This article discusses the model of oral health care implemented in the Unified Health System of Brazil in the last decade. This model was conceived as a sub-sector policy that, over the years, has sought to improve the quality of life of the Brazilian population. Through a chronological line, the study presents the National Policy on Oral Health as a counter-hegemonic patient care model for the dentistry practices existing in the country before this policy was implemented. The reorganization of the levels of oral health care, the creation of reference facilities for secondary and tertiary care, through Centers of Dental Specialties and Regional Dental Prosthesis Laboratories, and the differential funding and decentralized management of financial resources were able to expand the actions of oral health for more than 90 million inhabitants. The evolution shown after the deployment of the National Oral Health Policy, as of 2004, demonstrates the greater integration of oral health care under the Unified Health System and provides feedback information to help this policy to continue to be prioritized by the Federal Government and receive more support from the state and local levels in the coming years.
Sarah Meiklejohn, C. Chris Erway, Alptekın KĂŒpĂ§ĂŒ, Theodora Hinkle · 5 authors
In recent years, many advances have been made in cryptography, as well as in the performance of communication networks and processors. As a result, many advanced cryptographic protocols are now efficient enough to be considered practical, yet research in the area remains largely theoretical and little work has been done to use these protocols in practice, despite a wealth of potential applications. This paper introduces a simple description language, ZKPDL, and an interpreter for this language. ZKPDL implements non-interactive zero-knowledge proofs of knowledge, a primitive which has received much attention in recent years. Using our language, a single program may specify the computation required by both the prover and verifier of a zero-knowledge protocol, while our interpreter performs a number of optimizations to lower both computational and space overhead. Our motivating application for ZKPDL has been the efficient implementation of electronic cash. As such, we have used our language to develop a cryptographic library, Cashlib, that provides an interface for using e-cash and fair exchange protocols without requiring expert knowledge from the programmer. 1
Tax increment financing (TIF) is the most widely used local government program for financing economic development in the United States, but the proliferation of TIF is puzzling. TIF was originally created to support urban renewal programs and was narrowly focused on addressing urban blight, yet now it is used in areas that are plainly unblighted. TIF brings in no outside money and provides no new revenue-raising authority. There is little clear evidence that TIF has done much to help the municipalities that use it, and it is also a source of intergovernmental tension and a site of conflict over the scope of public aid to the private sector. Yet, the expansion of TIF makes sense in light of the basic structure of American local government law. Studying TIF can illuminate central features of our local government system. TIF succeeds -- in the sense of its widespread adoption and use -- because it, like local government more generally, is highly decentralized; reflects and reinforces the fiscalization of development policy; plays off the fragmentation of local governments and the resulting interlocal struggle for investment; and fits well with the entrepreneurial spirit characteristic of contemporary local economic development policy. A better understanding of TIF contributes to a better understanding of the political economy of American local government.
Struggles over what a region receives, or should receive, from the budget of the central government are common to many countries. Discussions often focus on the measures of ânet fiscal flowsâ or âfiscal balancesâ provided by the government or other actors. This unique book shows just how these flows are computed then interpreted and clarifies the often misunderstood economic and political motives that explain why some regions receive more monies than others.
Seit etwa 15 Jahren ist der Einsatz so genannter âșNeuer Medienâč im Hochschulkontext im Diskurs, was allerdings nicht dazu gefĂŒhrt hat, dass sich flĂ€chendeckend eine E-Learningkultur etabliert hat. Dabei ist die Akzeptanz von Neuen Medien nach unterschiedlichen Hochschulkontexten diversifiziert zu betrachten. Insbesondere zu Beginn der Entwicklung sind es am hĂ€ufigsten technische FakultĂ€ten, die E-Learning als neue Lernform etablieren wollen. In der Diskussion um die Errichtung entsprechender Strukturen steht u.a. die Substitution von Lehrenden durch moderne digitale Technologien im Vordergrund. Die verschiedenen AktivitĂ€ten sind bislang trotz hohem Ressourcenaufwand, z.B. zur aufwendigen Produktion von âșHochglanz-Multimediaâč, und trotz dem Ziel, immer intelligentere tutorielle Systeme (ITS) zu entwickeln, nicht sehr erfolgreich verlaufen. Insbesondere gegenĂŒber komplexen Inhalten und kreativen Lernenden geraten solche Systeme schnell an ihre Grenzen. Das Erfordernis, hohe Produktionskosten fĂŒr einzelne Features zu refinanzieren, fĂŒhrt zu hoch standardisierten Massenprodukten, die an mehr als einem Hochschulort gleichermaĂen einsetzbar sind. Aus lerntheoretischen ErwĂ€gungen sollen die Anwendungen gleichzeitig subjektorientiert sein. Hieraus entsteht nicht selten eine Entwicklungsparadoxie. Hochschulen selbst investieren bisher, insbesondere vor dem Hintergrund mangelnder Erkenntnisse hinsichtlich der Kosten-Nutzen-Relation, nur sehr zurĂŒckhaltend in reine Softwarelösungen.
