For a long time, patients were seen as weak and passive recipients of care, whose only role was to provide information and comply with doctors' orders. This is beginning to change, and patients are more seen as autonomous, active, and involved collaborators in care, co-creating value with service providers and others. In parallel, the healthcare sector is changing due to an aging population, advances in technology, medical knowhow, and the prevalence of chronic diseases, which all call for a more involved patient. During the last decade, patient involvement in healthcare has been recognized as important to provide more efficient, integrated, patient-focused healthcare. Despite this recent gain in attention, there is a gap between rhetoric's and practice, since the meaning and benefits of patient involvement are unclear both in theory and practice. This thesis takes an alternate perspective on patient involvement, departing from service theory on value creation and customer involvement. It aims to understand and explore patient involvement and how patients can be involved in both the use, and development, of healthcare services. This thesis is based on three different studies using both qualitative and quantitative research methods. The first study is a systematic literature review of healthcare research, addressing the topic of patient involvement and related concepts. Based on a total of 125 reviewed empirical articles, this study serves as an introduction and orientation to the diverse field. It aims to contribute to the knowledge base in the growing research field of patient involvement. The second study addresses and explores lead-user theory as a method to identify highly innovative patients who can be suitable for involvement in healthcare development. The third study explores how patients, depending on disease, care process and context, can take different roles in healthcare development. The results indicate that patient involvement is not an isolated activity but influences the whole healthcare system. This extends the view of patient involvement from just decision-making and isolated encounters to patients potentially being substantially involved in all aspects of healthcare. This is also important in involvement in use. The patient's individual experiences, context, and type of illness play an important role in development initiatives. Patients should be selected carefully, for involvement in healthcare development, depending on the goal of the initiative. The type of illness and the patient's context are key factors to the kind of contributions patients can make. Depending on the type of illness, and if it shows up mostly at home or at the care provider's, patients develop different contributions. This thesis contributes to understanding patient involvement by taking a service perspective on co-creation and customer involvement. This approach to patient involvement extends the traditional view by proposing that patients should be involved in all stages of healthcare. Understanding how individuals create value and manage their health is important for individuals, healthcare providers, and government. Much of a patient's value creation takes place outside the patientprovider sphere, and is therefore unknown to the healthcare provider. By actively involving patients in both use and development, healthcare providers can apply a whole-person perceptive. ; Förutsättningarna för vården har förändrats under de senaste decennierna. Anledningar till dessa förändringar utgörs av bland annat en åldrande befolkning, teknisk och medicinsk utveckling och en ökad förekomst av kroniska sjukdomar. Traditionellt har patienter setts som passiva mottagare av vård, vars roll endast varit att svara på frågor samt följa läkarens ordination av behandling. På senare tid har detta dock börjat förändras. Patienter börjar att i högre grad ses som självständiga, engagerade och deltagande i vården. Enligt detta nya betraktningssätt kan patienter bidra aktivt till värdeskapande, tillsammans med vårdpersonal och andra resurser. Under det senaste decenniet har patientinvolvering setts som en allt viktigare del för att kunna leverera en mer effektiv, integrerad och patientfokuserad vård. Trots detta ökande intresse, finns det en skillnad mellan retorik och praktik. Patientinvolvering och fördelarna med patientinvolvering är oklara både i teori och praktik – bland forskare, sjukvårdspersonal och patienter. Denna licentiatsavhandling utgår från ett tjänsteperspektiv på patientinvolvering och syftar till att förstå och undersöka hur patienter kan vara involverade i användandet och utvecklingen av vården. Avhandlingen bygger på tre olika studier med både kvalitativa och kvantitativa forskningsmetoder. Resultaten av studierna tyder på att patientinvolvering inte är en isolerad process utan istället kan ses som något som påverkar alla delar av sjukvården. Detta utökar synen på vad patientinvolvering kan vara. Istället för att se patientinvolvering som kopplat till att patienten ger information och är involverad i beslutsfattande, kan patienten vara involverad i alla aspekter av sjukvården, både i själva utförandet och utvecklingen. Men det är också viktigt att patientens individuella erfarenheter och preferenser, sammanhang och sjukdomsbild spelar en stor roll för hur mycket och vilken typ av involvering som är lämplig. Vid patientinvolvering i utvecklingen av vården, bör patienter väljas noggrant beroende på mål med utvecklingen och vilken typ av involvering det rör sig om. Även sammanhang och typ av sjukdom är viktiga faktorer för vilken typ av bidrag som kan förväntas av patienter. Beroende på typ av sjukdom och kontext, kan patienter förväntas bidra på olika sätt. Denna avhandling bidrar till en ökad förståelse för patienters involvering i vården genom att ta utgångspunkt ur ett tjänsteperspektiv men fokus på värdeskapande och patienters engagemang. Detta förhållningsätt till patientinvolvering utökar den traditionella synen på involvering genom att föreslå att patienter ska vara involverade i alla steg och aktiviteter i vården. Mycket av patientens värdeskapande sker utanför vården, i den privata sfären, och är därför dolt för vårdgivaren. Att förstå hur patienter skapar värde och sköter sin hälsa är grundläggande för att kunna förbättra vården och stödja patientens egna ansträngningar. Genom att aktivt involvera patienter både i den egna vården men även i utvecklingen av vården i stort är det möjligt att gemensamt skapa en bättre vård.
