Background: Decentralization in health systems enhances responsiveness and equity but is often accompanied by uneven implementation and resource disparities. Greece' health system has undergone successive phases of decentralization, culminating in a transformation in 2015 when regional health authorities (RHAs) assumed operational responsibility for public primary healthcare (PHC). This study presents the first comprehensive assessment of this transition, examining funding adequacy and resource allocation across RHAs. Methods: Financial and operational analyses were performed to assess disparities among RHAs and between RHAs and hospitals. Data were drawn from publicly available sources, including financial statements, reports from the Ministry of Health, and national statistics. The analysis examined patient visits, staffing levels, infrastructure, funding, labor productivity, and efficiency across health regions. Results: Between 2018 and 2023, patient visits declined at most RHAs. Staffing composition shifted toward nursing personnel, while medical staff numbers declined. Substantial intraregional and interregional disparities were observed in service utilization, staffing, infrastructure, funding, labor productivity, and efficiency. Hospitals continued to absorb a large share of PHC demand and funding, whereas RHA units held markedly fewer assets and received lower financial support. Funding imbalances among RHAs were evident, and the overall negative return on assets indicated systemic underfunding of public PHC. Conclusion: The ongoing decentralization of Greece's health system faces structural challenges, including overlapping territorial jurisdictions and uneven, occasionally insufficient, resource allocation. These challenges hinder progress toward health equity. Policy interventions should prioritize evidence-based resource allocation, standardized financing frameworks, and strengthened PHC integration to promote equitable and sustainable healthcare delivery under decentralized governance.
Pakistan confronts a severe mental health crisis that compels urgent action. Mental disorders constitute a burgeoning global burden, with depression alone accounting for a staggering 4.4% of worldwide Disability-Adjusted Life Years (DALYs) [1]. A stark inequity persists, with over 90% in low-and middle-income nations lacking access to mental health treatment, compared to over 50% receiving care in high-income countries [2]. These disparities emanate from a chronic underinvestment, with lowincome nations allocating a mere fraction, less than 1% of health budgets, to mental health [3].Pakistan mirrors these global inequities. With a paucity of just 0.19 psychiatrists per 100,000 people [4], and an underwhelming allocation of only 0.4% of the health budget for mental health [5], Pakistan grapples to meet the needs of an estimated 24 million individuals requiring mental health services [6]. Depressive, anxiety, and schizophrenia disorders are the most prevalent [7]. Stigma surrounding mental illness remains an entrenched societal challenge [8].Currently, Pakistan's mental health system operates primarily through tertiary care hospitals in major cities, with minimal integration into primary healthcare. Mental health services are largely concentrated in psychiatric departments of teaching hospitals, creating geographic and economic barriers for rural populations. The existing system relies heavily on psychiatrists and clinical psychologists, with limited involvement of general physicians, community health workers, or other non-specialist providers. Mental health education is notably absent from school curricula, and workplace mental health programs are virtually non-existent. Digital mental health solutions remain unexplored within the public sector, while community-based mental health services are severely limited. The proposed transformations would mark significant departures from this status quo through: task-sharing with non-specialist providers instead of exclusive specialist care; integration of services into primary healthcare facilities rather than tertiary hospitals alone; establishment of community clinics in place of centralized urban facilities; leveraging digital technology where traditional in-person care is the norm; and engaging community partners versus the current isolated clinical approach.To expand access, the WHO recommends strategies such as task-sharing care to nonspecialist providers, integrating services into primary care and educational institutions, developing community clinics, leveraging digital technology, and engaging community partners [9]. Pakistan could adapt approaches like training primary care workers in mental health protocols, building teacher capacity for school-based services, deploying lay counselors with specialist supervision, offering telemental health services, and engaging community health workers in outreach efforts [10].[Figure 1] telepsychiatry and digital tools, and address social determinants through campaigns on gender equity [11]. Organizations like Pakistan Institute of Living and Learning (PILL) advocate for policies, build workforce capacity, and scale up culturallyadapted interventions [12]. Digital startups like Sehat Kahani use telepsychiatry and mobile applications to bridge the workforce gap [13].A critical component in addressing Pakistan's mental health crisis is the implementation of comprehensive anti-stigma campaigns [14]. These initiatives should operate at multiple levels based on established evidence [15]:A. Community-level interventions [14,15] To comprehensively address the crisis, Pakistan must invest in scaling up its mental health workforce through training more specialists and task-sharing to non-specialists [3,16]. Integrating services into primary care and establishing community mental health centers is crucial for decentralizing access [9,10]. Increasing public mental health spending, developing sustainable financing mechanisms, and strengthening governance and policies are imperative [5,16]. Research on effective, contextuallyappropriate interventions should guide investments [14]. Developing quality monitoring mechanisms is key to ensuring standards of care [9].Addressing social determinants through multi-sectoral coordination and whole-ofsociety approaches involving government, private sector, and civil society is vital [14].Sustained political commitment and strategic investments enabling universally accessible, community-based mental healthcare are crucial for realizing wellbeing for all Pakistanis [15,16].In essence, Pakistan confronts a formidable treatment gap with escalating rates of mental illness amid extreme limitations in mental health system capacity.Comprehensive strategies are necessitated, spanning workforce expansion, service integration into communities, increased financing, anti-stigma efforts, school interventions, research, quality assurance, and multi-sectoral coordination. While challenges are immense, prioritizing community-driven, decentralized mental health systems can ensure no individual is left behind on the path to greater wellbeing.
Roberto Fantozzi, Stefania Gabriele, Alberto Zanardi
âą A reform in 2023 introduced new criteria for allocating healthcare funding in Italy. âą Socio-economic variables were included among the criteria for allocating funding across Regions. âą We simulate the new scheme and compare it with an alternative in which age and socio-economic indicators are jointly considered in estimating health needs. âą It turns out that more resources would be allocated to the Regions with greater deprivation. This paper discusses a reform recently implemented in the Italian National Health Service, aimed at adding some socio-economic indicators to the criteria adopted for allocating healthcare funding to Regions. The reform is based on international experience in healthcare financing in decentralized settings and provides a case study of special interest since Italy is a country with significant territorial disparities and severe budget constraints. The paper first discusses the long-standing debate between Italian Regions which led to the reform. Second, it reviews the main features of the reform which provides for the inclusion of socio-economic indicators via a simplified formula. Moreover, a possible revision of the reform is proposed, fully exploiting the information on the heterogeneity of health needs according to age and socio-economic indicators. By integrating the information on deprivation inside the risk adjustment mechanism, the weight of the different drivers is determined by the distribution of needs and not on a discretionary basis. Simulating the proposed revision suggests that more resources could be allocated to the Regions with higher levels of deprivation compared to a scenario that closely replicates the reform.