THE IDEA THAT WE AREâor should beâmoving from an âindustrial age governmentâ to an âinformation age governmentâ is a staple of political rhetoric. But has the information age significantly altered government in the liberal democracies? And if it has not yet done so, should we expect the liberal state to change in any fundamental way, or be entirely replaced, because of the chain of consequences set in motion by new technology? Since the early development of computers, there have been, broadly speaking, three phases in thinking about the potential of new technology to improve government. Beginning in the 1950s, the application of digital technology to the public sector was conceived of as automation and the hope was mainly for greater efficiency and control in governmental operations. A second phase, dating from the 1980s and rising to a climax in the following decade, pitted two alternative visions against each otherâprivatization and reinventionâeach premised on the idea that the information age made traditional forms of public administration obsolete. Finally, in the most recent phase, digital democracy has become a central theme of visions of new forms of governance based on the diffusion of cheap computing and online communication. Each of these phases has brought some notable but far from revolutionary achievements, and that is what we should continue to expect. Digital technology does enhance some features of democratic government, but the fundamental problems of democracy are not susceptible to technological solutions, and the same developments that strengthen some democratic capacities degrade others. In this new environment, it will be a struggle just to maintain some of the minimal conditions of political accountability that democracy requires. The U.S. federal government, particularly the military, was initially a leader in the development of computers, and from World War II to the 1960s, the state stood on the frontier of information technology. The application of computers to the public sector raised expectations not of radical change but of doing what government agencies already did, only faster and more cheaplyâthat is, automating the bureaucratic status quo. Top-down control and economy of administration were the primary purposes of computerization. Computers were supposed to cut paperwork and costs, reduce crime, and give managers and policymakers better information. The pursuit of control is at the core of bureaucratic administration. Bureaucracy is ideally supposed to ensure adherence to rules through such means as hierarchical command, specialization of functions, uniformity of procedure, and formal documentation. By limiting individual discretion, these elements of bureaucracy are supposed to increase the capacity of the state to carry out whatever purposes animate it. Democracy, far from being antithetical to bureaucracy, has often stimulated its growth. Scandals regularly prompt demand for new rules. The progressives who brought America the popular referendum and direct election of senators also introduced unified budgetary control and stricter rules about the award of government jobs and contracts. They sought as well to professionalize administration and make it more scientific. Computerization fit the progressive bureaucratic paradigm perfectly. The introduction of computers in the 1950s and 1960s coincided with budgetary reform efforts that were intended to give chief executives and their finance officers greater control over how money was spent. Computerization offered the promise of achieving the elusive fiscal goals of unified control and accurate cost accounting for public services. The very nature of early mainframe computers seemed to dictate centralized control, although line agencies fought to get their own computers. Thus, the most widely anticipated effect of computers on government was the centralization of power. Greater executive control over the bureaucracy was an explicit reform objective, but many critics feared that computerization would augment the state's dominion over the individual, and this concern focused the attention on privacy protection. These anxieties were hardly unreasonable. At all levels, government was oriented not to the computerization of service but to the computerization of constraintâthat is, to computerizing functions such as police, revenue collection, and motor vehicle licensing. Within the service agencies, computerization chiefly involved functions in back offices such as record keeping. The âbackstageâ locus of automation concerned both supporters, who thought the public might not appreciate the value of computers, and critics, who thought the public might fail to appreciate the threat to privacy. The early decades of computerization did bear positive fruit. The mid-twentieth century saw enormous growth in government, and after 1955, computers helped public agencies cope with the sheer increase in transactions. Despite the rise in federal expenditures in the United States, the number of federal civilian employees fell; productivity gains from computerization helped to make that possible. But by the 1980s, new developments in both politics and information technology led to a dramatic turn in thinking. Instead of improving bureaucracy, the goal became overthrowing it. The rise of conservative antigovernment sentiment in the Reagan era coincided with a shift in the relationship of government to technological change. The private sector had now moved into the forefront in the use of information technology. In 1983, a Reagan administration commission was stating the obvious when it declared that although the federal government in the 1960s had been âthe acknowledged leader in using state-of-the-art computer hardware and software,â the government had fallen âfarther and farther behind.