

Medicaid managed care for mental health services: the survival of safety net institutions in rural settings.

Few accounts document the rural context of mental health safety net institutions (SNIs), especially as they respond to changing public policies. Embedded in wider processes of welfare state restructuring, privatization has transformed state Medicaid systems nationwide. We carried out an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of Medicaid managed care (MMC) and the implications for future reform. After 160 interviews and participant observation at SNIs, we analyzed data through iterative coding procedures. SNIs responded to MMC by nonparticipation, partnering, downsizing, and tapping into alternative funding sources. Numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma, and immigration status. By privatizing Medicaid and contracting with for-profit managed care organizations, the state placed additional responsibilities on "disciplined" providers and clients. Managed care models might compromise the rural mental health safety net unless the serious gaps and limitations are addressed in existing services and funding.

Military Personnel Who Seek Health and Mental Health Services Outside the Military.

Background: Although research conducted within the military has assessed the health and mental health problems of military personnel, little information exists about personnel who seek care outside the military. The purpose of this study is to clarify the personal characteristics, mental health diagnoses, and experiences of active duty U.S. military personnel who sought civilian sector services due to unmet needs for care. Materials and Methods: This prospective, multi-method study included 233 clients, based in the United States, Afghanistan, South Korea, and Germany, who obtained care between 2013 and 2016 from a nationwide network of volunteer civilian practitioners. A hotline organized by faith-based and peace organizations received calls from clients and referred them to the network when the clients described unmet needs for physical or mental health services. Intake and follow-up interviews at 2 wk and 2 mo after intake captured demographic characteristics, mental health diagnoses, and reasons for seeking civilian rather than military care. Non-parametric bootstrap regression analyses identified predictors of psychiatric disorders, suicidality, and absence without leave (AWOL). Qualitative analyses of clients' narratives clarified their experiences and reasons for seeking care. The research protocol has been reviewed and approved annually by the Institutional Review Board at the University of New Mexico. Results: Depression (72%), post-traumatic stress disorder (62%), alcohol use disorder (27%), and panic disorder (25%) were the most common diagnoses. Forty-eight percent of clients reported suicidal ideation. Twenty percent were absence without leave. Combat trauma predicted post-traumatic stress disorder (odds ratio [OR] = 8.84, 95% confidence interval [CI] 1.66, 47.12, p = 0.01) and absence without leave (OR = x3.85, 95% CI 1.14, 12.94, p = 0.03). Non-combat trauma predicted panic disorder (OR = 3.64, 95% CI 1.29, 10.23, p = 0.01). Geographical region was associated with generalized anxiety disorder (OR 0.70, 95% CI 0.49, 0.99, p = 0.05). Significant predictors were not found for major depression, alcohol use disorder, or suicidal ideation. Clients' narrative themes included fear of reprisal for seeking services, mistrust of command, insufficient and unresponsive services, cost as a barrier to care, deception in recruitment, voluntary enlistment remorse, guilt about actual or potential killing of combatants or non-combatant civilians, preexisting mental health disorders, family and household challenges that contributed to distress, and military sexual trauma. Conclusions: Our work clarified substantial unmet needs for services among active duty military personnel, the limitations of programs based in the military sector, and the potential value of civilian sector services that are not linked to military goals. We and our institutional review board opted against using a control group that would create ethical problems stemming from the denial of needed services. For future research, an evaluative strategy that can assess the impact of civilian services and that reconciles ethical concerns with study design remains a challenge. Due to inherent contradictions in the roles of military professionals, especially the double agency that makes professionals responsible to both clients and the military command, the policy alternative of providing services for military personnel in the civilian sector warrants serious consideration, as do preventive strategies such as non-military alternatives to conflict resolution.

An ethnography of clinic "noise" in a community-based, promotora-centered mental health intervention.

Community-based health interventions have emerged as a growing focus for anthropological research. The application of ethnographic approaches in clinical practice settings reveals that community-based interventions must grapple with "noise," or unanticipated factors such as patients' own perceptions of illness and treatment, primary care providers' non-adherence to guidelines-based treatment, the social dynamics of the clinic site itself, and incomplete understanding and acceptance of an intervention by a clinic's staff members. Such noise can influence the implementation and quality of treatment. Thus, identifying clinic-based noise is critical in assessments of fidelity to intervention protocols as well as outcomes of community-based interventions. This paper highlights findings from an evaluation of a mental health intervention focusing on the role of promotoras (briefly trained, non-professional community health workers) as mental health practitioners in two urban New Mexico, USA, community health centers. Our research identified three areas of clinic-based noise: the clinics' physical ability to "absorb" the intervention, the challenges of co-worker instability and interpersonal relationships, and balancing extra workplace demands. The findings demonstrate the value of ethnographic approaches in community-based intervention research.

Privatization of health services in less developed countries: an empirical response to the proposals of the World Bank and Wharton School.

Academics and World Bank officials argue that, by reducing out-of-pocket expenditures, expanded private insurance may improve access to needed health services in less developed countries. In this empirical response, the authors examine this recommendation through observations from their research on privatization of health services in the United States, Argentina, Chile, and Mexico. Privatization, either through conversion of public sector to private sector insurance or by expansion of private insurance through enhanced participation by corporate entrepreneurs, generally has not succeeded in improving access to health services for vulnerable groups. Although the impact of privatization has differed among the Latin American countries studied, expansion of private insurance often has generated additional co-payments, which have increased rather than decreased out-of-pocket expenditures, thereby worsening access to needed services. Privatization usually has improved conditions for private corporations and has led to higher administrative costs. To address the devastating problems of access to services worldwide, we must find ways to enhance the delivery of public sector services and must move beyond conventional wisdom about market-based policies such as privatization.