Open access
Global Health Care Issues
Employment and Welfare Studies
Health Systems, Economic Evaluations, Quality of Life
Tanel KerikmĂ€e, Ćaban Ä°brahim Göksal, Archil Chochia
The advancements in Information Communication Technologies (ICT) have caused widespread adoption of immersive technologies throughout society. Among these, artificial intelligence (AI) is the most popular, increasingly integrated into various business practices. The capacity of this technology to process large volumes of data has made it indispensable for businesses, driving efficiency and innovation across sectors. Despite the benefits of these technologies, AI technology often compromises employee rights due to biased automated decision-making and pervasive monitoring processes. In response, the European Commission took a decisive step to protect platform workers with its proposal for the Directive on Improving Working Conditions in Platform Work (2021/0414 COD). This directive aims to ensure fairness, transparency, and accountability within digital labour platforms by introducing four crucial measures designed to counteract biased decision-making and intrusive monitoring in its algorithmic management chapter. However, one of these measures âsocial dialogueâ remains abstract. This paper proposes a blockchain-based AI feedback loop model: DAO-based Society-In-The-Loop (DAO-SITL) Model to concrete this key measurement by redesigning the Society-In-The-Loop (SITL) framework through Decentralized Autonomous Organizations (DAO) governance approach.
The gig economy, which is defined as transient and adaptable work arrangements facilitated by digital platforms, has experienced unprecedented growth in recent years, profoundly altering labor market dynamics. This profound transformation has introduced a multitude of repercussions for workers, simultaneously offering both opportunities and challenges. In one aspect, it entails providing individuals with heightened autonomy, the opportunity to cultivate multiple income streams, and an improved balance between work and personal life, thereby enabling them to autonomously shape their career paths. Conversely, increasing concerns on job security, workersâ rights and protection, and employment benefits arouse discussions of economic welfare of gig workers. For businesses, the gig economy represents a transformative force, promoting cost-effective, on-demand labor while necessitating responsive strategies to manage a decentralized and flexible workforce. As a signal of a new era in labour market dynamics, gig economy has significant impacts on the broader labour force and traditional employment patterns. Grappling with of crucial task, policymakers are in urgent need of finding a balance that preserves the rights and finance security of the labour force without mitigating enthusiasm of development and economic prosperity. Comprehending the multifaceted influences of the gig economy is paramount in formulating policies, thereby building a labor market that embraces opportunities and challenges arising from this transformative change and ultimately facilitating a future work of greater equity and adaptability.
One of the most intriguing discussions concerning blockchain technology revolves around its potential to âdo goodâ. Consequently, numerous projects and institutions are showing interest in the capacity of blockchain to impact the social sphere positively. However, so far, very little literature has addressed the fundamental notion of âgoodâ that underlies its implementation or explores its connection to social justice theories. This article aims to analyse the narratives that surround the use of blockchain for social good and to compare them with traditional concepts that are significant in social justice theories, such as distribution and recognition. Results show that the selected informants involved in the blockchain scene tend to frame social good in rational, mathematical, and often competitive terms. This tendency contributes to the reinforcement of a neoliberal imaginary that neglects to address structural inequalities as relevant issues. Instead, it envisions social justice as an avenue for generating value, enhancing meritocracy, and ensuring technical accountability, echoing Silicon Valley's aspirations to âchange the worldâ.
In the context of neoliberalism and its consequences for the economy and for democracy, this article offers a distinct framing of the political nature of the French âYellow Vestsâ ( Gilets Jaunes ) movement. Fundamentally, the movement should be understood as a popular and radically democratic response to the growing social inequalities of top-down austerity governance. The movement, which began in 2018, was spontaneous, autonomous, and decentralized, made up primarily of loosely connected citizen networks and popular committees not bound by political affiliation, social class, or age group. Responding to the neoliberal policies of the government of President Emmanuel Macron, symbolized by an unpopular fuel tax, the Yellow Vests quickly developed into a wide-ranging movement with diverse forms of action and organization. Despite a carrot-and-stick response from the government, the movement continues to the present, though its impact was greatest in the first year, which is the focus of this paper. Difficult to classify, we understand the Yellow Vests as an instantiation of âpopular politicsâ, or an atypical social movement, primarily defined by and significant for its ardent anti-austerity and pro-democracy positions. The movement is only misleadingly labeled populist or associated with populism; there is a collective intellectual awakening of political consciousness, with participants and supporters articulating their structural dispossession and setting out to strengthen their common good through collective action and more direct democracy, not through party politics or existing institutions, nor through charismatic leadership or other forms of centralized or top-down politics. The Yellow Vests therefore signify the prospect of democratizing democracy, or re-democratizing democracy, in the face of the legitimacy deficits of neoliberal governance.