â The technological lag of the public sector was particularly evident at government's front endâthat is, where the public had direct contact with government. By this time, businesses were using telecommunications and information technology to improve customer service and produce a wider array of products tailored to different tastes; consumers had become used to the convenience of automated teller machines (ATMs), credit cards, and free, round-the-clock calls to 800 numbers. By comparison, public agencies were far slower to take up the new possibilities. The shift from mainframes to minicomputers and the rise of personal computers also turned earlier assumptions upside down; instead of favoring centralized control, the new technology could be a means of decentralization. Conservatives and liberals responded to this situation in different ways. To conservatives, the failure of government to keep up with information technology confirmed the need for privatization. As many corporations were outsourcing specialized functions, so government should do the sameâindeed, the state should generally cut back its size and role. The information revolution thereby provided a legitimizing rhetoric for policies that conservatives had long favored for other reasons. To liberals, the logical response to public sector lag was not to privatize government but to âreinventâ it by making public agencies more flexible in organization, more focused on results rather than procedures, and more responsive to âcustomers.â The Clinton administration's National Performance Review, led by Al Gore, embodied this approach and linked it to the information revolution. In the same period as this debate was playing out, the Internet was becoming a popular medium, and the vision of a reinvented state increasingly emphasized the use of online communication in making government more customer friendly. The focus on improving government at the point of contact with the public involved more than a pretty new interface; electronic access offered the promise of better integrated and more consistently delivered services. But besides improving government's output, the Internet also awakened an interest in giving citizens more input. And with the development of the Web and tools built on it, that interest has gained traction. Digital media have unquestionably expanded the democratic repertoire. Political campaigns and social movements now have cheap, instant means of communication that circumvent the established mass media, and they can use those resources to mobilize followers, coordinate their activity, and aggregate contributions of money, labor, and knowledge. The successful use of new media in politics has raised expectations about its use in government, particularly for three purposesâincreased transparency, collaboration, and participation. Transparency is the most readily achievable of these goals. Just as some early advocates of âteledemocracyâ envisioned, the Internet now provides instant access to government documents and data, and allows the public to track legislation and regulatory decisions. The idea of transparency has grown, moreover, into the notion of government as a âplatformâ that routinely makes granular data available in a form that enables others to build applications on top of it. Here, the goal of open government moves from transparency to collaboration and participation, which raise more difficult questions. Other ideas along these lines call for crowdsourcing proposals for government action and putting such proposals up for electronic voting. The further one moves along the spectrum of actions from transparency to participation, the more vexed the idea of digital democracy becomes. Even though the digital divide has narrowed, any reliance of government on digital technology will put people with less income and education at an inequitable disadvantage because of persistent differences in digital skill as well as access. Moreover, where online participation is opened up, highly committed minorities and special interests are likely to dominate. In a crowdsourcing initiative after the election, the Obama transition effort invited the public to submit and vote on ideas, but the results were embarrassing. As the New York Times reported, âIn the middle of two wars and an economic meltdown, the highest-ranking idea was to legalize marijuana, an idea nearly twice as popular as repealing the Bush tax cuts on the wealthy. Legalizing online poker topped the technology ideas.â Conceived this way, digital democracy recapitulates the classic problems of direct democracyâskewed participation and lack of deliberation. Other difficulties with the idea of revitalizing democracy through online communication arise from the indirect effects of new media on traditional mechanisms of political accountability. By providing an alternative platform for advertising as well as news, the Internet has undercut the sources of newspaper revenue, plunging journalism into a deep crisis and weakening the ability of the press to keep watch on government, particularly at the state and local levels. Resources for journalism are now disappearing from the old media faster than the new media can create them. Furthermore, newspapers have assembled a broad public, including many people who have bought a paper for the sports or crossword puzzle but nonetheless scanned the front page and learned something about the news of their community and the world. Online, however, they can go to a sports or puzzle site without any exposure to the news. In the early years of television, when the evening news was on all three available channels, the national news had a similarly broad public. But beginning with cable television, the advent of new media has brought a profusion of choices of different kinds of entertainment. The share of the public who regularly follows the news and public affairs has declined, though those with the most interest in politics (usually people with strong partisan commitments) have access to more news and a wider range of opinions than before. Despite the cornucopia of information, the politically attentive public has diminished and become more sharply divided along ideological lines. The gains for democracy from new technology are real, but unfortunately, so are the losses. It may be a long time before we can add them up and determine the net impact. In each phase, early enthusiasms have run up against stubborn and uncomfortable limits, even as new democratic possibilities have opened up. We are still in the midst of tremendous ferment in technology, media, and politics, and the creativity now being unleashed is our best hope that when the digital revolution finally runs its course, free societies and popular self-government will be left standing.
