Suchergebnisse

Health is a direct source of human welfare and also an instrument for raising income levels. The authors discuss a number of mechanisms through which health can affect income, focusing on worker productivity, children's education, savings and investment, and demographic structure. As well as the impact of current illness, health may have large effects on prospective life spans and life cycle behavior. Studies suggest there may be a large effect of health and nutrition in uteri, and in the first few years of life, on physical and cognitive development and economic success as an adult. Macroeconomic evidence for an effect on growth is mixed, with evidence of a large effect in some studies. However, there is a possibility that gains from health may be outweighed by the effect of increased survival on population growth, until a fertility transition occurs. The low cost of some health interventions that have large-scale effects on population health makes health investments a promising policy tool for growth in developing countries. In addition, higher priority could be given to tackling widespread 'neglected' diseases that is, diseases with low mortality burdens that are not priorities from a pure health perspective, but that do have substantial effects on productivity.

Problem setting. The status of the state and private partnership in Ukraine and the prospects of its development under conditions of the healthcare reform were examined. The cooperation of the state and private sector becomes increasingly important in a social sense, however the existing practice does not demonstrate the efficiency of the fulfillment of the assigned tasks. The conducted analysis allowed to determine the risks and problems of the implementation of the state and private partnership in the sphere of healthcare under current conditions in Ukraine. It was substantiated that the fulfillment of the concept of the state and private partnership in the healthcare system of Ukraine is one of the key issues of the state policy. Recent research and publications analysis. The involvement of a private partner in the field of healthcare is highly common in many countries of the world. The effectiveness of such cooperation is confirmed and described in a number of various studies. At the same time, authors' publications fail to mention the aspects of involving the private sector in the activities of municipal and state healthcare facilities, including under conditions of healthcare reform in Ukraine. Highlighting previously unsettled parts of the general problem. At the modern stage of reforming of the healthcare system which is an integral part of socioeconomic transformations in Ukraine, the problem of the state regulation of investment support for the development of healthcare sector is becoming ever more important. The main goal of the reform is to build such a model of the healthcare system which would ensure equal and fair access of all members of society to necessary medical services, their high quality and cost-effectiveness while maintaining socially expected volume of state guarantees. The purpose of this article is to reveal the prospects of the state and private partnership under conditions of implementation of the healthcare reform. Paper main body. Ministry of Economic Development and Trade of Ukraine continues to play a key role in the institutional support of the state and private partnership in Ukraine. According to the regulatory document (Decree on the Ministry) it is entrusted with various functions related to the implementation of the state policy in this sector, and namely: monitoring the efficiency of the central, regional and municipal authorities in the field of the state and private partnership; verification of the fulfilment of the signed contracts on the state and private partnership; preparation and provision of information on the results of the state and private partnership to the public; monitoring and evaluation of various types of risks (and namely, general risk) of state partners within the framework of the contracts on the state and private partnership; accounting of contracts on the state and private partnership; organizing and conducting training in order to form and implement the contracts on the state and private partnership; monitoring of compliance with the requirements of current laws on the state and private partnership with respect to existing and new contracts. As of today, the development of the concept of the state and private partnership in the field of healthcare of Ukraine, unfortunately, is not a matter of priority of the state policy and modern budgeting system creates high financial risks for the state and private partnership which are related to short-term (yearly) budget cycles of planning and their annual approval procedures which are sometimes unnecessarily prolonged. Joint activities, distribution of products etc. may be forms of implementation of the projects of the state and private partnership and they may be financed from the funds of the state and local budgets, financial resources of the private partner, loaned funds and other sources which are not prohibited by laws. In this case, the legislation foresees the provision of support to projects of the state and private partnership through state guarantees, provision of funds from state and local budgets and other sources within the framework of the state-wide and local programmes. There are also preconditions for organizing high-tech centres for treating various types of diseases while using financial instruments of investors and staff capacity of the state healthcare facilities. However, presently there are certain doubts on the side of potential private partners regarding the possibility of implementation of long-term mutually beneficial cooperation. It resulted in the absence of transparency and clarity in the normative and legal regulation of the state and private partnership in Ukraine. Therefore, state and private partnership must ensure: The use of the mechanism for planning and funding projects of the state and private partnership because it contributes significantly to the interest of private domestic and foreign investors in participating in the state and private partnership. Normative and legal regulation of implementation of projects of the state and private partnership. Successful introduction of infrastructure projects of the state and private partnership into the activities of healthcare facilities. Construction of high-tech centres for treatment of various types of diseases. Increasing the accessibility of health services for the population and supporting the development of the private sector. Conclusions of the research and prospects for further studies. The majority of projects were implemented in order to reduce the expenses incurred by state and municipal healthcare facilities and neither to increase the quality of provision of health services nor to optimize the expenditure for upgrading material and technical equipment. As a result, the efficiency of such state and private cooperation is one-sided and, as a rule, it has a positive impact solely on the private partner or a short-term result for a healthcare facility where such cooperation is implemented. In this case, the primary task laid as part of implementation of the state policy within the framework of healthcare reform, and namely improving the quality and accessibility of health services for the population of Ukraine, remains uncompleted on the side of the state and municipal healthcare facilities. However, there is a positive experience of involvement of private business in the process of introduction of infrastructure projects of the state and private partnership into the activities of healthcare facilities; confirmation of the relevance of the development for practical introduction of infrastructural projects of the state and private partners into the activities of facilities of the system of emergency medical care of Ukraine. Introduction of the mentioned infrastructural forms of the state and private partnership into the activities of emergency medical care facilities in Ukraine may be an effective instrument for reducing the share of the non-market sector in the field of healthcare while simultaneously increasing the efficiency of the state management. The involvement of the private sector helps to resolve several issues at once: Involvement of personnel oriented towards the provision of services which will contribute significantly to the competitive ability of the state and municipal facilities. Management which reacts quickly to changes on the market of health services which is somewhat restricted under conditions of budgetary legislation on the side of the state and municipal healthcare facilities and is sufficiently important for constantly adapting the needs of the population to the modern global requirements. Raising funds from partners for upgrading material and technical equipment, on the one hand, may significantly reduce financial losses with the involvement of the most up-to-date technologies or give the facilities an opportunity to receive modern services and equipment with the use of the funds of private partners. Reducing financial burden of expenses on local authorities and the state budget of Ukraine in general while keeping a healthcare facility in a satisfactory condition and corresponding level of provision of health services. Improvement of socioeconomic standard of living on account of an increase in accessibility of healthcare to the population of Ukraine in accordance with global requirements. All of this will finally result in a change of the situation in the healthcare sector, will help to build trust in the domestic medicine and increase the health of the nation in the overall perspective. Further research prospects in this direction should include the study of successful foreign experience for strengthening the state and private partnership and determining the feasibility of implementation of the best foreign practices under current conditions in Ukraine on account of development, adaptation and introduction of changes into the legal framework. ; Розглянуто стан державно-приватного партнерства в Україні та перспективи його розвитку в умовах реформи охорони здоров'я. Зауважено, що співпраця державного та приватного сектору набуває все більшого соціального значення, проте існуюча практика не демонструє ефективність у реалізації визначених цілей. На основі проведеного аналізу визначено ризики та проблеми в реалізації державно-приватного партнерства у сфері охорони здоров'я у сучасних умовах в Україні. Обґрунтовано, що реалізація концепції державно-приватного партнерства у системі охорони здоров'я України є одним із ключових питань державної політики.