When I was growing up in the beautiful Red Lick Valley in eastern Kentucky, I saw many families practicing intensive subsistence production. They grew large gardens, raised chickens for eggs and meat, built their own homes, and fixed their own cars and trucks. On the Yurok Reservation, I again saw a profound and ongoing engagement with hunting, gathering, and crafting activities - and then encountered contemporary subsistence yet again when I visited my wife's childhood home in rural Ireland. When I began my graduate studies, however, I could find little reflection of these activities in either the scholarly record or popular media. When they were noticed at all, they were often targeted for stereotyped ridicule: contemporary homesteaders in the US were either remnant hippies from the `60s, or quaint mountain folks lost in time. I already knew that these stereotypes were misleading and insufficient. However, they also highlighted the lack of understanding of a genuinely puzzling phenomenon: why, in the heart of an advanced industrial nation, are so many people still embracing what is, in essence, peasant production?Using multiple research methods - including in-depth, semi-structured interviews, participant observation, surveys, and archival work - I have found that contemporary homesteading is not a window lingering open upon the past, but a thoughtful and serious attempt to respond to the present. It is best thought of as an unusual kind of social movement. Rather than attempting to foster change by modifying policy or reforming dominant institutions, homesteaders pursue change through a conscious reworking of the economic foundations of their lives. Barbara Epstein calls this a "prefigurative" strategy: it aims to directly manifest - to prefigure - ways of life and relationships that dissidents believe are more appropriate. Because they do not require the visible organizational armature and attention-grabbing strategies of more traditional social movements, prefigurative movements - like the back-to-the-land movement - have often been overlooked by researchers.Contemporary homesteading is also an unusual social movement in that it attracts participants from widely different socioeconomic backgrounds. In eastern Kentucky there is an acute cultural distinction between two groups, known to each other, somewhat pejoratively, as hicks and hippies. I have found that neither group is accurately described by the dismissive stereotypes to which they are often subjected. There is indeed a countercultural back-to-the-land movement in the research area that emerged originally out of the radical leftist ferment of the 1960s. But rather than representing a dwindling cohort of aging hippie communards, this movement is comprised of people of all ages; my research suggests that there are more back-to-the-landers in the area now than there were forty years ago. Moreover, it is a movement comprised of a multi-stranded left, in which participants are as likely to have been radicalized through, say, the Quaker tradition or Catholic liberation theology as through the Grateful Dead or Timothy Leary. The stereotype of the "hick" homesteaders is no more accurate. They are not simply country folks carrying on Appalachian subsistence traditions despite the fact that those traditions have lost all practical relevance. Many of them have lived in cities and worked modern jobs, and consciously embrace homesteading in response to those experiences. They, too, are part of a back-to-the-land movement, in the sense of having chosen to live a certain way as a strategy of resistance.The presence of two groups who embrace homesteading, and yet remain distinct and somewhat distanced from one another provides one of the most profound and difficult questions that my research confronts. While there are individuals who move freely between these two groups, in general they remain remarkably segregated - even when they live side by side along the same country road. What accounts for this cultural distance? Whatever the difference between "hick" and "hippie" homesteaders, it is not straightforward: nearly half of those who can clearly be identified as belonging to the group of "countercultural back-to-the-land homesteaders" are themselves from rural Appalachian families.By far, the single most consistent difference between these two groups is that one group is not only college educated, but actively and independently literate; members of the other group, with few exceptions, have not attended college and seldom read. But this finding begs another question: why should a difference in the practice of literate intellectuality stand at the heart of profound cultural differences that encompass everything from diet and diction to religious belief and political orientation?The answer is complicated, but it emerges from the recognition that a modern capitalist society is one in which people have profoundly different experiences in all aspects of their lives, from cradle to grave, based on their socioeconomic position. As children, they attend radically different kinds of schools, or are slotted into separate tracks within a given school. After they leave school they have access to different kinds of jobs - shelving products at Wal-Mart, say, versus teaching in a college classroom. When people spend decades of their lives working such jobs, they end up with such divergent life experiences that they might as well be living in different societies. These divided institutional experiences are reinforced in turn by sharp segregation and by the development of opposition to the culture of those in other socioeconomic positions. The command or lack of literate intellectuality plays multiple roles in shaping and sustaining these starkly distinct life experiences, perhaps most clearly by shaping how a particular individual moves through the positions provided by dominant institutions. Taken together, these dynamics culminate in a forceful process that I refer to as "capitalist ethnogenesis": a process of cultural differentiation within a single society, rather than through geographic separation within separate, non-interacting or weakly interacting societies.The homesteading movement contains two groups who turn to the rural landscape for answers to the problems of modern civilization - but how they perceive and interpret that civilization and its problems are markedly different. They are, in effect, responding to different modernities. They turn to homesteading as people indelibly marked by the system they dream of escaping.