Climate change will widen health inequities; action on the social determinants of health is essential In a conversation recently, a former senior public servant suggested to me that the social determinants of health are too theoretical. It is true that there are a number of theoretical perspectives associated with social determinants. A key one, from Nobel Laureate Amartya Sen,1 highlights the importance of having the freedoms and capabilities to lead a flourishing life. According to theory, these are shaped by the conditions in which people are born, live, work and age, which are unequally distributed.2 There is, however, nothing theoretical about the manifestation of social inequities and their impact on peoplesâ health. Every day, people living in Australia embody stark inequities in income, working conditions, lived environment, and access to quality health and social care. For example, before the coronavirus disease 2019 (COVID-19) pandemic, Australians in the top 20% income bracket received six times more money than the lowest 20%.3 Three million Australians were estimated to be living below the poverty line in 2017, including 18% of all children.3 Before the pandemic, more than a million people were in rental stress, and waiting lists for social housing were into the hundreds of thousands.4 Within the first few months of 2020, 880 000 Australians lost their jobs, with women, young people, and those in precarious employment disproportionally affected.3 Workers in casual employment accounted for 63% of job losses between February and May 2020.3 Since the COVID-19 pandemic began, Australiaâs 31 billionaires have increased their wealth by $85 billion.5 People embody these inequities,6 which makes them sick and contributes to high levels of premature death. In 2017, 17% of Victorians reported high psychological distress. In 2020, that rose to 44% and to 60% among those who lost their jobs.7 Across Australia, people living in the lowest socio-economic quintile had mortality rates twice as high as those in the highest quintile, and these inequities widened between 2011 and 2016.8 Despite narrowing, the gap in life expectancy between Indigenous and non-Indigenous Australians remains high.9 What do social determinants have to do with climate change and planetary health? The fires, hail, floods and droughts that Australia has endured in recent years10 affect everyone, but not everyone experiences them equally.11 Affluent people can afford to live in insulated buildings with air conditioning and air purifiers, or add flood proofing and extra drainage. Meanwhile, people who are poor, older individuals, people with disabilities, and those who are socially marginalised are the least able to adapt to the changing climate, unable to escape the fires and heat, and live in dwellings and environments that amplify its effects.11 As has happened in other countries experiencing similar impacts from climate change, having lost homes and livelihoods, and fearful for the future, some people may leave their communities and perhaps the country.12 This will exacerbate inequities, with those who have more financial and social capital having more options â wealthy Australians are already buying land in Tasmania to escape the worst ravages of climate change.13 For people living in caravan parks in Lismore, New South Wales, having insurance is a stretch.13 Moving is not an option. This climate change-exacerbated social inequity adds to existing inequities in disease burdens and premature mortality â this is climate change interacting with the social determinants of health inequities.11 Planetary health inequity is a concept that recognises the impact of climate change on social and health inequities. It also recognises the importance for health equity of considering planetary systems â if we do not have a functioning Earth system, we have social disruption and risk to human survival. Planetary health inequity therefore embodies the common drivers of climate change and health inequity. These common drivers comprise major structural forces. Power asymmetries between actors, institutions and ideas, a neoliberal fetishism of market forces and individualism, hyperglobalisation, and the associated norms and values that permeate institutions and communities affect policy decisions that structure society and differentially affect daily living conditions and, ultimately, health.14-18 These structural social determinants of health inequity overlap substantially with the drivers of climate change and can be described collectively as the global âconsumptogenic systemâ. The consumptogenic system is characterised by institutions, policies, business practices, and social norms that embed and entrench principles of extractive capitalism and colonialism.19 Such a system encourages and rewards excessive production and hyperconsumerism of fossil fuel-reliant goods and services that are unhealthy and inequitably valued and distributed.20 If left on the current trajectory, the consumptogenic system will amplify potentially irreversible consequences for environmental degradation, inequalities and poor health. Governments have the chance to advance planetary health equity goals by addressing the consumptogenic system and inequitable distribution of resources that create negative health outcomes and climate change. The issue is not that it is too theoretical, the issue is the often lack of political will to address inequality, adopt a social model of health, and tackle climate change. In the May 2022 federal election, the Australian electorate demanded change. Encouragingly, the new Labor government promised to do better by the people and, although not in the language of the social determinants, their proposed action plan21 will go some of the way to advance planetary health equity goals. But it must go further. Achieving the transformative goal of planetary health equity requires a âsocial vaccineâ22 (Box), the targets of which are the conditions underpinning four basic requirements for health and equity to flourish: a life with security, opportunities that are fair, a planet that is habitable by humans and supports biodiversity, and governance that is just. Achieving these conditions requires the ambition, design and implementation of policies that ensure a fair social foundation and economic environment operating within the ecological ceiling.23 In Australia, as elsewhere, we have long needed policy that helps with adaptation to the damage already done by climate change. Good social and planning policy that ensures access to safe, stable and affordable housing, decent working conditions for all, income support levels that enable living with dignity, and inclusive infrastructure development is good climate adaptation policy. They are also good health equity policies. Adaptation is essential. So too is mitigation. The Climate Change Bill 2022 commits Australia to a greenhouse gas emissions reduction target of a 43% reduction from 2005 levels by 2030. This target should be considered only a starting point. A roadmap to net zero and an empowered secure Climate Change Authority is essential. Adequate climate change mitigation and planetary health equity will not be achieved unless there is ambitious and immediate action that disrupts the consumptogenic system. The targets should be the institutions, actors, structures and discourses that embed, facilitate and normalise the global dominance of a consumptogenic system addicted to growth regardless of the environmental, social and health costs. At the very least, any new fossil fuel project must be assessed for potential damage to species and environments through its impacts on climate change. Fundamentally, however, disruption of this system requires Australia and the rest of the world to stop extracting, burning and investing in oil, coal, gas and other fossil fuels, with government vetoing all new fossil fuel developments. The absence of an overarching framework guiding the actions of all Australian Government departments in a mission towards planetary health equity is problematic. This lack of authorising environment enables at best an ineffective siloed, scattergun approach; at worst policy silence. Implementing a national strategy that brings together climate change, inequality and health, such as the proposed Climate and Health Allianceâs Healthy, Regenerative and Just framework, is essential.24 An engaged strong civil society is key to the delivery of a social vaccine. Implementing a progressive policy framework will confront stubborn resistance and challenge the power of dominant vested interests. Public-interest coalitions can support governments to act, as well as hold them to account.25 Climate change and health alliances are essential â doctors and other health professionals have knowledge, opportunity and political leverage that can help ensure actions are taken.24 This article has laid out ways of advancing planetary health equity goals. To help achieve these, the health community must advocate for and engage in intersectoral policy discussions relating to the social determinants and the structural consumptogenic system. Acting immediately on these issues is critically important if we are to avert a planetary health inequity crisis. No relevant disclosures. Commissioned; externally peer reviewed. Open access publishing facilitated by Australian National University, as part of the Wiley - Australian National University agreement via the Council of Australian University Librarians.