Problem setting. The status of the state and private partnership in Ukraine and the prospects of its development under conditions of the healthcare reform were examined. The cooperation of the state and private sector becomes increasingly important in a social sense, however the existing practice does not demonstrate the efficiency of the fulfillment of the assigned tasks. The conducted analysis allowed to determine the risks and problems of the implementation of the state and private partnership in the sphere of healthcare under current conditions in Ukraine. It was substantiated that the fulfillment of the concept of the state and private partnership in the healthcare system of Ukraine is one of the key issues of the state policy. Recent research and publications analysis. The involvement of a private partner in the field of healthcare is highly common in many countries of the world. The effectiveness of such cooperation is confirmed and described in a number of various studies. At the same time, authors' publications fail to mention the aspects of involving the private sector in the activities of municipal and state healthcare facilities, including under conditions of healthcare reform in Ukraine. Highlighting previously unsettled parts of the general problem. At the modern stage of reforming of the healthcare system which is an integral part of socioeconomic transformations in Ukraine, the problem of the state regulation of investment support for the development of healthcare sector is becoming ever more important. The main goal of the reform is to build such a model of the healthcare system which would ensure equal and fair access of all members of society to necessary medical services, their high quality and cost-effectiveness while maintaining socially expected volume of state guarantees. The purpose of this article is to reveal the prospects of the state and private partnership under conditions of implementation of the healthcare reform. Paper main body. Ministry of Economic Development and Trade of Ukraine continues to play a key role in the institutional support of the state and private partnership in Ukraine. According to the regulatory document (Decree on the Ministry) it is entrusted with various functions related to the implementation of the state policy in this sector, and namely: monitoring the efficiency of the central, regional and municipal authorities in the field of the state and private partnership; verification of the fulfilment of the signed contracts on the state and private partnership; preparation and provision of information on the results of the state and private partnership to the public; monitoring and evaluation of various types of risks (and namely, general risk) of state partners within the framework of the contracts on the state and private partnership; accounting of contracts on the state and private partnership; organizing and conducting training in order to form and implement the contracts on the state and private partnership; monitoring of compliance with the requirements of current laws on the state and private partnership with respect to existing and new contracts. As of today, the development of the concept of the state and private partnership in the field of healthcare of Ukraine, unfortunately, is not a matter of priority of the state policy and modern budgeting system creates high financial risks for the state and private partnership which are related to short-term (yearly) budget cycles of planning and their annual approval procedures which are sometimes unnecessarily prolonged. Joint activities, distribution of products etc. may be forms of implementation of the projects of the state and private partnership and they may be financed from the funds of the state and local budgets, financial resources of the private partner, loaned funds and other sources which are not prohibited by laws. In this case, the legislation foresees the provision of support to projects of the state and private partnership through state guarantees, provision of funds from state and local budgets and other sources within the framework of the state-wide and local programmes. There are also preconditions for organizing high-tech centres for treating various types of diseases while using financial instruments of investors and staff capacity of the state healthcare facilities. However, presently there are certain doubts on the side of potential private partners regarding the possibility of implementation of long-term mutually beneficial cooperation. It resulted in the absence of transparency and clarity in the normative and legal regulation of the state and private partnership in Ukraine. Therefore, state and private partnership must ensure: The use of the mechanism for planning and funding projects of the state and private partnership because it contributes significantly to the interest of private domestic and foreign investors in participating in the state and private partnership. Normative and legal regulation of implementation of projects of the state and private partnership. Successful introduction of infrastructure projects of the state and private partnership into the activities of healthcare facilities. Construction of high-tech centres for treatment of various types of diseases. Increasing the accessibility of health services for the population and supporting the development of the private sector. Conclusions of the research and prospects for further studies. The majority of projects were implemented in order to reduce the expenses incurred by state and municipal healthcare facilities and neither to increase the quality of provision of health services nor to optimize the expenditure for upgrading material and technical equipment. As a result, the efficiency of such state and private cooperation is one-sided and, as a rule, it has a positive impact solely on the private partner or a short-term result for a healthcare facility where such cooperation is implemented. In this case, the primary task laid as part of implementation of the state policy within the framework of healthcare reform, and namely improving the quality and accessibility of health services for the population of Ukraine, remains uncompleted on the side of the state and municipal healthcare facilities. However, there is a positive experience of involvement of private business in the process of introduction of infrastructure projects of the state and private partnership into the activities of healthcare facilities; confirmation of the relevance of the development for practical introduction of infrastructural projects of the state and private partners into the activities of facilities of the system of emergency medical care of Ukraine. Introduction of the mentioned infrastructural forms of the state and private partnership into the activities of emergency medical care facilities in Ukraine may be an effective instrument for reducing the share of the non-market sector in the field of healthcare while simultaneously increasing the efficiency of the state management. The involvement of the private sector helps to resolve several issues at once: Involvement of personnel oriented towards the provision of services which will contribute significantly to the competitive ability of the state and municipal facilities. Management which reacts quickly to changes on the market of health services which is somewhat restricted under conditions of budgetary legislation on the side of the state and municipal healthcare facilities and is sufficiently important for constantly adapting the needs of the population to the modern global requirements. Raising funds from partners for upgrading material and technical equipment, on the one hand, may significantly reduce financial losses with the involvement of the most up-to-date technologies or give the facilities an opportunity to receive modern services and equipment with the use of the funds of private partners. Reducing financial burden of expenses on local authorities and the state budget of Ukraine in general while keeping a healthcare facility in a satisfactory condition and corresponding level of provision of health services. Improvement of socioeconomic standard of living on account of an increase in accessibility of healthcare to the population of Ukraine in accordance with global requirements. All of this will finally result in a change of the situation in the healthcare sector, will help to build trust in the domestic medicine and increase the health of the nation in the overall perspective. Further research prospects in this direction should include the study of successful foreign experience for strengthening the state and private partnership and determining the feasibility of implementation of the best foreign practices under current conditions in Ukraine on account of development, adaptation and introduction of changes into the legal framework. ; Розглянуто стан державно-приватного партнерства в Україні та перспективи його розвитку в умовах реформи охорони здоров'я. Зауважено, що співпраця державного та приватного сектору набуває все більшого соціального значення, проте існуюча практика не демонструє ефективність у реалізації визначених цілей. На основі проведеного аналізу визначено ризики та проблеми в реалізації державно-приватного партнерства у сфері охорони здоров'я у сучасних умовах в Україні. Обґрунтовано, що реалізація концепції державно-приватного партнерства у системі охорони здоров'я України є одним із ключових питань державної політики.

There are three main messages running throughout this report. First, Non Communicable Diseases (NCDs) can impose large health, financial and economic costs on countries. This is particularly important in the Pacific where Government already finances, and provides, the bulk of health services. Second, risk factors in the Pacific are feeding a pipeline of potentially expensive to treat NCDs, including diabetes and heart disease, but governments are already fiscally constrained in how much more they can provide to the health system. Third, from public health and public finance perspective, many of the NCDs are avoidable, or their health and financial costs can at least be postponed, through good primary and secondary prevention. This will require a more coherent approach to health system financing, and health system operations more generally.

White shrimp has become a key commodity in Vietnamese aquaculture. White shrimp farming does not only enable the participation of smallholders, but also attracts companies and other stakeholders along the value chain. The value generating activities in white shrimp farming have contributed to improved livelihood opportunities of its stakeholders, and the socioeconomic growth of coastal communities in general. However, low accessibility to high value markets, low bargaining power and high dependence are existing issues for farmers, which affect the efficiency of white shrimp farming, as well as the development of the white shrimp value chain. Based on a qualitative analysis of the white shrimp value chain in Vietnam, the presented research explores the current situation of production and consumption of the white shrimp industry, as well as advantages, disadvantages and development strategies in white shrimp farming. The value chain analysis approaches are theoretically based on the concepts of global production networks and global value chains (e.g. Gerreffi et al., 1994, 2005, 2016; Humphrey and Schmitz, 2001; Dicken, 2015; Coe and Yeung, 2015). Gereffi et al.'s (2005) approach of five types of governance and Humphrey and Schmitz' (2002) concept of four types of upgrading within the concept of value chain analysis are the backbone of this study. The goal of this study was to provide information on the current status and sustainability issues in white shrimp farming, the differences among marketing channels and response ability of farmers to access each channel. Additionally, the power relationships among actors within the white shrimp value chain and the impact of these relationships on farmers are also outlined. Qualitative research methods were applied by conducting 24 semi-structured interviews. Interviewed stakeholders include white shrimp farmers, suppliers, middlemen, wholesalers, retailers, and relevant representatives of local governments. Further, secondary data was collected through socio-economic reports of government levels and related previous research. Thua Thien Hue province in central Vietnam was selected as the case study area. The first part of this thesis is an introduction on global food, the importance of aquaculture and the rationale behind conducting research on value chain analysis. Afterwards, the framework of value chain analysis, governance and upgrading dimensions and the agri-food value chain, Vietnamese aquaculture with regard to development processes, distribution and existing issues, as well as the research methodology are outlined before presenting the empirical results, discussion and conclusion. The research results are outlined in four stand-alone research papers (chapters 5-8), which have the following common characteristics: the research focuses on small-scale white shrimp farmers; the theoretical approach of global production networks and global value chains is used for the analysis; governance dimensions are also a theoretical lens used throughout the research; furthermore, informal transactions and informal relationships often coin the white shrimp value chain and are thus integral parts of the empirical work. The results show that the volume of white shrimp has significantly increased in central Vietnam in both, production and export since 2002. White shrimp farming requires high investments while it can provide comparably high revenue for farmers; normally, farmers can gain profit margins from 4.5 to 10%. However, lack of expertise, low availability of relevant infrastructure, missing access to capital and traditional production routines of farmers are affecting sustainability as well as resilient livelihoods with regard to the quality of white shrimp seed, changing technical knowledge, use of aquatic medicine, water pollution and curing diseases. Furthermore, there is a dependency of farmers on input suppliers because farmers are often debtors of input suppliers, especially of industrial feed suppliers. Meanwhile, the output market of white shrimp is controlled by intermediaries and most of the Vietnamese white shrimp production is traded via these middlemen before being distributed to consumers or processors. Although farmers can access the processing plant to capture a higher share of value, international standards appear as barriers for these kinds of direct business relations. The change from informal relationships to formal relationships is constrained by the gap between the quality requirements of processing plants and the ability of farmers to adapt to those requirements. Thus, selecting intermediaries is currently the easiest solution for farmers for accessing sales markets. This development led to ignoring the regulations on using antibiotics for shrimp production and wastewater treatment among farmers; instead, they solely focused on growing the production and maximizing revenues, which can be considered an attempt of farmers to compensate their disadvantages. Compared to other actors in the white shrimp value chain, farmers have less bargaining power, and little to no possibilities of independent decision-making, which leaves them only able to react instead of act within business relations. The relationships among actors in the chain were established based on personal trust, regular face-to-face interaction and the exchange of tacit information. The typical feature of the relationships is a high degree of informality and that the binding character can be stronger than with a formal contract. Local governments and farmers have implemented various strategies to upgrade the white shrimp value chain. That might result in issuing the regulations in white shrimp farming, establishing cooperative organizations. However, these activities are still limited and the majority of farmers are still facing major issues of access to distribution channels and dependencies on middlemen and suppliers. Hence, the thesis concludes, that in order to be competitive and ecologically sustainable, white shrimp farmers need to change production habits and improve product quality to respond to the requirements of domestic and international markets. The local government needs to continue to support farmers with infrastructure, capital and technology.