The study was conducted to determine, analyze, and evaluate the coping mechanisms of the former and current balut processors in Pateros. The general objective of the study was to present the coping mechanisms and diversification options of balut processors in Pateros. The specific objectives were to present the profiles of the existing and former balut processors in Pateros; to trace the development/changes in the actual practices of balut processors over a period of time; to evaluate the coping mechanisms undertaken and diversification decisions made by existing and former balut processors and identify potential problems arising from it; to determine the external and internal factors affecting the sustainability of operations of balut processors; and to recommend possible solutions/strategies based on the findings of the study. A total of 11 balut processors were identified and interviewed. The lists were obtained from the official website of Pateros and from the record of the Business Section of the town's municipality. On the other hand, there were eight former balut processors identified through snowball or referral method. The profile information of the existing and former balut processors were presented such as sex, age educational attainment, household size, number of years of residence, and membership to an organization. The influence of these entrepreneurial characteristics to the type of diversification decisions and coping mechanisms adapted by the processors were analyzed and described. The external factors affecting the balut operations and its sustainability were also identified and analyzed. The external factors were supply of duck eggs, costs of feeds, competition with balut producing provinces and Vietnamese processors, mass production with the aid of modern incubator, government assistance through OTOP and Balut festival, tertiary educational system in Pateros, and aging population. These factors were acting on the balut business that led to the coping mechanisms and diversification decision made by the balut processors. The balut business practices were also presented to trace the changes and development in the business as a response to the changes in the industry's environment. It was done across functional areas; marketing, production, human resource and finance. And to assess the profitability of the diversification decision o trading balut, a cost-benefit analysis was done. The study showed that the target markets of balut are those people with exotic taste. The price of balut was also highly dependent on the price of duck eggs and increasing the price too much would result to a decrease in the consumption of the balut eaters since it was not a necessity good. Pateros also used traditional method in producing balut that gave it the delicious taste. It was also showed in the study that balut making was labor intensive and that there were few people now who were engaged in the balut making. The capital for balut business was also a constant problem to the processors due to the inappropriate allocation of sales between the household needs and business operations. The internal factors affecting the sustainability of the balut operations were also identified and analyzed. The internal factors were seasonal demand, overcapacity and under capacity in production of balut during the peak and lean seasons, skills of the balut processors in handling balut, role of the balutan workers, interest of the entrepreneur, the financial standing of the balut business. Meanwhile, evaluation of the coping mechanisms undertaken and diversification decisions made by the processors was done through the analysis of the advantages and disadvantages of the given business decisions. The coping mechanisms and diversification strategies that were evaluated and analyzed were concentric diversification through selling balut by-products and trading balut, conglomerate diversification through water refilling station and rental building business, price and quality differentiation strategies, forward integration, strategic alliance, product development, market development, and liquidation. Profitability analysis of each strategy was done to determine the earnings gained from the business. It was found out that the processors were able to gain profits but the net margins were low. This was due to different factors such as high price of duck eggs, and labour costs. Analysis on the strengths, weaknesses, opportunities and threats was also done to summarize the internal and external factors acting upon the balut business that consequently affected their coping mechanisms and diversification decisions. The identified strengths of Pateros balut industry were high quality of balut, established name and the traditional method of processing balut while the identified weaknesses were sources of raw materials, seasonal demand and limited product form. On the other hand, the identified opportunities of the industry were the international market, balut festival, OTOP support services, and the local government's plan while the identified threats were competition with other balut-producing provinces, urbanization, and increasing price of poultry feeds. Other concern like the lack of business succession was also included in the analysis. Meanwhile, the problems of the processors were identified such as competition both in the local and domestic markets, sources of raw materials, and oversupply of balut from the suppliers of the processors engaged in trading balut, costly marketing strategies and so on. Recommendations were done to help the processors and the former balut processors to cope with the problems arising from the coping mechanism and diversification decisions made. It was done by stakeholders such as balut processors, government, potential processors, and support agencies. For the balut processors, it was recommended that they perform the market development for the international market and focused strategy for the institutional buyers in the local market since both markets were not fully penetrated by the balut processors in Pateros. For the government, it was recommended that they should assist the balut processors to backward integrate or contract grow to help address the problem in the source of raw materials, for the potential balut processors, it was recommended that they attend trainings on how to process balut ion a traditional method and how to process bottled balut. Lastly, for the support agencies like DOST and DTI, it was recommended that they assist the balut processors in marketing their balut in a greater market reach through conducting different programs like trade fairs that will showcase the Pateros balut.