At the time of its inception, in 1978, prevention and primary care were set as fundamental pillars of the Italian National Health Service (NHS), emphasizing the collective and social dimension of health. These principles were progressively neglected over the following four decades. Marketization, managed competition and managerialization privileged the individualized, highly specialized healthcare services mainly provided in hospitals, to the detriment of local outpatient and primary care services. After 2008â09, austerity policies exacerbated this situation determining under-financing as well as structural and staff shortages, while increasing tensions arose between the central government and Regions in the decentralized NHS. In 2020â21, the pandemic highlighted these critical issues. The need to develop a universal and strong outpatient, primary and community care system became evident in order to ensure the appropriateness and quality of foundational health services. This requires the State to play a more prominent role in the NHS governance.
Purpose This paper aims to assess the tie-in between psychological contract breach (PCB) and job satisfaction (JST) amongst medical doctors (MDs) working in two stress-prone regions of Ghana, and further analyses the moderating effect of openness to experience (OPE) on this tie-in. Design/methodology/approach Responses from 214 MDs were analysed. Questionnaires were self-administered. Research philosophy was positivism, research approach was quantitative, research design was explanatory and study design was cross-sectional. Test of normality, Kaiser-Meyer-Olkin measure of sampling adequacy and Bartlettâs test of sphericity were applied. Both reflective measurement and structural models were assessed. Path coefficients were analysed using partial least squares (PLS) algorithm tool and moderation effect was conducted using the product indicator approach. Control variables were sex ( GEN1 ), age ( GEN2 ), employment type ( GEN3 ) and tenure ( GEN1 ). A significant level was set at 5%. Smart PLS 2.0 M.3 software was used. Findings The analysts found support for a significant moderating effect of OPE on the tie between PCB and JST, such that the consequences of PCB on JST was minimised for MDs who scored high on OPE trait. Practical implications PCB, if not addressed, may lead MDs to be less satisfied with their jobs. In stress-prone health zones where PCB exists, MDs who are inspired, creative, self-sufficient, experimenting and visionary are more likely to be satisfied with their job. Originality/value This study offers health-care literature on the moderating role of OPE personality dimension on the bond between PCB and JST, using PLS-structural equations modelling, which is a superior and robust analytical tool.
Workforce challenges are a persistent feature of the long-term care landscape, while the landscape itself is shifting. In the United States, from 1985 to 2015, a decline in the proportion of low-acuity residents has occurred in concert with the growth of assisted living (Silver et al., 2018) and a shift of Medicaid-financed long-term care toward home- and community-based services (Eiken, 2015). As a result, nursing homes serve a larger proportion of people who are admitted from hospitals and paid for by Medicare (Fashaw et al., 2019). As acuity of care needs increases in these settings, the industry increasingly depends on a complex myriad of direct care and specialized workers. Workforce issues intersect with provider and policy interests: The workforce is the providersâ largest cost, whereas policymakers see the workforce as a lever to influence the quality of care. Workforce issues also intersect with larger social issues. For example, immigration policy influences the long-term care workforce, as do state and federal minimum wage laws. The larger economic environment and prevailing wages in other service industries affect the labor supply, especially in long-term care. As we saw in 2020, existing workforce concerns collided with infection control and acute illness care during the pandemic of coronavirus disease 2019 (COVID-19). Lastly, but not least in importance, workforce issues affect the quality of life for the people who live in long-term care settings. In short, workforce issues are the most significant challenges facing the long-term care industry. Although considerable research attention has been paid to long-term care workforce topics, the editorial team at The Gerontologist recognized that important questions remain, prompting the call, in the fall of 2019, for this special issue on workforce issues in long-term care. We little knew when the call for papers went out that a pandemic would throw a bright spotlight on long-term care, especially nursing homes, making this issue even more timely. The articles in this issue paint a picture of stagnated progress and thorny challenges, but their rich and varied methodologies and perspectives also offer the field some glimpses of optimism that we can leverage diverse approaches to improve long-term care. Taking a broad perspective, Foley and Luz (2021) evaluate progress on the workforce development goals set forth in the 2008 Institute on Medicine (IoM) report âRetooling for an Aging Americaâ (IoM, 2008). They highlight the continuing shortages of both geriatricians, a workforce sector that appears to be shrinking despite the increasing need, and direct care workers. Their conclusions are disturbing: Since 2008 only one of the IoM report recommendations has been completely met, and several have not been addressed at all. As the numbers of older patients grow, the United States, at least, has made little progress on meeting the workforce pressures to meet their care needs. Scalesâ (2021) Forum article summarizes the current state of the direct care workforce, highlighting the preponderance of women of color and emphasizing how the work of caring continues to be devalued, as manifested in poor compensation, heavy workloads, and inadequate training and support. Despite these ongoing challenges, Scales offers optimism and a call to action, noting the opportunity to leverage the emergency responses to the COVID-19 pandemic and the crisis in long-term care settings it engendered. She calls for disseminating tested interventions, especially upskilling and empowering direct care workers and changing to value-based payment models. Two studies in our collection support these recommendations. Wu et al. (2021) studied the impact of a policy change in Taiwan that instituted a new payment system for home care services. The policy shifted payment from a per-hour rate to a per-service rate, increasing flexibility of home care workersâ time and allowing the opportunity for higher reimbursement for more efficient service delivery, leading to an increase in the workforce. Gleason and Miller (2021) found that supervisor support and degree of control on the job were associated with home health aidesâ job satisfaction and intention to leave among respondents to the 2017 Massachusetts Home Care Aide Survey. Together these two studies illustrate how policy and workplace practices might influence workforce size by attracting workers, on the one hand, and retaining them, on the other. Articles by Castle (2021) and Kennedy et al. (2021) are also relevant to the important challenge of retaining direct care workers. Castle points out that the problem cannot be studied adequately if the concept of retention is not operationalized adequately. In this useful measurement study, he compared different definitions of retention, integrating data from the Nursing Home Compare and Certification and Survey Provider Enhanced Reporting databases. He concludes that the best indicators of care quality are 3- and 5-year retention rates. Kennedy et al. compared retention