Introduction Choice and access to health care are important determinants of health outcomes. Various issues influence choice and determine the degree of, and differences in access to health care. Choice of health care facilities by individuals is often determined by the interplay between patient and provider characteristics. The influence of factors that determine choice of a health care facility or a provider varies depending on individual patient's socio-ecological factors, type and severity of illness (including the presence or absence of co-morbidities), cost of healthcare (including travel costs), and the presence or absence of a third party such as a health insurance plan. On the other hand, provider or facility factors, which include spatial and non-spatial factors such as technical and functional dimensions of quality of care, are the supply–side factors that influence choice of provider and facility. In order to achieve universal health coverage and attain the Sustainable Development Goals, Nigeria adopted a prepayment health care financing method through the National Health Insurance Scheme (NHIS) in 2005. However, population coverage of the scheme remains very low, while it also has a reputation of less than optimal performance. Evidence showed that while some accredited NHIS facilities were burdened with a high volume of enrolees, others had registered low volume (of enrolees). This study explored the influence and magnitude of the various factors responsible for the poor performance of the scheme as well as the lopsided/uneven distribution of enrolees across these health care facilities. Findings will assist in repositioning the scheme for better performance as well as serve as a guide for other countries planning to design and implement similar schemes. This will enable such schemes to learn from and avoid mistakes made under the present scheme. Methods This study was cross-sectional in design, with descriptive and analytical components. Data were collected using a mixed-method approach (geo-spatial, quantitative and qualitative). The geo-spatial component was achieved using three data layers of x and y coordinates: the enrolees' locations, locations of NHIS facilities and locations of health care facilities typically used by enrolees, were used in the spatial analysis to identify the closest NHIS accredited health care facility to each enrolee's residence and also estimate the distance between enrolee's location and NHIS facility being utilised. The Distance to the Nearest Hub (points) function in Quantum GIS 3.10 was used to automatically assign enrolees to the nearest NHIS facility while the Join by lines (Hub Lines) function was used to assign enrolees to the NHIS facility they used. Spider web diagrams that depict geo-spatial relationship between enrolees' residence, patronised health care facilities and health care facilities closest to the residences were constructed. Quantitative data were collected from 432 NHIS enrolees using an adapted questionnaire. A checklist was also used to collect data on structural components of health facilities such as the number and cadre of the health workforce, availability and functionality of medical equipment and facility infrastructure. Quantitative data were analysed using STATA and frequency tables were generated. Qualitative data were collected through in-depth interviews conducted among 29 participants of the NHIS, HMOs, enrolees, head of facilities and an academic. Qualitative data analysis was done using an inductive thematic approach. Audio-taped interviews were transcribed and codes were generated. Themes were thereafter searched for and generated from the codes. Emerging themes were named, documented and analysed accordingly. A conceptual framework that illustrated the Nigeria contextual environment, the health system and the current governance of the NHIS with a highlight on the relationships, factors and patterns of interaction among stakeholders was designed. Results The majority of the enrolees received care across a small proportion of the accredited facilities and bypassed nearby health facilities to receive care. Almost all the study respondents, 405 (93.9%) bypassed, however, only 147 (34.0%) reported to have done so. In this study, predictors of bypass of healthcare facilities were younger age (OR 0.67, CI 0.46 – 0.99, p = 0.046) and employment in the civil service (OR 0.49, CI 0.31-0.79, p = 0.003). Older age (1.66, CI 1.07-2.58, p = 0.024), attainment of tertiary level of education (OR 1.57, CI 1.02-2.44, p = 0.043), high socioeconomic status (OR 1.94, CI 1.24 -3.02, p = 0.003) and presence of multiple morbidities (OR 1.66, CI 0.99-2.78, p = 0.053) were predictors of personal choice of health facility. Physical infrastructure was poor in all the facilities; most of the facilities depended on more than one source of power supply and water supply was mainly from other sources apart from pipe-borne. Identified predictors of satisfaction with care were age, occupation and seeking information about quality of care. Knowledge of the NHIS and patronage of faith-based health facilities were also predictors of satisfaction with care. Respondents who were younger than 35 years of age were more likely to be satisfied with care than those who were older (OR 1.85, CI = 1.05 – 3.25, p< 0.05). Private sector workers under the scheme (OR 1.84, CI 1.03 – 3.28, p< 0.05) were more likely to be satisfied with care than those employed in the civil service. Likewise, compared with those who did not seek information, those who did (OR 1.63, CI = 1.04 – 2. 53, p< 0.05) were more likely to report satisfaction with care. Respondents who claimed not to have a knowledge of the NHIS were more likely to be satisfied with care (OR 1.65, CI = 1.06 – 2.55, p< 0.05). Likewise, patronage of faith–based facilities was identified to be a predictor of satisfaction with care (OR 1.84, CI = 1.09 – 3.08, p< 0.05). Qualitative data revealed that there was a very low level of trust among the stakeholders. The design and operations of the scheme indicated that the NHIS managers lacked the technical and managerial skills required to manage the scheme and other stakeholders. Both the NHIS officials and the health care providers were of the opinion that the HMOs had more political influence than other stakeholders in the scheme, and were using this to take advantage of others. Enrolees and health care providers were reluctant to collaborate with the scheme at inception, because of the low level of trust in government policies generally. In addition, at inception of the scheme, the majority of the enrolees were arbitrarily allocated to the few available health care providers. For some of the enrolees, choice of health care facilities was based on perceived quality of care and occasionally, as a result of proximity to places of residence. Instances of corrupt and unethical practices were reported across the board among the scheme stakeholders. Discussion There was a high level of facility bypassing among study respondents, though only a few of them claimed to be aware of this. This finding is because of the allocation or assignment of majority of the enrolees to the few facilities that were available to participants in the scheme at its inception. The study also revealed that younger age enrolees and civil servants bypassed more than their respective counterparts did. Studies have shown that younger people are more likely to explore and become more adventurous than older individuals. The apparent bypassing among civil servants was largely because of the arbitrary allocation of reluctant enrolees to the available few health care providers at the inception of the scheme. This also explained the skewed distribution of the enrolees in these few facilities under the scheme. Findings also support the observation that most of the facilities with fewer enrolees were those that stayed away from the scheme at inception. However, the observed lopsided/uneven pattern was difficult to reverse despite the complaints of the facilities with fewer enrolees and the efforts of the scheme to address the skewness. It should also be noted that high social economic class is a strong factor of personal choice of healthcare facilities. The only plausible explanation was the fact that this group of enrolees were not civil servants and who had the financial capacity to pay the premiums, which enabled them buy into the scheme voluntarily and personally chose facilities where to receive care. The state of physical infrastructure in all the facilities that were involved in the study is illustrative of the weak health system in Nigeria. Poor facility infrastructure is a known recipe for the failure of social health insurance. Ability to search for healthcare facilities and in the process, the phenomenon of bypass as seen in this study appeared to play a major role in satisfaction with care amongst younger people, and among those from the private sector, the economic ability to search for and receive care in healthcare facilities of choice, and that meets their expectations. Similarly, enrolees who had the opportunity and sought information about the quality of care in the facilities before enrolment were more likely to be satisfied with care than those who did not seek information. Enrolees who claimed they had no knowledge of the scheme were more likely to be satisfied than those who had knowledge of it and may have had a higher expectation of the quality of care than they received. Satisfaction with care that was attributed to patronage of faith-based facilities in this study has similarities with findings in previous studies. Compared with other types of facilities, it has been reported that the likelihood of higher levels of satisfaction with care among those who patronise faith-based facilities, may have been as a result of higher levels of functional quality, (including spiritual care, that is more valued in this setting) in addition to the technical quality of care. The fundamental finding from the qualitative component of the study was a high level of mistrust of government by almost all the stakeholders involved in the scheme. This manifested itself in the reluctance of the majority of the private health facilities to collaborate with the government in providing health care services to enrolees on the scheme at inception. The same explanation goes for the then potential enrolees' outright refusal to take up the opportunity to access health care services through the scheme. Previous failed government policies both in the health and in the non-health sectors were cited as reasons for the low interest in the scheme. Because of this, except for the government health facilities that were instructed to do so, majority of the private facilities stayed away from providing care to enrolees on the scheme until some years later. Thus, the majority of these enrolees at inception were assigned to the few health facilities that were available. This is what was primarily responsible for the lopsided/uneven distribution of enrolees across the NHIS accredited facilities, whereby some had a high volume of enrolees, while the majority, especially those that showed interest in the scheme much later had very low volumes. Unfortunately, this pattern of enrolees' distribution may be irreversible. In addition, mistrust also exists between the NHIS and the HMOs, between the HMOs and providers, and to some extent between the enrolees and providers. It is important to note that the design of the scheme put the HMOs in a powerful position, which they used to influence the political class to their advantage. To compound the situation, NHIS officials had poor technical and managerial skills to administer the scheme. These are indications of an inefficiently managed health intervention. Under these circumstances, it is highly unlikely that universal health coverage could be achieved unless the observed challenges are appropriately addressed. In addressing these issues, a reform should be considered in the design of the scheme and appropriate training given to the NHIS officials saddled with its day-to-day operation. Conclusion This study has elucidated the reasons for the poor uptake and skewed distribution of enrolees across accredited NHIS facilities in the study area. In addition to poor structure and inefficient management, the high level of mistrust among the stakeholders has played a major role in the lopsided/uneven geo-spatial pattern of enrolees' distribution across the NHIS accredited health facilities. As it is presently structured and managed, the NHIS is highly unlikely to achieve its set objectives. It is advocated that a reform that addresses the observed anomalies be instituted to enable the scheme achieve its goals. This is a lesson for other countries planning to design and implement similar schemes.