Background InVietnam, the proportion of people aged 60 and above has increased rapidly in recent decades. The majority live in rural areas where socioeconomic status is more disadvantaged than in urban areas.Vietnam's economic status is improving but disparities in income and living conditions are widening between groups and regions. A consistent and emerging danger of communicable diseases and an increase of non-communicable diseases exist concurrently. The emigration of young people and the impact of other socioeconomic changes leave more elderly on their own and with less family support. Introduction of user fees and development of a private sector improve the coverage and quality of health care but increase household health expenditures and inequalities in health care. Life expectancy at birth has increased, but not much is known about changes during old age. There is a lack of evidence, particularly in rural settings, about health-related quality of life (HRQoL) among older people within the context of socioeconomic changes and health-sector reform. Knowledge of long-term elderly care needs in the community and the relevant models are still limited. To provide evidence for developing new policies and models of care, this thesis aimed to assess general health status, health care needs, and perspectives on future health care options for community-dwelling older people. Methods An abridged life table was used to estimate cohort life expectancies at old age from longitudinal data collected by FilaBavi DSS during 1999-2006. This covered 7,668 people aged 60 and above with 43,272 person-years. A 2007 cross-sectional survey was conducted among people aged 60 and over living in 2,240 households that were randomly selected from the FilaBavi DSS. Interviews used a structured questionnaire to assess HRQoL, daily care needs, and willingness to use and to pay for models of care. Participant and household socioeconomic characteristics were extracted from the 2007 DSS re-census. Differences in life expectancy are examined by socioeconomic factors. The EQ-5D index is calculated based on the time trade-off tariff. Distributions of study subjects by study variables are described with 95% confidence intervals. Multivariate analyses are performed to identify socioeconomic determinants of HRQoL, need of support, ADL index, and willingness to use and pay for models of care. In addition, four focus group discussions with the elderly, their household members, and community association representatives were conducted to explore perspectives on the use of services by applying content analysis. Results Life expectancy at age 60 increased by approximately one year from 1999-2002 to 2003-2006, but tended to decrease in the most vulnerable groups. There is a wide gap in life expectancy by poverty status and living arrangement. The sex gap in life expectancy is consistent across all socioeconomic groups and is wider among the more disadvantaged populations. The EQ-5D index at old age is 0.876. Younger age groups, position as household head, working, literacy, and belonging to better wealth quintiles are determinants of higher HRQoL. Ageing has a primary influence on HRQoL that is mainly due to reduction in physical (rather than mental) functions. Being a household head and working at old age are advantageous for attaining better HRQoL in physical rather than psychological terms. Economic conditions affect HRQoL through sensory rather than physical functions. Long-term living conditions are more likely to affect HRQoL than short-term economic conditions. Dependence in instrumental or intellectual activities of daily living (ADLs) is more common than in basic ADLs. People who need complete help are fewer than those who need some help in almost all ADLs. Over two-fifths of people who needed help received enough support in all ADL dimensions. Children and grand-children are confirmed to be the main caregivers. Presence of chronic illness, age groups, sex, educational level, marital status, household membership, working status, household size, living arrangement, residential area, household wealth, and poverty status are determinants of the need for care. Use of mobile teams is the most requested service; the fewest respondents intend to use a nursing centre. Households expect to use services for their elderly to a greater extent than did the elderly themselves. Willingness to use services decreases when potential fees increase. The proportion of respondents who require free services is 2 to 3 times higher than those willing to pay full cost. Households are willing to pay more for day care and nursing centres than are the elderly. The elderly are more willing to pay for mobile teams than are their households. ADL index, age group, sex, literacy, marital status, living arrangement, head of household status, living area, working status, poverty and household wealth are factors related to willingness to use services. Conclusions There is a trend of increasing life expectancy at older ages in ruralVietnam. Inequalities in life expectancy exist between socioeconomic groups. HRQoL at old age is at a high level, but varies substantially according to socioeconomic factors. An unmet need of daily care for older people remains. Family is the main source of support for care. Need for care is in more demand among disadvantaged groups. Development of a social network for community-based long-term elderly care is needed. The network should focus on instrumental and intellectual ADLs rather than basic ADLs. Home-based care is more essential than institutionalized care. Community-based elderly care will be used and partly paid for if it is provided by the government or associations. The determinants of elderly health and care needs should be addressed by appropriate social and health policies with greater targeting of the poorest and most disadvantaged groups. Building capacity for health professionals and informal caregivers, as well as support for the most vulnerable elderly groups, is essential for providing and assessing the services. ; Aging and Living Conditions Program ; Vietnam-Sweden Collaborative Program in Health, SIDA/Sarec