rates for direct care workers in assisted living and nursing homes using an Ohio data set. Their results showed comparable retention rates across settings, but predictors of retention differed. Retention strategies should take into account context, including work settings and their attendant resources and regulation. Although long-term care workforce policy is often associated with standardized quality indicators, these are only indirectly associated with resident quality of life. Using a novel, hermeneutic approach to policy analysis, Hande et al. (2021) examined the connections between decentralized Canadian long-term care regulations and resident quality of life. They found that newer regulations tended to provide more flexibility for staff to promote resident quality of life. Despite the overall tendency of regulations to be rigid and safety-oriented, the findings offer some optimism that more flexible regulations might support the goal of empowering staff to emphasize quality of life for residents. Whereas the aforementioned articles approached the direct care workforce from a policy and large data set perspective, three qualitative papers privilege the perspectives of those workers. Douglas et al. (2021) explored the pressures associated with mealtime assistance, a burdensome task that is often an âextraâ duty for nursing assistants. Their findings show the importance of training for this task, emphasizing the importance of verbal and nonverbal communication skills to this intimate social interaction. Cooke and Baumbusch (2021) further examined the interpersonal climate of the care facility in their critical ethnographic study of two Canadian nursing homes. This work documents power dynamics among nursing home staff, showing how incivility and bullying relate to team collaboration, and how these dynamics affect care delivery. Cooke and Baumbusch conclude that, although increasing staffing numbers may alleviate some care burdens and improve quality of care, considering who is working and how they interact may be equally important. Themes of managing time pressures cut across these qualitative analyses and are the focus of a study of Swedish nursing assistants (Lundin et al., 2021). The workersâ accounts depict nursing assistants as a collective âwe,â facing, on the one hand, the âtheyâ of residents, largely drawn as passive recipients of care, and, on the other hand, the âtheyâ of administrators who impose burdens that are not always related to direct care of residents. This paper explored how workers prioritize their time among these demands, the values that they use for prioritizing, and how those values are compromised. Together these three qualitative studies enrich our understanding of the day-to-day experiences of direct care workers and emphasize how institutional contexts may affect the link between workers and quality of care. The challenges faced by direct care workers are compounded by an external environment that devalues this work. The systematic review by Machha et al. (2021) found that work in aging care remains highly stigmatized. This review applied a linguistic framework to English-language articles addressing stigma in aging care. The analysis demonstrates how the work of caring for older people and the workers who do this work are stigmatized, although the nature of that stigmatization depends on the social position of the people studied. Unsurprisingly, such stigma affects recruitment, job satisfaction, and worker well-being. The joint import of support and training connects the quantitative and qualitative work in this collection; enhancing the direct care workforce involves increasing numbers and increasing their skills. A key skill needed in all long-term care settings is the ability to work with people living with dementia. McKay et al. (2021) address training directly in their comparison of a traditional skills training approach to an approach based on an occupational adaptation (OA) framework. Although both groups improved in skills mastery, the OA-based group showed greater gains, developing more cooperative approaches to solving the complex problems typical in dementia care. This exploratory study suggests that OA-based training has the potential to address climate and skills issues that challenge worker satisfaction and effectiveness in long-term care settings. As Foley and Luz (2021) point out, the increasing acuity of nursing home residents demands changing models of medical care delivery. Katz et al. (2021) review current models, noting that shortages of geriatricians have led to greater proportions of care delivered by nurse practitioners, physician assistants, and skilled nursing facility specialists. At the patient care level, involvement of these nonphysician professionals may lead to higher quality of care, but Katz et al. argue that there is insufficient research to determine which models of care are ideal. They call for rigorously testing these models in the future. As a start, Wagner et al. (2021) regressed Nursing Home Compare quality measures onto provider and institutional characteristics. They found that having a staff physician was associated with fewer emergency room admissions, but greater use of antipsychotic medication for long-stay residents. Their findings suggest that policies that favor a particular model may not yield unambiguously positive outcomes. Further research is needed to compare different care models directly to one another. McGilton et al. (2021) demonstrated how, during the COVID-19 crisis, nurse practitioners in rural and urban Canadian nursing homes took on the burdens of containing the spread of the virus, stepping in to cover gaps across the workforce spectrum from nursing to medical care, providing support for staff and families, and creating linkages across health care systems such as emergency medicine and psychiatry. Nurse practitioners in this qualitative study demonstrated flexibility in being able to span the complex needs of postacute care systems, supporting McGilton et al.âs call for increasing the formal involvement of nurse practitioners in these systems. Clearly, administrative structures, workplace climate, training, and support are important factors in creating a thriving workforce for long-term care. Missing thus far in the articles discussed is a focus on the individuals with the most administrative power within these settings: administrators and directors of nursing. A scoping review by Siegel and Young (2021) reveals important gaps in our knowledge about these key players. They found no studies of how administrators and directors of nursing work together to navigate the complexity of demands they face, although anecdotal evidence suggests that this relationship is critical. This review suggests that there is a great need for theory-based studies of the organizational process to understand how to improve important workplace characteristics to make long-term care jobs more appealing. Overall, this collection of articles spans the long-term care workforce from the front line to the back office, from rigid hierarchies to flexible models that promote creativity. When we started on the path to producing this collection, we knew that the way forward would have to negotiate a complex and changing landscape. If the shared goal is that long-term care should provide both high-quality care and the opportunity for a good life, the resulting articles lay out many of the challenges faced by policymakers, practitioners, and providers. At the same time, new models of care and new ways of thinking about and defining âworkâ have perhaps moved us a few steps down the path. The COVID-19 pandemic has laid bare the need to reinvest in the long-term care workforce, and we hope that this collection will provide positive guidance for future research and policy.