Der demografische und soziale Wandel führt zu weitreichenden Veränderungen in Deutschland. Eine 'Gesellschaft des langen Lebens', wie sie sich in Deutschland in den letzten Jahrzehnten entwickelt hat, ist ein großer Erfolg. Seit Mitte des 20. Jahrhunderts erleben immer mehr Menschen ein höheres und sogar sehr hohes Lebensalter. Dieser Wandel bringt eine Vielzahl von Chancen für Individuen und Gesellschaft mit sich. Durch eine verbesserte Gesundheit und durch die länger werdende nachberufliche Lebensphase ist es vielen Menschen in Deutschland möglich, ein gutes Leben im Alter zu führen und dabei ihre Lebensumstände bis ins hohe Alter aktiv mitzugestalten.
Allerdings sind neben diesen Chancen auch individuelle und gesellschaftliche Herausforderungen zu nennen: Das veränderte Verhältnis von Alten zu Jungen - mehr älteren Menschen stehen weniger junge Menschen gegenüber - wirft neue Fragen hinsichtlich der Finanzierung von Renten-, Gesundheits-und Pflegeversicherung auf. Weil immer mehr Menschen das hohe und sehr hohe Alter erleben, sind auch mehr Menschen von Mehrfacherkrankungen oder Pflegebedürftigkeit betroffen. Dies stellt Politik und Gesellschaft in Deutschland vor die Herausforderung, soziale Teilhabe und Integration für die verschiedenen gesellschaftlichen Gruppen gleichermaßen zu gewährleisten.
Im vorliegenden Bericht werden Befunde des Deutschen Alterssurveys aus dem Jahr 2014 vorgestellt, einer seit 1996 durchgeführten repräsentativen Befragung von Menschen in der zweiten Lebenshälfte in Deutschland. Im vorliegenden Einführungskapitel stellen wir zunächst den Deutschen Alterssurvey vor, diskutieren Integration und Teilhabe als übergeordnete Ziele der Alternspolitik. Wir beschreiben den sozialen Wandel, der Lebenssituationen in der zweiten Lebenshälfte mitbestimmt und stellen abschließend Faktoren dar, anhand derer sich Vielfalt und Ungleichheit in der zweiten Lebenshälfte beschreiben und verstehen lassen.

The approval of Directive 2000/60/EC, better known as the Water Framework Directive (WFD), resulted from efforts to create a coherent approach to water policy at the European scale. It requires surface waters (rivers, lakes, wetlands and transitional and coastal waters) to attain good ecological and chemical status and establishes quantitative and chemical standards for groundwater. The WFD required a significant shift in priorities, goals and operational procedures by placing the emphasis on ecosystem protection and ecological health as a means to guarantee the availability of sufficient good quality water to meet sustainable needs. By establishing the river basin as the pre-eminent geographical scale for water management, it also explicitly recognized that any policy aiming at protecting European waters necessarily had to deal with the policies that guided activities in the surrounding watershed. The discussion and approval of the WFD coincided with a growing debate about, and advocacy for, a paradigm shift in water management. The shift was the expression, in the field of water resources management, of a transformation in the way we understand the relationship between society and nature, reflecting changes in other realms of our socioeconomic environment. The new approach results from the need to acknowledge the hybrid nature of water, emphasizing the complexity of the ecological, socioeconomic, technological, cultural and institutional processes that are intertwined in discourses and understandings of water. Claims about the legitimacy of intervention no longer reside exclusively in the realms of authority and privileged knowledge. Rather, legitimacy now depends on shared definitions of both problem and potential solutions. The evolving water management paradigm thus results from the fact that we are dealing with complex and reflexive socioecological systems and there are diverse incommensurable and equally valid interpretations of our physical environments. In the context of uncertainty, complexity, differing world views and high stakes that characterize water management challenges, new governance approaches have been offered as panaceas to effectively handle them. Most significant among them is the Integrated Water Resources Management (IWRM), which promotes the principles of integration, participatory management approaches, and the use of economic instruments to achieve water policy goals. The WFD is perhaps the most comprehensive and far reaching attempt to align water management policy and practice along these principles. An evaluation of its implementation can therefore throw some light on the potential for these management prescriptions to successfully deal with the challenges that are inherent to problems of complex socio-ecological systems This dissertation contributes to a significant body of scholarly work that has studied the European experience with the WFD by critically analyzing the experience of its implementation from three complementary theoretical perspectives that refer three of the four pillars of the WFD: the scalar choices that derive from the application of the IWRM approach to water resources management that the WFD embodies; the use of economic instruments to achieve water policy goals; and the emphasis on public information, consultation and participation to legitimize water planning and management decisions and improve the effectiveness of the Directive. Through the analysis of the geographically specific case of Spain, it questions the underlying assumptions that justify this approach to European water governance and tries to discern whether the policy goals have been met. The analysis is presented through three articles that have been published in peer reviewed academic journals and a fourth publication, of a more normative nature, that reviews the evolution of water policy in Spain with a particular focus on the post-WFD implementation period. The first article (Chapter 4) summarizes the state of the art of the current debate on scalar politics and water governance. In this context, the paper reviews the territorial and organizational evolution of river basin authorities in Spain, since their origins in 1926 as Confederaciones Sindicales Hidrográficas, to their situation in 2015, in light of the current critical approach to the river basin as the unquestionable scale for water governance. It analyzes the complex process of adjustment of the river basin management approach to the politicaladministrative division of the state into increasingly powerful Autonomous regions that emerged with the advent of democracy in the 1970s, and the ensuing reconfiguration of areas of influence, division of authority, and emergence of power conflicts that are still unresolved. The paper argues that when discussing 'spatial fit' issues dealing with natural resources management, special attention should be given to ensuing changes in social relationships and power structures that each option entails, within their specific historical and geographical context. The second article (Chapter 5) discusses the way economic instruments are being promoted as a desirable alternative to public sector action in the allocation and management of natural resources. The case of water is at the vanguard of these processes and is proving to be particularly contentious. In the European Union water policies are increasingly emphasizing the application of economic instruments to improve the allocative equity and economic efficiency in the use of scarce resources. However, there are few analyses of how these instruments are really working on the ground and whether they are meeting their objectives. The paper aims to contribute to this debate by critically analyzing the experience with water markets in Spain, the only country in the European Union where they are operative. It looks at water permit sales during the 2005-2008drought period using the Tajo-Segura transfer infrastructure. The paper describes how the institutional process of mercantilización of water works in practice in Spain. It shows that the use of markets requires an intense process of institutional development to facilitate and encourage their operation. Additionally it argues that these institutions tend to favor the interests of clearly identifiable elites, instead of the public interest they supposedly promote. The third article (Chapter 6) looks at the shift from hierarchical-administrative water management toward more transparent, multi-level and participated governance approaches that has brought about a shifting geography of players, scales of action, and means of influencing decisions and outcomes. In Spain, where the hydraulic paradigm has dominated since the early 1920s, participation in decisions over water was traditionally limited to a closed water policy community, made up of economic water users, primarily irrigator associations and hydropower generators, civil engineering corps and large public works companies. The river basin planning process under the WFD presented a promise of transformation, giving access to non-economic water users, environmental concerns and the wider public to water-related information on planning and decision-making. This process coincided with the consolidation of the use of Information and Communication Technologies (ICTs) by the water administration, with the associated potential for information and data generation and dissemination. ICTs are also increasingly used by citizen groups and other interested parties as a way to communicate, network and challenge existing paradigms and official discourses over water, in the broader context of the emergence of 'technopolitics'. The paper investigates if and in what way ICTs may be providing new avenues for participated water resources management and contributing to alter the dominating power balance. We critically analyze several examples where networking possibilities provided by ICTs have enabled the articulation of interest groups and social agents (what we call citizen water networks - CWN) that have, with different degrees of success, questioned the existing hegemonic view over water. The critical review of these cases sheds light on the opportunities and limitations of ICTs, and their relation with traditional modes of social mobilization in creating new means of societal involvement in water governance. It also shows that the low democratic profile of current water management institutions in Spain clearly hinders ICTs' potential to democratize decision-making processes. Without a real willingness to open up true spaces of deliberation where all actors can participate in conditions of equality, the role of ICTs will remain one of strengthening CWNs' organizational capabilities and ability to obtain and generate information, but will not alter the basic framework for water policy-making. The final article (Chapter 7) complements the more theoretical focus of the previous chapters and from a normative perspective analyzes the evolution of Spanish water policy since the approval of the 1985 Water act. It focuses on the post-WFD implementation period (from 2003 onwards) and on the role economic water users, environmental interests and engaged citizens have played in the achievement of some key WFD-related water policy goals: environmental objectives; public and user participation in water planning and management; and use of economic instruments to achieve water policy goals. Relying on a review of different examples and experiences, the paper concludes that the necessary transformation in water policy goals, operations and procedures required by the implementation of the WFD has not taken place. The traditional water policy community has resisted this transformation and largely continues to dominate water policy decision-making. At the same time, in the context of the WFD a variety of citizen water networks that defend the patrimonial values of water have developed and consolidated and can play a significant role in the consecution of this transformation. In any case, the reforms along the three key WFD-axis analyzed have been more formal than substantial, and the key decisions over water continue to respond to the interests and priorities of the traditional water policy community.