Tau phosphorylated at threonine 181 (p-tau181) measured in blood plasma has recently been proposed as an accessible, scalable, and highly specific biomarker for Alzheimer's disease. Longitudinal studies, however, investigating the temporal dynamics of this novel biomarker are lacking. It is therefore unclear when in the disease process plasma p-tau181 increases above physiological levels and how it relates to the spatiotemporal progression of Alzheimer's disease characteristic pathologies. We aimed to establish the natural time course of plasma p-tau181 across the sporadic Alzheimer's disease spectrum in comparison to those of established imaging and fluid-derived biomarkers of Alzheimer's disease. We examined longitudinal data from a large prospective cohort of elderly individuals enrolled in the Alzheimer's Disease Neuroimaging Initiative (ADNI) (n = 1067) covering a wide clinical spectrum from normal cognition to dementia, and with measures of plasma p-tau181 and an 18F-florbetapir amyloid-β PET scan at baseline. A subset of participants (n = 864) also had measures of amyloid-β1-42 and p-tau181 levels in CSF, and another subset (n = 298) had undergone an 18F-flortaucipir tau PET scan 6 years later. We performed brain-wide analyses to investigate the associations of plasma p-tau181 baseline levels and longitudinal change with progression of regional amyloid-β pathology and tau burden 6 years later, and estimated the time course of changes in plasma p-tau181 and other Alzheimer's disease biomarkers using a previously developed method for the construction of long-term biomarker temporal trajectories using shorter-term longitudinal data. Smoothing splines demonstrated that earliest plasma p-tau181 changes occurred even before amyloid-β markers reached abnormal levels, with greater rates of change correlating with increased amyloid-β pathology. Voxel-wise PET analyses yielded relatively weak, yet significant, associations of plasma p-tau181 with amyloid-β pathology in early accumulating brain regions in cognitively healthy individuals, while the strongest associations with amyloid-β were observed in late accumulating regions in patients with mild cognitive impairment. Cross-sectional and particularly longitudinal measures of plasma p-tau181 were associated with widespread cortical tau aggregation 6 years later, covering temporoparietal regions typical for neurofibrillary tangle distribution in Alzheimer's disease. Finally, we estimated that plasma p-tau181 reaches abnormal levels ∼6.5 and 5.7 years after CSF and PET measures of amyloid-β, respectively, following similar dynamics as CSF p-tau181. Our findings suggest that plasma p-tau181 increases are associated with the presence of widespread cortical amyloid-β pathology and with prospective Alzheimer's disease typical tau aggregation, providing clear implications for the use of this novel blood biomarker as a diagnostic and screening tool for Alzheimer's disease. ; M.J.G. is supported by the "Miguel Servet" program [CP19/00031] of the Spanish Instituto de Salud Carlos III (ISCIII-FEDER). T.K.K. holds a research fellowship from the Brightfocus Foundation (#A2020812F), and is further supported by the Swedish Alzheimer Foundation (Alzheimerfonden; #AF-930627), the Swedish Brain Foundation (Hjärnfonden; #FO2020-0240), the Swedish Dementia Foundation (Demensförbundet), the Agneta Prytz-Folkes & Gösta Folkes Foundation (#2020-00124), the Aina (Ann) Wallströms and Mary-Ann Sjöbloms Foundation, the Anna Lisa and Brother Björnsson's Foundation, Gamla Tjänarinnor, and the Gun and Bertil Stohnes Foundation. A.S. is supported by the Paulo Foundation and the Orion Research Foundation. M.S.C. received funding from the European Union's Horizon 2020 Research and Innovation Program under the Marie Sklodowska-Curie action grant agreement No 752310, and currently receives funding from Instituto de Salud Carlos III (PI19/00155) and from the Spanish Ministry of Science, Innovation and Universities (Juan de la Cierva Programme grant IJC2018-037478-I). H.Z. is a Wallenberg Scholar supported by grants from the Swedish Research Council (#2018-02532), the European Research Council (#681712), Swedish State Support for Clinical Research (#ALFGBG-720931), the Alzheimer Drug Discovery Foundation (ADDF), USA (#201809-2016862), and the UK Dementia Research Institute at UCL. K.B. is supported by the Swedish Research Council (#2017-00915), the Alzheimer Drug Discovery Foundation (ADDF), USA (#RDAPB-201809-2016615), the Swedish Alzheimer Foundation (#AF-742881), Hjärnfonden, Sweden (#FO2017-0243), the Swedish state under the agreement between the Swedish government and the County Councils, the ALF-agreement (#ALFGBG-715986), and European Union Joint Program for Neurodegenerative Disorders (JPND2019-466-236). M.S. is supported by the Knut and Alice Wallenberg Foundation (Wallenberg Centre for Molecular and Translational Medicine; KAW 2014.0363), the Swedish Research Council (#2017-02869), the Swedish state under the agreement between the Swedish government and the County Councils, the ALF-agreement (#ALFGBG-813971), and the Swedish Alzheimer Foundation (#AF-740191). Data collection and sharing for this project was funded by the Alzheimer's Disease Neuroimaging Initiative (ADNI) (National Institutes of Health Grant U01 AG024904) and DOD ADNI (Department of Defense award number W81XWH-12-2-0012). ADNI is funded by the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, and through generous contributions from the following: AbbVie, Alzheimer's Association; Alzheimer's Drug Discovery Foundation; Araclon Biotech; BioClinica, Inc.; Biogen; Bristol-Myers Squibb Company; CereSpir, Inc.; Cogstate; Eisai Inc.; Elan Pharmaceuticals, Inc.; Eli Lilly and Company; EuroImmun; F. Hoffmann-La Roche Ltd and its affiliated company Genentech, Inc.; Fujirebio; GE Healthcare; IXICO Ltd.; Janssen Alzheimer Immunotherapy Research & Development, LLC.; Johnson & Johnson Pharmaceutical Research & Development LLC.; Lumosity; Lundbeck; Merck & Co., Inc.; Meso Scale Diagnostics, LLC.; NeuroRx Research; Neurotrack Technologies; Novartis Pharmaceuticals Corporation; Pfizer Inc.; Piramal Imaging; Servier; Takeda Pharmaceutical Company; and Transition Therapeutics. The Canadian Institutes of Health Research is providing funds to support ADNI clinical sites in Canada. Private sector contributions are facilitated by the Foundation for the National Institutes of Health (www.fnih.org). The grantee organization is the Northern California Institute for Research and Education, and the study is coordinated by the Alzheimer's Therapeutic Research Institute at the University of Southern California. ADNI data are disseminated by the Laboratory for Neuro Imaging at the University of Southern California.