Over the last decade, the term âgig economyâ has risen to prominence in public discourse, but has failed to attract sustained attention from political philosophers. The gig economy is a subsection of the overall economy that predominantly relies on âon-demand workâ:11 Prassl 2018, p. 11. workers22 Throughout this article, we deliberately speak of âworkersâ in a broad sense: not only those permanently employed count as workers of a firm, but all those who actually work for it. receive short-term and freelance contracts rather than permanent jobs. Firms treat them as independent sellers of services and only hire them to perform a particular âgigâ, that is, to complete a specified task or project. Gig work thereby increases the granularity of work contracts: work is sold in ever smaller quantities and, in extremis, firms only buy the exact amount of labour they need, at the particular moment they need it. On a social level, the higher granularity of labour market transactions leads to an expansion of the reach of markets. Not only a one-off hiring decision, but the conditions of every single micro-labour contract become subject to the market forces of supply and demand. From an economic perspective, the ability to hire and dispense with workers at will is often seen as a measure for âremoving frictionâ in labour markets, and unlocking efficiency gains as âunproductive human capitalâ is âset freeâ.33 On the flexibilization of labour markets in the 1990s, see Davies and Freedland 2007. Major expositions of this policy programme include European Commission 1994; OECD 1994. Whenever a firm can do without a workerâs additional unit of labour, she re-enters the labour market, which can then, in theory, allocate her work to the most productive use. The business practices of ride-service providers like Uber and Lyft in the US best embody this trend, paying drivers by the ride and only if there are rides. But, beyond such extreme and well-publicized cases, many firms are gradually moving away from the paradigmatic form of employment in the industrial ageâa job with a fixed number of hours, worked in set shifts, in one place, and for a predetermined salary (call this âstandard employmentâ)âtowards work that is contracted at short notice on the basis of current demand (call this âgig workâ).44 Some other forms of work, like fixed-term employment with a longer duration or employment at temporary work agencies, lie somewhere in the middle of this spectrum. They often display many of the normatively problematic features of gig work, but to a lesser extent. While various statistics employ different criteria for determining whether or not someone counts as a contract worker, the number of people affected by this shift has dramatically increased over the past decades and is projected to rise further. According to a recent study, those in alternative work arrangementsâlike on-call workers, contract workers, and freelancersâmade up 15.8 per cent of the US workforce in 2015, up from 10.7 per cent a decade before.55 Katz and Krueger 2019, p. 382. At Google, contract workers are now reported to outnumber permanent staff.66 Wakabayashi 2019. The trend towards gig work poses a challenge to the paradigm of standard employment, which is modelled on the industrial worker and has dominated debates in political philosophy and labour economics.77 See also Vallas and Schor (2020), who focus on the specific context of the platform economy, where firms obtain a near-monopoly position in connecting buyers and sellers of labour. They contend that such gig-economy platforms require new regulatory approaches, as they reject responsibility for individual but over one many regulatory of the past the work and not to gig such work rise to the context of standard employment, has a social workers will not become but they will work, only of or at a social like as is not to short-term the but trend towards work and a new for that on the of in on to the rise of forms of employment and that the shift in employment is best as a of of firms business by of workers, thereby them to that this that current and the shift are normatively the of the article, this has the shift from the of affected that workers, ability to form and thereby of of gig work not we the gig economy to of and, the shift from the of that firms in the gig economy in a they a on the of the on the of work in affected and on social the as the of gig the to at an the of gig work, and for the of this article, such is a the of a of which that the and a form of employment, the higher the to social by the which can the of a has to the of gig work the of gig workers by a new this we that there has a shift towards forms of employment, which is best but not the rise of the gig has by who and to by social by and of in with and the of the trend towards gig that this trend is best as a the of firms business by of workers, thereby them to increased on we a broad of as or where of human has at and where the is p. are by in business are are business can for increased in is often by and social that See for a of in debates in the philosophy of work, this of is for the of forms of the to is an and political in See and to the of the or See in the and the to a social and social and can if they do not as we will by people from and Over the past labour markets in seen a rise in the number of people who are in temporary or forms of that the of work can the of conditions over and the or to in of work is by an of economic a a recent that the in US employment the has in temporary and contract Katz and Krueger 2019. the for that the number of is, of employment contracts that do not amount of the has risen from to over the past for Not has become an for the and that per cent of the by from in from the and p. the flexibilization of employment has to the forces of and and the of in the of in regulatory political in the labour market not but only by of are of in the of has as has the of by as a form of has are to the rise of temporary in as temporary workers to and and at the are also the of of the of the flexibilization of the labour the of forms of employment is not that they with or to but that they workers to thereby them in a form of and ability to and to the recent not in of an or a but a business is to workers and thereby business as as The in a which in or in an in to a The most of this is by them on to See who as business and the a firm can employment and in to demand or for other this to workers to such increases in they to or buy additional The up a firms but in the context of standard employment they of permanent work fixed with and workers from such an to for other of business on to that this is but the to which they all on the rise the in most to the contracts of permanent to employ workers only contracts as workers need not to contracts of to the number of of work a for business The most extreme of this trend are where do not number of of work and workers are only if The from fixed or contracts a of platforms the to the for individual gig and only at the a worker not but set by a for business is in the from fixed work firms to in a to in demand. often to on work at short and to work if the for on to workers a or the workers the for such by and work is of thereby to the other the in the of rather than the the for and workers are are but to business and the of such by on to firms in the to which they do the of specific but is also affected by the of business of the of labour the of in firms like Uber and Lyft the in an employment a fixed number of work hours, a fixed work they hire people as in workers often labour for a single Throughout all of the economy, employ of They on to temporary workers, only temporary to new workers or work contracts for if the most the that the gig economy in also a number of that on of in or the or in the of business in the gig economy, this a of this The the of gig work on workers and at which the of gig we a new paradigm for conditions of a of often has of and not only at but also at is The subsection gig work in shift the of where gig work is is to that it. 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Abstract How might the structure of banking affect economic resilience? We address this question by analyzing how the organizational structures of banks and banking markets were associated with unemployment trajectories in local economies during the Great Recession. Two county-level analyses yield convergent results. Increasing branch densities of giant derivative holding banks within local economies were associated with greater surges in unemployment, weaker employment recoveries and stronger recession effects on unemployment from 2007 through 2016. Increasing branch densities of community banks and credit unions and localism in banking were associated with lower unemployment spikes, stronger recoveries and dampened crisis effects. These findings advance sociological studies of finance by providing new quantitative evidence for links between the social structures of banking and economic performance. They also confound arguments that decentralized systems of small, locally based financial institutions are inherently fragile by design, suggesting instead that alternatives to âtoo-big-to-failâ banking can enhance local economiesâ capacities to adapt proactively, withstand crisis and sustain employment during recessions.