Using data from Vietnam, this article describes several types of analysis that can be conducted before launching a major downsizing operation to identify possible gender effects. It draws several conclusions about Vietnam s downsizing reforms. First, although women s prospects of obtaining salaried jobs following displacement from state-owned enterprise worsened as a result of recent reforms, they are likely to improve in the near future. Second, reforms are associated with a sharp decline in the gender gap in earnings, both in and outside the state sector. Third, overstaffing is greatest in sectors in which most employees are men, such as construction, mining, and transportation; it is much less prevalent in sectors in which women dominate the work force, such as footwear, textiles, and garments. Fourth, training, and assistance programs to help redundant workers reveal no evidence of strong gender bias. Fifth, severance packages based on a multiple of earnings are more favorable to men, whereas lump sum packages favor women.

Since the Asian Financial Crisis in the late 1990s and through the Global Financial Crisis of the last decade, commendable progress has been made by the member states of the Association of South East Asian Nations (ASEAN) in improving economic and human development outcomes both within each country and across countries. Since 1997, the economies of the poorest countries in the ASEAN, Cambodia, Lao PDR, Myanmar and Vietnam, have generally grown faster than the richer economies, which has reduced gaps in per capita incomes. Overall, child mortality rates have been cut by two-thirds across the ASEAN. And significant reductions have occurred even in some of the poorer member countries such as Cambodia and Lao PDR. However, this report The ASEAN Equitable Development Monitor (henceforth referred to as The Monitor), also shows that much remains to be done to ensure that the poorest members of the ASEAN community, within countries and across countries, are not left behind as the countries of the ASEAN integrate further. In both policies and development outcomes, differences across the countries of the ASEAN remain large. In this context, the monitor is designed to facilitate further discussion on policies and programs that can promote inclusive growth within ASEAN member countries and across the ASEAN community. It presents a number of indicators that are intended to provide a summary of development outcomes across and within the ten ASEAN countries and over time. On this basis, the monitor is intended to help policymakers in ASEAN member states to identify areas of concerns and prioritize national and regional interventions. The monitor tracks indicators across two broad sets of development outcomes and policies: (i) economic development; and (ii) human development.

Since 2022 an external factor has threatened Ukraine's existence: the full-scale Russian invasion. Now internal factors—namely, the need to renew Ukrainian government's mandate with the help of democratic elections—have added to Ukraine's problems. The essence of the dilemma is as follows. On the one hand, there are legal grounds, popular consent and elites' agreement that trying to hold elections during wartime could hinder internal stability. On another, external and internal elements could use the exhausted legitimacy of Ukrainian government to accuse democratic Ukraine of formal disrespect of democratic principles. This last factor may become damaging, especially in the attrition phase of the war and in view of the West's need to respond to the increasing number of wars around the globe. Constitutional and Administrative ChallengesUkraine's constitution holds that the country may not hold parliamentary elections until martial law, in effect since February 24, 2022, is lifted, and for six months thereafter. Several laws would need to be changed in order for presidential elections to be held, which raises its own problems. Even if a legal solution could be found, security, financial, and organizational obstacles to holding free, fair, and representative elections are far more serious. President Zelensky is not opposed to holding elections but insists they must be held in accordance with the highest standards of democratic elections possible and should not detract from the country's national defense efforts. Many Ukrainian civic organizations promoting free and fair elections agree on the need to held elections only when the right conditions are present to ensure the integrity of the process and results.Security is an overarching concern. Almost 20 percent of Ukraine's territory is occupied. Some settlements are entirely destroyed, while others lack the necessary infrastructure to enable voting. With Russian military forces targeting civilian infrastructure, ensuring the safety of voters, election officials, and observers is simply impossible. President Zelensky has suggested that Western election advocates share in the risks, perhaps by stationing election observers in the trenches to assure the world of the legitimacy of the elections.Funding the elections is another major problem. According to the Central Election Committee's 2023 calculations, the presidential elections are estimated to cost around $196.7 million, while the parliamentary elections may require approximately $135.9 million. At the same time, Ukraine's 2024 budget anticipates $43.7 billion in revenues but almost twice that, $82.3 billion, in expenditures, without including election costs. The difference is projected to be covered by international loans and grants.President Zelensky has stated that he will not hold elections on credit, nor will he "take money from weapons and give it to elections." Instead, he has suggested that Western countries, especially the United States, that are pressing Ukraine to hold elections could help fund them, in this way sharing the financial risk. With funding and security assured, the country could potentially develop a legal framework to hold elections during wartime, he implied.That said, Ukraine has learned the hard way that the essence of elections extends beyond the voting day; it encompasses extended campaigns during which society can have honest debates on a range of divisive issues. To preserve national unity for a people facing existential threat is a life-and-death matter. Even antagonistic political forces are reluctant to gain office at the expense of losing the country.This is why the Ukrainian parliament's opposition leaders signed a joint statement that both parliamentary and presidential elections should take place after the cessation of the war and the conclusion of martial law. The document indicates a consensus among major political parties regarding the need for an appropriate period of time to prepare for elections and favorable conditions for campaigning and voting.What Do Voters Think?For the general population, holding elections under current conditions would be problematic. For example, in a November survey conducted by Kyiv's International Institute of Sociology, over 80 percent of respondents expressed a preference for deferring elections until the war had ended.The voters' views on holding elections can be explained by the fact that they understand the challenges of trying to participate in wartime elections. Voter dispersal across Ukraine and outside the country further complicates any electoral effort. With six million internally displaced citizens alone, updating the list of voters would be a daunting task. The right to vote should also be ensured for over eight million Ukrainian refugees, 60 percent of whom are eligible voters. Currently Poland hosts about 1.6 million refugees and Germany more than a million. In the 2019 Ukrainian parliamentary elections, there were only a small handful of overseas polling places. Moreover, current registration procedures could easily paralyze the work of consulates and embassies. For example, host countries wanting to help Ukraine hold elections by opening polling stations on their own territory might have to change their national laws.This opinion is supported by over 100 leading election and human rights CSOs, which in a joint statement emphasized the impossibility of holding elections during the active war phase. The statement urges international partners to increase support for Ukraine to finally conclude the war, making democratic elections feasible (at least six months after the end of martial law).Why It MattersUkraine's elections spark debates in the United States and Europe. The absence of elections is now being cited as a reason to withhold aid or to question Ukraine's democratic status. Observers believe such a stance is a political ploy on the part of members of the U.S. Congress designed to secure changes to immigration policy governing the U.S. border with Mexico.Ukraine is a democracy at war. It needs to deal with the external threat and then to hold elections. As Olga Ayvazovska, head of the board of the civil network OPORA and an expert in elections, rightly stresses, Ukraine has a record of hewing to a high standard for free and fair elections, but it is impossible to adhere to that standard in wartime. Instead of further entangling in the dilemma, a clear plan is needed. First, Ukraine and West together must resolve the external threat. Second, Ukrainians must elect a new government, continue Ukraine's democratic development, and start the needed postwar socioeconomic recovery. The opinions expressed in this article are those solely of the author and do not reflect the views of the Kennan Institute