Kazakhstan's foreign policy, since its independence, has successfully avoided favoring any one country based on what Astana styles as a "multi-vectored" approach to foreign policy. Yet in terms of its conduct of defense and security policies, this paradigm simply does not fit with how the regime makes policy in its most sensitive areas of security cooperation. Indeed, its closest defense ties are still with Russia, which have deepened and intensified at a bilateral level as well as through multilateral initiatives in the context of the Collective Security Treaty Organization (CSTO) and the Shanghai Cooperation Organization (SCO). This is most evident in a close analysis of the evolution of its armed forces, including various efforts to reform its military and achieve mobile, combat capable, and professional forces. Since September 11, 2001 (9/11), Kazakhstan's defense posture has favored closer links with the United States and the North Atlantic Treaty Organization (NATO), while it has also pursued inconsistent efforts to extract better defense cooperation from Moscow. In 2003, shortly after the U.S. intervention in Iraq, President Nursultan Nazarbayev took the controversial step of agreeing to send engineers from Kazakhstan's embryonic peacekeeping battalion (KAZBAT) to support demining efforts placed under Polish command. Of course, the "deployment," though politically useful for Washington in displaying evidence of the diverse nature of the "coalition of the willing," was also beneficial for a highly ambitious political elite in Astana keen to showcase Kazakhstan's armed forces and project a positive image for the Kazakhstani military and its contribution to the new international order. It was not without domestic risk, since it represented the first instance of troops being sent beyond the region by any state within Central Asia, but this was managed carefully through the state controlled media and despite opposition from a pacifist contingent within Kazakhstan's parliament. Nevertheless, the Kazakhstani authorities gauged the risk to be manageable, since these engineers were not deployed operationally in the sense of taking on active peacekeeping duties; they were unlikely to see action in the theater itself. Moreover, the high profile and overemphasized importance of this cooperative initiative, which finally ended with the withdrawal of KAZBAT from Iraq at the request of the Iraqi government in October 2008, reaped dividends for the Nazarbayev regime as it could claim to be active in international stabilization efforts. In reality, the elements of KAZBAT were transported to Iraq using U.S. military transport aircraft since Kazakhstan lacked strategic airlift capabilities, and were maintained and helped through U.S. assistance. In the aftermath of Uzbekistan's alienation by the West following the tragic events in Andijan in May 2005, Kazakhstan was temporarily willing to acquiesce in being regarded as the region's security leader; NATO officials referred to Kazakhstan as NATO's "anchor" in Central Asia. This, in fact, is way beyond Kazakhstan's capabilities. The authorities have since mostly dropped these claims from official discourse. In other words, by paying close attention to KAZBAT, an entirely false impression of a largely unreformed and cumbersome post Soviet legacy force is engendered, with all the issues this entails, ranging from bullying, poor morale, underfunding, limited combat capabilities, and corruption at senior levels. This is also worsened by the manifold problems stemming from Soviet or Russian manufactured military equipment and hardware, often aging and desperately in need of repair, which severely inhibits the operational capabilities of Kazakhstan's air force, for example. Kazakhstan proved willing to receive much aid and assistance for its military from Western donors, principally the United States, Turkey, and NATO. Astana deepened its partnership with NATO and made efforts to strengthen its defense ties with Washington by agreeing to implement longer-term cooperation plans in the frameworks of "5-year plans" agreed between the U.S. Department of Defense and Kazakhstan's Ministry of Defense. In January 2007, Nazarbayev appointed Daniyal Akhmetov as the country's first ever civilian defense minister. This, coupled with Kazakhstan securing the Chaimanship of the OSCE in 2010, seemed to herald promising achievements in its defense posture, but these hopes have rapidly faded since. Understanding the problems, challenges, and continued failings of the defense leadership in Kazakhstan involves first appreciating how limited its military reforms have proven in practical terms. Akhmetov was reportedly shocked in the early part of his tenure to discover how poorly trained, disciplined, and often corrupt Kazakhstan's armed forces remain, despite several years of the state talking up "military reform." Although corruption is something of a sine qua non in the region, it is particularly crucial to recognize its debilitating effect on efforts to reform the armed forces. This will persist as an obstacle to achieving progress in successfully implementing military reform for the foreseeable future.Also, despite Kazakhstan's closer relations with Western militaries, it has in real terms deepened and strengthened its ties with Russia. The close nature of this defense cooperation relationship, reflected in Kazakhstan's new military doctrine, its intensified military and security training and educational agreements, as well as stepping up the frequency of military exercises, is also coupled with shared multilateral ties within the frameworks of the CSTO and SCO. Washington's military assistance programs have therefore often run into geopolitical issues, such as the limiting effect on its objectives emanating from Kazakhstan's political and defense relationship with Russia, or sensitivities to its close proximity to China, as well as internal issues surrounding Astana's military reform agenda. Defense spending in Kazakhstan will also be subject in the short to medium term depending on how the government handles its unfolding financial crisis and continued exposure to the global financial crisis, coupled with the sliding price of oil on the world markets. These issues, sharply refocused by the Russian military exposure of weaknesses within Georgia's armed forces despite several years of time-phased U.S. training and equipment programs, serve to question the aims, scope, and utility of American defense assistance programs calibrated to enhance Kazakhstan's military capabilities. While Astana grapples with these internal issues and remains politically sensitive to the anxieties of Moscow as it perceives U.S. training and aid to the Kazakhstani armed forces, success will be modest. New deeper and more closely monitored programs are needed and, combined with multilateral cooperative initiatives, should be a matter of urgent priority; otherwise, such programs will underperform and languish in the repetition of the misjudgements of the past.