This article analyses the rules on wage coordination and their effectiveness in the Italian two-tier bargaining system. It seeks to cast light on bargaining coordination by starting from the analysis of collective agreements, rather than focusing exclusively on normative and institutional aspects of wage bargaining. Accordingly, the study examines a dataset of 498 company-level collective agreements concluded between 2012â2015 in three sectors â metalworking, food, banking and finance â to analyse wage developments in company-level bargaining. The study considers the extent to which local wage negotiations are consistent with the rules on wage bargaining coordination laid down in economy-wide agreements and national collective labour agreements. Wage coordination rules are generally respected, though a significant number of company-level agreements still provide fixed-rate pay rises in breach of the rule that wage increases at company level should be linked to productivity and other factors relating to the workersâ and/or the firmâs economic performance. Although the violation of wage bargaining rules between national agreements and company-level collective agreements is in line with the favourability principle, it is argued that local negotiations on fixed-rate pay rises could be regarded as a form of uncoordinated decentralization, diminishing the effectiveness of horizontal coordination policies and the normative role of the social partners.
Background Task-shifting has been implemented in the United States, Canada, Australia and New Zealand and increasingly in Europe. A cross-country comparison of task-shifting has been lacking across Europe. We assessed task-shifting practices in Europe and other OECD countries, and secondly, performed correlation analyses with OECD data. Methods A survey was developed, pilot tested and sent to 109 country informants in 39 countries covering Europe, the United States, Canada, Australia and New Zealand (response rate 85.3%). Country informants were chosen based on a pre-defined set of criteria. Countries levels of implementation was correlated with OECD secondary data: physician and nurse ratios, education, and primary mode of financing (fee-for-service vs other). Results Eleven countries have implemented extensive task-shifting (Australia, Canada, New Zealand, the Netherlands, US, UK (England, Wales, N. Ireland, Scotland), Finland, Ireland), measured by authority to diagnose, refer, treat and prescribe. However, countries' levels of regulation and financing varied, as did training requirements. The majority of countries showed emerging, yet limited task-shifting where nurses took up some advanced roles within confined boundaries. Five countries did not implement task-shifting. Conclusions Countries most advanced showed variations of the regulatory contexts, which may impact on nurses' practice patterns. Countries with decentralized regulation resulted in uneven levels of implementation, posing barriers to an efficient use of this workforce. Countries in early development stages focused primarily on adapting training capacity. From an international and especially, EU perspective, harmonizing competencies and training â in those countries showing similar levels of advanced practice â will be an important step to ensure the quality of care, avoid potential skill-loss and facilitate the recognition of education in increasingly connected labor markets. Key messages Task-shifting from physicians to nurses is an increasing workforce trend in Europe, however, extent of task-shifting and levels of implementation vary An enabling policy context involves up-to-date regulation, quality education pipeline and a supportive financing structure
This article addresses the market for employment services. It adopts a dynamic perspective on welfare markets and demonstrates how the institutional design of quasiâmarkets in the Danish Public Employment service has been promoted, altered, and reâregulated over a period of 10 years. It was in 2002 when quasiâmarkets have been created by using the instrument of contractingâout employment services to private providers. Seen from the perspective of policymakers at the national level, contractingâout is attractive as it has a buffering function and allows adapting the amount of the public financed employment services comparatively easy to changing needs resulting from changing labor market conditions. However, contractingâout makes accountability to public goods more difficult as the chain of accountability is stretched or may even be broken. Against the background of accountability scandals, which have revealed the poor quality of privately provided services, the market design was reâmodeled again by replacing standardized national tendering with a decentralized, partnershipâbased and dialogueâoriented approach, where services are developed in joint efforts between purchaser and provider. All in all, the development of quasiâmarkets in the Danish Public Employment system can be described as a partial reversal from marketization. Paradoxically, elements of network governance, which were abolished initially, have been introduced again.
The Spanish National Health System (SNHS) has sustainability problems resulting from weaknesses in institutional design and governance compounded by the economic crisis it faces. The global economic crisis has had a particularly virulent impact in Spain, characterized by high levels of unemployment and public and private debt. Fiscal adjustment policies implemented may significantly compromise the SNHS. Along with general funding problems, the strong territorial decentralization of health jurisdictions in the Autonomous Communities has not been backed up by efficient State-level health coordination. The SNHS suffers from problems in its rules of governance, its autonomous financing system, human resource policies and diversity of direct and indirect management models in different Autonomous Communities. A reform strategy in Spanish healthcare governancemust be articulated within the context of a broader review of public policies to stabilize the lines of defense of the welfare state. Within the scope of the health sector, the financing system must be improved and institutional changes to increase efficiency must be implemented.
[Excerpt] It is not surprising that most theories of human capital treat the firm as the key unit of analysis, given the deep imprint that Becker (1964 [1993]) left with his early efforts to distinguish between general and specific human capital. It is especially understandable for research that focuses on American institutions and practices. Ever since the passage of the New Deal employment policies of the 1930s, firms have been assigned central roles in the delivery and financing of a variety of labor-market services, including the provision of workforce training and development (Osterman et al, 2001). Most of the chapters in this volume reflect this emphasis by exploring how individuals and firms allocate the costs and share the benefits of human capital, incorporating human capital development into alternative theories of the firm (such as transaction cost, resource-based, agency, entrepreneurial, and knowledge-based perspectives), and how human capital plays into emerging research on social capital, organizational capabilities, learning, and human resource strategies and architectures. But, as Chapters 12, 22, and 23 each suggest, firm-centric theories, particularly those founded upon the neoclassical economics framework, need to more fully take into account how firm boundaries, strategies, and practices relate to other institutions in society. This is particularly important given the changes in employment relationships that are acting to reduce the labor-market functions served by individual employers. In short, the central argument of this chapter is that a more up-to-date theory of the changing nature of employment relationships is needed to understand whether and how human capital is to serve as a source of competitive advantage in a modern economyâeven one as decentralized as that of the US.