Since 2022 an external factor has threatened Ukraine's existence: the full-scale Russian invasion. Now internal factors—namely, the need to renew Ukrainian government's mandate with the help of democratic elections—have added to Ukraine's problems. The essence of the dilemma is as follows. On the one hand, there are legal grounds, popular consent and elites' agreement that trying to hold elections during wartime could hinder internal stability. On another, external and internal elements could use the exhausted legitimacy of Ukrainian government to accuse democratic Ukraine of formal disrespect of democratic principles. This last factor may become damaging, especially in the attrition phase of the war and in view of the West's need to respond to the increasing number of wars around the globe. Constitutional and Administrative ChallengesUkraine's constitution holds that the country may not hold parliamentary elections until martial law, in effect since February 24, 2022, is lifted, and for six months thereafter. Several laws would need to be changed in order for presidential elections to be held, which raises its own problems. Even if a legal solution could be found, security, financial, and organizational obstacles to holding free, fair, and representative elections are far more serious. President Zelensky is not opposed to holding elections but insists they must be held in accordance with the highest standards of democratic elections possible and should not detract from the country's national defense efforts. Many Ukrainian civic organizations promoting free and fair elections agree on the need to held elections only when the right conditions are present to ensure the integrity of the process and results.Security is an overarching concern. Almost 20 percent of Ukraine's territory is occupied. Some settlements are entirely destroyed, while others lack the necessary infrastructure to enable voting. With Russian military forces targeting civilian infrastructure, ensuring the safety of voters, election officials, and observers is simply impossible. President Zelensky has suggested that Western election advocates share in the risks, perhaps by stationing election observers in the trenches to assure the world of the legitimacy of the elections.Funding the elections is another major problem. According to the Central Election Committee's 2023 calculations, the presidential elections are estimated to cost around $196.7 million, while the parliamentary elections may require approximately $135.9 million. At the same time, Ukraine's 2024 budget anticipates $43.7 billion in revenues but almost twice that, $82.3 billion, in expenditures, without including election costs. The difference is projected to be covered by international loans and grants.President Zelensky has stated that he will not hold elections on credit, nor will he "take money from weapons and give it to elections." Instead, he has suggested that Western countries, especially the United States, that are pressing Ukraine to hold elections could help fund them, in this way sharing the financial risk. With funding and security assured, the country could potentially develop a legal framework to hold elections during wartime, he implied.That said, Ukraine has learned the hard way that the essence of elections extends beyond the voting day; it encompasses extended campaigns during which society can have honest debates on a range of divisive issues. To preserve national unity for a people facing existential threat is a life-and-death matter. Even antagonistic political forces are reluctant to gain office at the expense of losing the country.This is why the Ukrainian parliament's opposition leaders signed a joint statement that both parliamentary and presidential elections should take place after the cessation of the war and the conclusion of martial law. The document indicates a consensus among major political parties regarding the need for an appropriate period of time to prepare for elections and favorable conditions for campaigning and voting.What Do Voters Think?For the general population, holding elections under current conditions would be problematic. For example, in a November survey conducted by Kyiv's International Institute of Sociology, over 80 percent of respondents expressed a preference for deferring elections until the war had ended.The voters' views on holding elections can be explained by the fact that they understand the challenges of trying to participate in wartime elections. Voter dispersal across Ukraine and outside the country further complicates any electoral effort. With six million internally displaced citizens alone, updating the list of voters would be a daunting task. The right to vote should also be ensured for over eight million Ukrainian refugees, 60 percent of whom are eligible voters. Currently Poland hosts about 1.6 million refugees and Germany more than a million. In the 2019 Ukrainian parliamentary elections, there were only a small handful of overseas polling places. Moreover, current registration procedures could easily paralyze the work of consulates and embassies. For example, host countries wanting to help Ukraine hold elections by opening polling stations on their own territory might have to change their national laws.This opinion is supported by over 100 leading election and human rights CSOs, which in a joint statement emphasized the impossibility of holding elections during the active war phase. The statement urges international partners to increase support for Ukraine to finally conclude the war, making democratic elections feasible (at least six months after the end of martial law).Why It MattersUkraine's elections spark debates in the United States and Europe. The absence of elections is now being cited as a reason to withhold aid or to question Ukraine's democratic status. Observers believe such a stance is a political ploy on the part of members of the U.S. Congress designed to secure changes to immigration policy governing the U.S. border with Mexico.Ukraine is a democracy at war. It needs to deal with the external threat and then to hold elections. As Olga Ayvazovska, head of the board of the civil network OPORA and an expert in elections, rightly stresses, Ukraine has a record of hewing to a high standard for free and fair elections, but it is impossible to adhere to that standard in wartime. Instead of further entangling in the dilemma, a clear plan is needed. First, Ukraine and West together must resolve the external threat. Second, Ukrainians must elect a new government, continue Ukraine's democratic development, and start the needed postwar socioeconomic recovery. The opinions expressed in this article are those solely of the author and do not reflect the views of the Kennan Institute

Η ποιότητα στον τομέα της υγείας έχει μελετηθεί σε μεγάλο βαθμό από την κλινική οπτική γωνία, αφήνοντας εκτός την αντίληψη του ασθενούς για την ποιότητα των παρεχόμενων υπηρεσιών. Η ικανοποίηση των ασθενών είναι πολύ σημαντική για τους ιατρικούς παρόχους, τους ίδιους τους ασθενείς (καταναλωτές) και για τρίτους ενδιαφερόμενους στον ιατρικό κλάδο της υγειονομικής περίθαλψης. Οι απόψεις των ασθενών υιοθετούνται ως μέρος της διαδικασίας παραγωγής ενός συστήματος διαχείρισης ποιότητας και η ικανοποίηση των χρηστών για να καθοριστεί η διάσταση της ποιότητας των παρεχόμενων υπηρεσιών. Η παρούσα διατριβή αποσκοπεί στην αξιολόγηση της ποιότητας του Ελληνικού Συστήματος Υγείας μέσω των προτιμήσεων των ίδιων των καταναλωτών του. Ανάμεσα σε άλλους παράγοντες, αρκετοί κοινωνικοοικονομικές παράμετροι λαμβάνονται υπόψη, όπως και αντίστοιχοι δημογραφικές, και χαράσσονται σχετικές πολιτικές. Το Κεφάλαιο 1 εισάγει το θέμα της ικανοποίησης των ασθενών και το συνδέει με την ποιότητα του συστήματος υγείας. Μέσω της βιβλιογραφικής ανασκόπησης αναδεικνύεται η σημασία του, οι παράγοντες που το επηρεάζουν και άλλες προσπάθειες ποσοτικοποίησης και μέτρησής του. Παρουσιάζονται, επίσης, τα κίνητρα για την παρούσα διατριβή, καθώς και τα προβλήματα και τα ερωτήματα μελέτης. Το Κεφάλαιο 2 μελετά το βαθμό ικανοποίησης των Ευρωπαίων πολιτών-ασθενών από την αποδοτικότητα και την ποιότητα του συστήματος υγείας της χώρας τους. Τα αποτελέσματα δείχνουν ότι περισσότεροι από τους μισούς Ευρωπαίους πολίτες είναι ικανοποιημένοι με το σύστημα υγείας της χώρας τους, με το επίπεδο αυτό να σχετίζεται θετικά με τις δημόσιες δαπάνες υγείας, τη γήρανση του πληθυσμού και τον αριθμό των νοσηλευτών-κλινών. Το Κεφάλαιο 3 εξετάζει την απόκλιση που παρατηρείται ανάμεσα στις προτιμήσεις των ασθενών για τη χρηματοδότηση του συστήματος υγείας και στην πραγματική δημόσια χρηματοδότησή του. Η απόκλιση που καταγράφεται ανάμεσα στην πραγματική δαπάνη σε σχέση με τις προτιμήσεις των ασθενών για την κατανομή των πόρων είναι μικρή. Οι προτιμήσεις αυτές φαίνεται να επηρεάζονται σε μεγάλο βαθμό από το επίπεδο εισοδήματος, τον αριθμό των μελών οικογένειας και τον τόπο κατοικίας. Το Κεφάλαιο 4 αναδεικνύει τη σημασία της ηλεκτρονικής παιδείας για τον τομέα της υγείας και μελετά το επίπεδο των Ελλήνων πολιτών. Οι Έλληνες έχουν χαμηλό επίπεδο ηλεκτρονικής παιδείας όσον αφορά στα θέματα υγείας. Το επίπεδο της σχετικής με τα ζητήματα υγείας ηλεκτρονικής παιδείας σχετίζεται θετικά με το επίπεδο εκπαίδευσης και με το βαθμό φυσικής άσκησης, ενώ αρνητικά σχετίζεται με την ηλικία. Το Κεφάλαιο 5 παρουσιάζει τη μελέτη περίπτωσης του Γενικού Νοσοκομείου «Κωνσταντοπούλειο». Τα δεδομένα συγκεντρώθηκαν από τον Ιούνιο του 2011 μέχρι τον Οκτώβριο του 2012 και αφορούν σε 745 νοσηλευόμενους ασθενείς (εσωτερικούς) και 420 ασθενείς που επισκέφτηκαν τα εξωτερικά ιατρεία (εξωτερικούς). Για την εκμαίευση του επιπέδου ικανοποίησης των ασθενών, μελετήθηκε η συσχέτιση της πρόθεσής τους να συστήσουν το νοσοκομείου σε άλλους με δημογραφικούς παράγοντες και παράγοντες που αφορούν στην αποτελεσματικότητα της παροχής υπηρεσιών υγείας. Τα αποτελέσματα δείχνουν ότι οι παράγοντες που σχετίζονται με τη λειτουργία του νοσοκομείου είναι οι πιο σημαντικοί για τη διαμόρφωση του επιπέδου ικανοποίησης των ασθενών. Από τους δημογραφικούς παράγοντες, η ηλικία των ασθενών είναι η μεταβλητή που παραμένει στατιστικά σημαντικά και για τις δύο ομάδες. Συνοπτικά, η ικανοποίηση των ασθενών σχετίζεται με τις εκροές του συστήματος υγείας, αλλά, επίσης, θεωρείται ως ένα εργαλείο για τη διεύρυνση των κοινωνιών ανισοτήτων. Για το λόγο αυτό, η αποτύπωση των παραγόντων που επηρεάζουν το επίπεδο την ικανοποίησης των ασθενών, λαμβάνοντας υπόψη διάφορα χαρακτηριστικά τους, είναι πολύ σημαντική. Η παρούσα διατριβή συμβάλει σε σημαντικά θέματα της διεθνούς βιβλιογραφίας, όπως για παράδειγμα την ενθάρρυνση της συμμετοχής των ασθενών μέσω πολιτικών ενδυνάμωσης της γνώσης τους, διευρύνοντας ακόμα περισσότερο τη δημοκρατική φύση της διαδικασίας λήψης αποφάσεων. ; Quality in healthcare has been studied largely from the clinical perspective, excluding the patient's perception of service quality. Patient satisfaction is a topic that is important both to medical (health) providers, the patients (consumers) and other third-party stakeholders in the medical care industry. Patients' opinions are taken as part of producing a quality management, and the users' satisfaction is taken to determine the service quality dimension. This dissertation aims to evaluate the quality of the Health System through the revealed preferences of its users. Among other factors, we take into account various socioeconomic factors and demographic parameters and derive relevant policy implications. Chapter 1 introduces the topic of patient's satisfaction, relates it with the quality of healthcare service. The literature review reveals its importance, the factors related to it and previous ways to quantify it and measure it. The research motivation factors along with the research problems and questions are also presented. Chapter 2 studies whether the European patients are satisfied with their country's healthcare system quality. The results demonstrate that more than half of the European patients are in general satisfied with their healthcare system. Public health expenditures as a percentage of GDP, population aging, as well as number of doctors and number of nurses increase patient satisfaction. Chapter 3 examines the deviation documented between patients' preferences with respect to healthcare resources allocation and actual public spending on health. There is a small deviation between citizens' preferences with respect to health resources allocation and actual public health spending, while income, number of family members and residence seem to greatly shape these preferences. Chapter 4 explores ehealth literacy as the ability in searching, analyzing, processing and comprehending information from the Internet in order to address or solve health related issues and reveals that the ehealth literacy level of Greek citizens is fair. The degree of ehealth literacy depends positively on education level and physical exercise, and negatively on the age of the participant. Chapter 5 examines the case study of Konstantopouleio General Hospital, providing evidence for the relationship between patient's satisfaction level and received services. The results demonstrate the important role of the attention received by the medical staff, nursing staff, and hospital's environment for both groups of in- and out-patients, while among the demographic factors, the perceived health status and age also play a significant role for the inpatients' satisfaction. The latter remains significant for out-patients, along with education and insurance. Overall, patient satisfaction is related to healthcare outcomes, but it is also considered to be a tool for disseminating social inequalities; therefore, lightening how several factors associate with patients' preferences, and in consequence with patient satisfaction, taking into consideration specific characteristics of users, is extremely important. This research contributes to important discussions in the literature, for instance, the encouragement of patients' participation by introducing policies of empowerment the knowledge dissemination along with the democratization of the decision making process.