--P. v-viii. ; "February 2009." ; Includes bibliographical references (p. 59-65). ; Kazakhstan's foreign policy, since its independence, has successfully avoided favoring any one country based on what Astana styles as a "multi-vectored" approach to foreign policy. Yet in terms of its conduct of defense and security policies, this paradigm simply does not fit with how the regime makes policy in its most sensitive areas of security cooperation. Indeed, its closest defense ties are still with Russia, which have deepened and intensified at a bilateral level as well as through multilateral initiatives in the context of the Collective Security Treaty Organization (CSTO) and the Shanghai Cooperation Organization (SCO). This is most evident in a close analysis of the evolution of its armed forces, including various efforts to reform its military and achieve mobile, combat capable, and professional forces. Since September 11, 2001 (9/11), Kazakhstan's defense posture has favored closer links with the United States and the North Atlantic Treaty Organization (NATO), while it has also pursued inconsistent efforts to extract better defense cooperation from Moscow. In 2003, shortly after the U.S. intervention in Iraq, President Nursultan Nazarbayev took the controversial step of agreeing to send engineers from Kazakhstan's embryonic peacekeeping battalion (KAZBAT) to support demining efforts placed under Polish command. Of course, the "deployment," though politically useful for Washington in displaying evidence of the diverse nature of the "coalition of the willing," was also beneficial for a highly ambitious political elite in Astana keen to showcase Kazakhstan's armed forces and project a positive image for the Kazakhstani military and its contribution to the new international order. It was not without domestic risk, since it represented the first instance of troops being sent beyond the region by any state within Central Asia, but this was managed carefully through the state controlled media and despite opposition from a pacifist contingent within Kazakhstan's parliament. Nevertheless, the Kazakhstani authorities gauged the risk to be manageable, since these engineers were not deployed operationally in the sense of taking on active peacekeeping duties; they were unlikely to see action in the theater itself. Moreover, the high profile and overemphasized importance of this cooperative initiative, which finally ended with the withdrawal of KAZBAT from Iraq at the request of the Iraqi government in October 2008, reaped dividends for the Nazarbayev regime as it could claim to be active in international stabilization efforts. In reality, the elements of KAZBAT were transported to Iraq using U.S. military transport aircraft since Kazakhstan lacked strategic airlift capabilities, and were maintained and helped through U.S. assistance. In the aftermath of Uzbekistan's alienation by the West following the tragic events in Andijan in May 2005, Kazakhstan was temporarily willing to acquiesce in being regarded as the region's security leader; NATO officials referred to Kazakhstan as NATO's "anchor" in Central Asia. This, in fact, is way beyond Kazakhstan's capabilities. The authorities have since mostly dropped these claims from official discourse. In other words, by paying close attention to KAZBAT, an entirely false impression of a largely unreformed and cumbersome post Soviet legacy force is engendered, with all the issues this entails, ranging from bullying, poor morale, underfunding, limited combat capabilities, and corruption at senior levels. This is also worsened by the manifold problems stemming from Soviet or Russian manufactured military equipment and hardware, often aging and desperately in need of repair, which severely inhibits the operational capabilities of Kazakhstan's air force, for example. Kazakhstan proved willing to receive much aid and assistance for its military from Western donors, principally the United States, Turkey, and NATO. Astana deepened its partnership with NATO and made efforts to strengthen its defense ties with Washington by agreeing to implement longer-term cooperation plans in the frameworks of "5-year plans" agreed between the U.S. Department of Defense and Kazakhstan's Ministry of Defense. In January 2007, Nazarbayev appointed Daniyal Akhmetov as the country's first ever civilian defense minister. This, coupled with Kazakhstan securing the Chaimanship of the OSCE in 2010, seemed to herald promising achievements in its defense posture, but these hopes have rapidly faded since. Understanding the problems, challenges, and continued failings of the defense leadership in Kazakhstan involves first appreciating how limited its military reforms have proven in practical terms. Akhmetov was reportedly shocked in the early part of his tenure to discover how poorly trained, disciplined, and often corrupt Kazakhstan's armed forces remain, despite several years of the state talking up "military reform." Although corruption is something of a sine qua non in the region, it is particularly crucial to recognize its debilitating effect on efforts to reform the armed forces. This will persist as an obstacle to achieving progress in successfully implementing military reform for the foreseeable future.Also, despite Kazakhstan's closer relations with Western militaries, it has in real terms deepened and strengthened its ties with Russia. The close nature of this defense cooperation relationship, reflected in Kazakhstan's new military doctrine, its intensified military and security training and educational agreements, as well as stepping up the frequency of military exercises, is also coupled with shared multilateral ties within the frameworks of the CSTO and SCO. Washington's military assistance programs have therefore often run into geopolitical issues, such as the limiting effect on its objectives emanating from Kazakhstan's political and defense relationship with Russia, or sensitivities to its close proximity to China, as well as internal issues surrounding Astana's military reform agenda. Defense spending in Kazakhstan will also be subject in the short to medium term depending on how the government handles its unfolding financial crisis and continued exposure to the global financial crisis, coupled with the sliding price of oil on the world markets. These issues, sharply refocused by the Russian military exposure of weaknesses within Georgia's armed forces despite several years of time-phased U.S. training and equipment programs, serve to question the aims, scope, and utility of American defense assistance programs calibrated to enhance Kazakhstan's military capabilities. While Astana grapples with these internal issues and remains politically sensitive to the anxieties of Moscow as it perceives U.S. training and aid to the Kazakhstani armed forces, success will be modest. New deeper and more closely monitored programs are needed and, combined with multilateral cooperative initiatives, should be a matter of urgent priority; otherwise, such programs will underperform and languish in the repetition of the misjudgements of the past.--P. v-viii. ; Mode of access: Internet.