The present study describes and explains the changing role of the state in the Italian healthcare system since the beginning of the 1970s, with a particular focus on developments following 1978 when the healthcare system was transformed from a social insurance system into a national health service. In order to address these changes in a systematic way, we track healthcare system development along three dimensions: regulation, financing, and service provision. With regard to regulation, we observe a relative retreat of the state due to decentralization processes and internal market mechanisms. Quantitative measures for the financing and service provision dimension also indicate a modest relative retreat of the state. Taking regional data into account, we identify a clear North-South-divide in the public/private mix of financing and service provision. Although the focus of the paper is to describe the changing role of the state in the Italian healthcare system, we also offer preliminary explanations. We seek to identify the role of exogenous shocks such as economic crises versus endogenous stressors specific to the healthcare system itself (i.e. inherent inefficiencies) on healthcare system change. Therefore, the paper aims to provide a tentative, yet dynamic account of healthcare system change that is both descriptive and explanatory.
Latin American social medicine (LASM) emerged as a movement in the 1970s and played an important role in the Brazilian health care reform of the 1980s, both of which focused on decentralization and on health care as a social right. The dominant health care reform model in Latin America has included a market-driven, private subsystem for the insured and a public subsystem for the uninsured and the poor. In contrast, the Mexico City government has launched a comprehensive policy based on social rights and redistribution of resources. A universal pension for senior citizens and free medical services are financed by grants, eliminating routine government corruption and waste. The Mexico City policy reflects the influence of Latin American social medicine. In this article, I outline the basic traits of LASM and those of the prevailing health care reform model in Latin America and describe the Mexico City social and health policy, emphasizing the influence of LASM in values, principles, and concrete programs.
Social assistance as the technique providing means-tested income guaranteed financed by general taxation in Spain is composed by different benefits. There is not a only one policy, but different measures oriented to different groups of population and organised by different public administrations. During the last two decades, the different levels of public administration have implemented a set of benefits, which observed together can considered as the Spanish âsafety netâ. The main lines of this development has been: a) fragmented in different protection systems (unemployment, pensions, social services), b) subsidiary of the development of these systems and c) decentralized in different levels of public administration (mainly in regional level, i.e. Autonomous Communities).
In the course of the present transition in Russian society, a new system of social security has been developed. The previous Soviet system has been replaced by a system of four more or less independent social funds, covering the main branches of social security. These funds are supposed to be run according to insurance principles and to be financed by contributions, mainly from employers. Given the difficult economic and social situation of the country, there have been increasing demands for effectiveness in the management of the different funds and also in the management of the whole social security system. The results of this study show that the social funds have developed different organizational structures with different degrees of centralization and decentralization. Only one of the funds seems to be relatively wellâfunctioning and effective, while the others have experienced more or less serious problems in fulfilling their main tasks and functions. The most serious problems, however, seem to stem from the structure of the social security system as a whole, which is perceived as fragmented and badly coordinated. In order to improve the coordination of the system, there have been proposals to merge two or more funds into a unified social security organization. This strategy is open to question, however, since it would increase the bureaucracy of the system. There are other ways in which the structure of the social security system might be advanced. Such developments should be based on an analysis of the system from the perspective of the individual client or patient.
We model the links between skills and changes in work organization. As the proportion of skilled workers increases, the economy travels through a sequence of organizational equilibria. We show that as the relative supply of skills increases the organization of work becomes more decentralized. Both skilled and unskilled workers become more autonomous and perform a wider range of tasks: decentralization spreads across firms at the expense of the old centralized organization based on a strict division of labor. Moreover, as firms switch to decentralization, their employment structure becomes more homogeneous and wage inequality stops decreasing. These predictions are compared with empirical evidence based on French establishmentâlevel data and we find support for both of them. This suggests that the longâterm increase in the skill level of the workforce may have been one important factor driving the recent introduction of new work practices by a large number of firms.
In continental Europe, the unemployment rate has risen continuously from a low level of below 3 percent in the early 1970s to more than 10 percent in the late 1990s. If those who are in governmental employment schemes and in early retirement are included, the unemployment rate runs as high as 20 percent in quite a few European countries, including France and Spain. The basic rule for a stable employment situation in an economy is: nominal wages should stay in line with labor productivity growth plus the increase in producer prices. In a situation of high unemployment, however, when the unemployed are to be integrated into the labor market, the productivity rule has to be modified: the increase in real wages should stay below the productivity growth rate until a satisfactory level of employment has been obtained. The most elegant approach to creating more employment is to improve labor productivity. If an economy succeeds in raising labor productivity, there is more scope for real wage increases or for more employment. We should, however, not overestimate the potential of an economy to increase labor productivity. If we want to integrate the unemployed, average labor productivity in the economy is likely to decrease. We should be realistic enough as to expect trends in Europe to be similar to those in the United States, where labor productivity per hour has increased by less than 1 percent per year since 1980. The task for Europe is to change the institutional setup of labor relations, to move wage formation closer to the market process, and to allow greater wage differentiation. It is unlikely that the "social partners", i.e., the trade unions and employers' associations, will be able to change the rule system sufficiently. Therefore, it is necessary to change the legal rules, especially those in favor of the unemployed, for instance, by introducing a legal right for each individual to enter the labor market at a wage of his or her choice. If continental Europe wants to reduce unemployment, it will have to change the impact of the welfare state. With respect to the level of benefits provided by unemployment and health insurance, a distinction should be made between large risks and small risks for the individual. Such a distinction between large and small risks would allow the costs of the social security system to be reduced, thus lowering the tax on labor. Insurance against large risks would be mandatory, small risk coverage would be optional. With respect to financing the welfare state, more choice should be given to the individual as concerns the insurance coverage that he/she desires. One serious issue concerning social welfare payments is determining the extent to which the level of social welfare benefits should be scaled down for those who are able to work in order to increase the incentive to work and the intensity of the search for work. A related issue is whether unemployment benefits should be reduced in their level or in the length of time they are paid in order to intensify the job search and reduce the reservation wage. âą Shifting the employment issue to the EL) level would take attention away from the need to decentralize wage formation, i.e., to negotiate wages at the level of firms. It would be an incentive not to undertake the necessary steps to solve national unemployment problems and it would shift the financial burden to those countries that are successful in reducing unemployment. It would elevate the national labor market cartels to the EU level and it would blur the lines of responsibility. National governments would shift their responsibility to the EU level. This would be an extremely dangerous development for European integration because the European cause would become the scapegoat of failed national policies.