From the foreword of this issue: The 24th Annual Oil Shale Symposium was held at a time when the future of commercial shale oil production was very uncertain. Shortly before the Symposium, Unocal Corporation announced that the Parachute Creek oil shale operation was to cease operation as of July 1, 1991, and the company did not plan to reopen the facility. This effectively closed the only commercial shale oil operation in the United States. Fred Hartly, former President and Chairman of the Board of Unocal, had been active in oil shale development since World War II, and it was largely through his forcefulness that Unocal built the Parachute facility. This effectively closed the only commercial shale oil operation in the United States. Fred Hartly, former President and Chairman of the Board of Unocal, had been active in oil shale development since World War II, and it was largely through his forcefulness that Unocal built the Parachute facility. After his retirement and death, the Parachute facility was placed on a break-even or better operation and, when it became unprofitable during the 1990 calendar year, the decision was made to close the operation. Armand Hammer, Chairman of the Board of Occidental Oil Company, strongly believed in the need for the United States to have an alternative liquid-fuel supply source because the demand for transportation fuels was increasing every year from 1978 to 1991. Nearly two-thirds of the worlds crude oil reserves (600 billion barrels) were in the Middle East, and U.S. dependence on the Middle East was increasing every year. Oil shale deposits in Colorado, Utah, and Wyoming contain an estimated 800 billion barrels of recoverable shale oil. The problem, of course, is to recover this shale oil at a cost competitive with that of conventional crude oil. Mr. Hammer was optimistic that a modified in situ retorting process could be developed by which shale oil could be produced at a competitive cost. He, with the support of Western Congressional representatives, obtained government support on a matching basis for a long-term research and development program. As long as he was alive, Occidental Oil Company was committed to developing this process, but, upon his death, his successors terminated the operation because they believed that the research development costs of modified in situ processing technology could not be justified under present economic and environmental climate. Today, government and industrial support of a research and development program for Western oil shale is virtually nonexistent. The major oil companies who own oil shale lands and in the past funded oil shale research and development, now have only skeleton staffs of one or two persons working on oil shale topics, and they generally are involved in readying files for long-term storage. At this time, the future of the shale oil industry appears to be in the far distance. In spite of the outlook, the papers presented at this 24th Annual Oil Shale Symposium covered the entire of range of topics and are of excellent quality. Included in the Proceedings is a paper that inadvertently was omitted from the Proceedings of the 23rd Symposium. It is published here to make the record complete and I apologize to M. Ron Cattany for its omission. This Proceedings once again is being published as a Colorado School of Mines Quarterly. During the early years of the symposia, the proceedings were published as Quarterlies, but when the sessions grew to the point that the papers given required more than one Quarterly per year, the Proceedings were published as separate volumes. Now that that number of papers is smaller and the number of attendees is less than 100, publishing the Proceedings once again as a Quarterly will give broader dissemination of the information. The quality of the Symposium would not have been possible without the support of the authors and their employers. The Colorado School of Mines and I wish to express our thanks for their continuing support. - James H. Gary, Director, 24th Annual Oil Shale Symposium. ; Foreword / James H. Gary -- Methane Occurrences and Potential Resources in the Lower Parachute Creek Member of Green River Formation, Piceance Creek Basin, Colorado / Rex D. Cole and Gerald J. Daub -- Robert B. Crookston His Oil Shale Achievements, His Collections, and the Tell Ertl Oil Shale Archives / Robert N. Heistand and Mark T. Atwood -- Blasting-Induced Rock-Motion Modeling Including Gas Pressure Effects / Dale S. Preece and Steven D. Knudsen -- Field Evaluations with a Low-Incendive Blasting Agent in Oil Shale Mines / Eric S. Weiss, Kenneth L. Cashdollar, Michael J. Sapko, and Eugene M. Bazala -- Attrition and Breakage of a Western Reference Oil Shale at Process Temperatures / Ulrich Grimm and Glenn Swaney. Update on the Radio-Frequency In Situ Extraction of Shale Oil / J.E. Bridges and G.C. Sresty -- Economic Aspects of Oil Shale Production Using Radio-Frequency In Situ Retorting / W.S. Streeter, J.E. Bridges, and G.C. Sresty -- Oil Shale Retorting with Steam and Recycle Gas / L.S. Merrill and L.D. Wheaton -- Hot-Recycled-Solid Pilot Plant1991 Status Report / Robert J. Cena -- Analysis of Particle Slip and Drag in a Lift Pipe Used in the Hot-Recycled-Solid Oil Shale Retort / D.F. Aldis and CB. Thorsness -- Chemical Basis of Middle-Distillate Fuel Instability Interactive Effects of Selected Nitrogen Heterocycles with Organic Acids and Bases in a Shale-Derived Diesel Fuel / George W. Mushrush, Erna J. Beal, Robert N. Hazlett, and Dennis R. Hardy -- Exploitation of Shale Hydration for Leachate Control in Disposed Oil Shale / David B. McWhorter, George H. Watson, Juergen Braun, and Earl D. York. The Positive Environmental Experience at Unocal's Commercial Shale Oil Project / William L. Sharrer -- Socioeconomic Impact of the Unocal Oil Shale Project An Analysis / Jim Evans -- Commercial Feasibility of Producing Shale Oil-Modified Asphalt / Larry A. Lukens and Mark A. Plummer -- Commercial Economics of Shale Oil-Modified Asphalt / Larry A. Lukens -- Update on the Colorado Tract C-b Oil Shale Demonstration Facility / Leroy Dockter -- Environmental Analysis of Occidental Oil Shale Inc's Proof-of-Concept Oil Shale Project / P.F. Ziemkiewicz -- The Combustion Press Effectiveness Factor of Oil Shale Char Particles / Min Lin, Xianqing Wang, Jialin Qian, and Yajia Zhu -- Colorado Oil Shale Initiatives for the '90s / Ronald W. Cattany.