The Philippine national government, through the Department of Health (DOH), has a long tradition of augmenting the supply of health care workers in underserved areas. Even with the adoption of the Local Government Code in 1991, which shifts the mandate of DOH from being sole provider of health services to provider of technical services for health, the DOH continues to deploy health care professionals throughout the country. Over the last decade, the national health resources for health (HRH) deployment program has expanded from a relatively small program with a budgetary support of less than PhP200 million that deployed less than 500 health professionals in 2010 to a massive program of about PhP10 billion that deployed almost 30,000 health care workers in 2020. This process evaluation aims to assess the DOH-HRH deployment program design and logic, and document its implementation vis-à-vis its stated design. We find that while the program has many advantages over individual local governments in reallocating HRH across geographic boundaries, there are both design and implementation challenges that may negatively impact on the experiences of deployed health care workers, which, in turn, may reflect negatively on the program. We provide some actionable recommendations specific to these issues to improve the program.
On 5 March, the World Bank released a report entitled Taking the Pulse of Poverty and Inequality in Thailand. This report was keenly anticipated, as the past decade has seen mounting concern over economic inequality in the country. In the event, findings concerning poverty presented in the report proved as noteworthy as the light that it shed on inequality. They indicated that 2016 and 2018 saw increases in poverty in Thailand. These increases, coming in the absence of major shocks, suggest troubling vulnerability to falling into poverty among important segments of the population. That vulnerability highlights structural issues of a kind that, in other contexts, analysts associate with conditions of precarity, though the March 2020 World Bank report does not use that term. Nor does that report draw on scholarship on Thailand's political economy. Despite the country's having reported the first confirmed case of Covid-19 outside China more than six weeks before the release of Taking the Pulse of Poverty and Inequality in Thailand, the report fails to address the implications of the pandemic for Thailand. Nonetheless, as the country looks toward "recovery" from the economic impact of the coronavirus, both understanding the findings of the report in the broadest possible perspective and asking whether it is not time to talk about precarity in this upper middleincome Southeast Asian economy are essential.
This guide to small area estimation aims to help users compile more reliable granular or disaggregated data in cost-effective ways. It explains small area estimation techniques with examples of how the easily accessible R analytical platform can be used to implement them, particularly to estimate indicators on poverty, employment, and health outcomes. The guide is intended for staff of national statistics offices and for other development practitioners. It aims to help them to develop and implement targeted socioeconomic policies to ensure that the vulnerable segments of societies are not left behind, and to monitor progress toward the Sustainable Development Goals.
This paper is about how to improve the wellbeing of children living in poverty. We propose a framework for thinking about child poverty that supplements a focus on resource adequacy with insights from Amartya Sen's capability approach to wellbeing.
This report presents nine case studies of recent Asian Development Bank projects in Mongolia, Nepal, the People's Republic of China, the Philippines, Sri Lanka, Uzbekistan, and Viet Nam. The case studies highlight innovative interventions and common effective approaches used to reduce poverty: (i) providing broader access to economic opportunities, (ii) promoting resilience, and (iii) empowering communities through improved governance. By sharing experiences gained from the successful implementation of these projects, this report aims to contribute to international efforts to develop and adopt better policies and practices toward eradicating poverty.
This ADBI newsletter is published periodically throughout the year to provide information on current events, seminars and summits, Job opportunities, blogs and news and current publications concerning growth and development in Asia and the Pacific.
Indonesia is a highly unequal country. According to Oxfam, the richest one percent of Indonesians controls 49 percent of the country's wealth. Such disparity is a contentious political issue in a country where corruption scandals are routine, and where a large slice of the wealthiest citizens are from the minority ethnic Chinese community. During President Jokowi's first term in office, levels of inequality improved incrementally. Yet his political adversary and rival in the 2019 presidential elections, Prabowo Subianto, continues to resurrect rhetorical tropes about economic disparities that he has used for almost a decade, which paint Indonesia as a nation of poor, downtrodden slaves exploited by a wealthy elite. In this article, we first look at the state and trajectory of inequality in Indonesia. Next, we reflect on political narratives about economic injustice and inequality in the context of recent election campaigns, and particularly the 2019 presidential election. We then draw on recent survey about how Indonesians themselves feel about inequality, and to consider whether problems of income disparity matter to voters, and whether they matter more to particular constituencies.
This publication presents the background and rationale, project implementation progress, and achievements of the Japan Fund for Poverty Reduction covering the period from 1 January to 31 December 2016. It contains general information about the fund's project grants and technical assistance, with details about their operational performance during the year. Administered by the Asian Development Bank and established in May 2000, the fund provides direct grant assistance to the poorest and most vulnerable groups in Asia and the Pacific while fostering long-term social and economic development.