The paper analyses the migration and ethnocultural processes in the Kosinj Valley in western Lika, which peaked during and immediately after the end of the Great Turkish War at the end of the 17th century and the start of the 18th century. During that time, the area became the intersection of the primary early modern migration flows in this part of the imperial multiple borderlands – southeast and northwest – with their diverse religious (Roman Catholics, Orthodox Christians), linguistic (neo-Shtokavian Ijekavian and Ikavian, Chakavian, and transitional Chakavian- Kajkavian), traditional (Dinaric, Adriatic, Pannonian, Eastern Alpine), and socioeconomic characteristics (frontiersmen/peasants, pastoral/agrarian). Each ethnocultural component was internally heterogeneous, characterised by distinct layers shaped by migrations across the turbulent imperial borderlands from the 16th to the 18th centuries. This led to various interactions and intermingling of cultural traditions, ethnic elements, languages, and dialects. It is concluded that the state military-provincial and Chamber authorities played a dominant role in these processes, directly or indirectly encouraging and directing migration flows for geopolitical and economic reasons. Therefore, from the outset, these migratory movements were characterised by planned military and agrarian colonisation. They favoured Catholic elements originating from Habsburg territories. Phenomenologically, they closely parallel the Vlach colonization of the Kosinj Valley a century earlier, which was conducted and directed by Ottoman authorities. Migrations in the turbulent border area of conflicting empires, with the Kosinj Valley at its centre for over 160 years, exhibited distinct dynamics. It was a region marked by intense emigration and immigration of defectors, including internal, external, or cross-border, and return migrations. The 16th and 17th centuries witnessed intense migration that began to subside only at the beginning of the 18th century. Namely, very few families in the 17th century had the chance to live in one place for three generations. The sons and grandsons of the Croats who fled to Carniola returned to Croatian territory in Gorski Kotar, only for the second generation of returnees to move to Lika. Similar return migrations are also observed among the Croats, Vlachs, and Bunjevci from Ogulin. To understand the settlement process, certain internal aspects of differentiated rural society also need to be considered. It is no coincidence that the elders, who were also leaders of migrations, often acquired the largest plots of land and formed the most numerous families in their new homeland. The same applies to Vlach elder families who, on both sides of the old border, retained their prestigious role as village leaders. In that period, the basic outlines of the modern ethnocultural structure of the Kosinj region were formed. The region became an intersection of primary migration flows in the Early Modern Period: the Vlach-Bunjevac, originating from the deep southeastern Dinaric interior, and the Croatian-Carniolan from the northwest, which also included elements originating in the eastern Alpine region. Their protagonists were early modern ethnic groups such as Vlachs, Croats, Carniolans and Bunjevci, who differed from each other along several criteria: socio-economic status, livelihoods, religious affiliation, dialects, family models and cultural areas. They all had in common that each ethnic group was internally heterogeneous and multi-layered. For instance, among the Vlachs, we observe traces of the old Balkan layer, Croats from Ogulin display Carniolan and Uskok-Vlach elements, Carniolan Croats exhibit Slovenian and German influences, and the Bunjevci include Orthodox Vlach converts. Vlachs from Kosinj historically migrated from East Herzegovina. They were part of the "Glamoč" and "Dinaric" migration flows, much like the majority of the Orthodox Vlach population that settled in Lika during the 16th century. Only a small fraction of the newly arrived population was strategically settled by Ottoman authorities across vast areas along their northwestern border, spanning from the Adriatic hinterland to the Drava River between 1550 and 1560. Serb Orthodoxy, neo-Shtokavian Ijekavian (also known as the East Herzegovina-Krajina dialect), seasonal transhumance, and the pastoral-patriarchal culture of the Dinaric area are elements that made them distinctive and distinguishable from their surroundings. After breaking away from their origins in southeastern Herzegovina during the early migrations of the 15th and 16th centuries, they followed a unique development trajectory that shaped a distinct "krajiški" (borderland) type within this historical ethnocultural group in their new habitats across northwestern Ottoman, and later Habsburg and Venetian territories. In 1689, Croatian Krajišnici (frontiersmen) from the Ogulin captaincy settled in Lower Kosinj, situated on the northern edge of a valley that today comprises the hamlets of Sveti Ivan, Draškovići, Selište, Rudine, Klobučari, and Goljak. They were part of the Croatian Chakavian population, specifically peasant soldiers who congregated around borderland fortresses in Ogulin, Oštarije, and Modruš during the 17th century. Some of their Chakavian linguistic features have been preserved to this day in the hamlets of Goljak, Rudinka, and Selište. The ethno-demographic structure of these Croats, which emerged during the first half of the 17th century, shows a tripartite composition. It comprised natives of Modruš, newcomers and/or returnees from Vinodol and Carniola, along with various branches of the Uskok-Vlach migration flows, predominantly migrants from Senj. In 1689, approximately 40 settler families from Gorski Kotar or the borders of Carniola settled the land along the Bakovac stream, extending all the way to its confluence with the Lika River. This area encompasses present-day Upper Kosinj, including the hamlets of Sušanj, Podjelar, and Poljanka, as well as the region of Bakovac and its hamlets Ribnik and Ruja. In most cases, these were descendants of the Croatian population who fled to Carniola in the 16th century. Therefore, it is more appropri¬ate to refer to this segment of the Catholic population in Kosinj in the pre-modern sense as "Carniolan Croats" despite the presence of some Slovenian and German elements among them. Secondly, it is necessary to differentiate between narrower and broader contexts of the usage of the Carniolan ethnicity within Lika itself. Carniolans, in the narrower sense, are represented by these settlers from Gorski Kotar, who were dependent peasants settled in Lika by the Inner Austrian Court Chamber, which introduced its chamber system there. In a broader sense, this ethnic term became a general label for Catholics in the Karlovac Generalate, particularly among the Orthodox population of Lika and Kordun. Bunjevci, also known as "Catholic Vlachs", who settled in the Kosinj Valley, belonged to the so-called "Krmpote branch". They were Catholic Vlachs originating from West Herzegovina who gradually migrated northwest, following the Dinaric migration flow along the Dinara and Velebit mountains during the 16th and 17th centuries. Due to their Herzegovian roots, history of Ottoman subjugation, Vlach social structure, pastoral and patriarchal cultural traditions of the Dinaric area (the culture of "dark cloth and gusle"), and the linguistic features of neo-Shtokavian Ikavian dialect, they exhibited cultural affinities with schismatic Vlachs in Lika. Special attention is given to the historical anthroponymy of the inhabitants of Kosinj, which verifies the aforementioned dynamics. Archival materials, including various documents, lists, and registers, provide valuable insights into their origins, movements, and distribution. Surnames among the Catholic population were documented considerably earlier, allowing for continuous tracing, especially among Croats from Ogulin and Carniola, dating back to the 15th and 16th centuries. The surnames of Orthodox families in Kosinj, and to a lesser extent Bunjevci families, can only be traced from their appearance in the Karlovac Generalate records, which means at best from the 17th century. The structural formation and meaning of surnames in Kosinj largely align with the dialectal and sociocultural characteristics of ethnic groups. Essentially, we can identify two anthroponymic origins: Croatian-Carniolan and Vlach-Bunjevac. It should be noted that surnames became established significantly earlier among Catholics, starting from the decisions of the Council of Trent in 1563, which introduced the practice of church registers for baptisms (Liber baptizatorum), marriages (Liber copulatorum), and deaths (Liber mortuorum). The Roman Ritual of 1614 mandated and required the keeping of parish family books known as Status animarum ("State of Souls") in each parish. Combining it with other sources makes it significantly easier to reconstruct the migration patterns and dispersion of certain Catholic families of Croats and Carniolans, unlike the Bunjevci and especially the Vlachs, who were under Ottoman rule for a long time. By incorporating certain Croatian families that were once part of the middle and lower nobility, anthroponymic continuity is fully established. The Orthodox Church only began to introduce records of its congregation in the 18th century, prompted by the Habsburg Monarchy. First, through parish Domovni protokoli (Household protocols) in the mid-18th century, which listed Orthodox families in specific parishes, but it was only with the Regulament (Regulation) of 1770 that the introduction of parish registers began, mirroring the practice of the Catholic Church. However, in most Orthodox parishes in the Eparchy of Upper Karlovac, this practice was not adopted until the first half of the 19th century. Therefore, it's not possible to trace most of Kosinj Vlachs' early movements or pinpoint their origins before the 18th century. Family traditions and the custom of Slava are not always reliable indicators. For the establishment of surnames among Vlach Orthodox families, and to a lesser extent among Bunjevci, secular military-frontier structures were far more influential than church structures. For military record-keeping purposes, frontier conscriptions were conducted, involving lists of military conscripts, which led to Vlach surnames becoming permanent and hereditary. This probably also explains the higher occurrence of colourful and satirical nicknames, or simply nicknames of differentiated family branches, in their anthroponymic repertoire.