Size and Structure of Budget The state budget constituted the center of the Soviet financial system and Soviet financial planning. It disposed of different resources than those of the government budgets in market-directed economies and spent these resources for different purposes. It was an instrument of the state as owner and manager of the economy, an instrument for coordinating the material and financial plans, correlating the centralized and decentralized funds, controlling the activities of enterprises and associations, and channeling a large part of the state's resources and of various kinds of subsidies toward the selected branches of the economy. The budget system was hierarchically consolidated. The USSR state budget ( Gosudarstvennyi biudzhet SSSR ) included the Union budget ( Soiuznyi biudzhet ) as well as the budgets of each of the fifteen union republics ( Gosudarstvennyi biudzhet soiuznoi respubliki ). The latter, in turn, included the republic budgetitself as well as the budgets of the autonomous republics and the local budgets ( mestnyie biudzhety ). In keeping with the principle of all-union centralization, only the budget of the USSR had the right to levy taxes, whether all-union, republic, or local; the budgets of the lower level had the right to their âownâ revenues, but these were designated from above. In the system that prevailed until the late 1980s, there were no clear-cut indications as to which specific budget collected which revenue and which specific expenditures were made by each budget. Data on the structure of budget revenues and expenditures indicated only the total distribution by levels.
Studies of the city have been addressed from many different approaches such as law, political science, art history and public administration, in which the economic, political and legal status of the city have played a major role. However, a new agenda for conceptualizing the city has emerged, in which the city assumes new roles. By using stakeholder theory as a framework for conceptualizing the city, we argue that the city assumes a political-economic agenda-setting role as well as providing a stage for identity constructions and relational performances for consumers, organizations, the media, politicians and other stakeholders. Stakeholder theory allows us to conceptualize the city as being constituted by stakes and relationships between stakeholders which are approached from three analytical positions (modern, postmodern and hypermodern, respectively), thereby allowing us to grasp different stakes and types of relationships, ranging from functional and contractual relationships to individualized and emotionally driven or more non-committal and fluid forms of relationships. In order to support and illustrate the analytical potentials of our framework for conceptualizing urban living, we introduce a project which aims to turn the city of Aarhus into a CO2-neutral city by the year 2030, entitled Aarhus CO2030. We conclude that applying stakeholder theory to a hyper-complex organization such as a city opens up for a reconceptualization of the city as a web of stakes and stakeholder relations. Stakeholder theory contributes to a nuanced and elaborate understanding of the urban complexity and web of both enforced and voluntary relationships as well as the different types of relationships that characterize urban life.
David Katzenstein, Sinata KoullaâShiro, Marie Laga, JeanâPaul Moatti
The extraordinary success of antiretroviral therapy (ART) in the North during the closing years of the last century directly led to the United Nations' resolutions in 2000, about universal access to HIV treatment, and to the inclusion of this target among the Millenium Development Goals [1]. A previous AIDS supplement, supported by the French Agency for AIDS Research (ANRS) and published as early as 2003, presented the evaluation of the first national pilot programs for access to antiretroviral HIV treatment in three African countries (CĂŽte d'Ivoire, Senegal and Uganda). These results contributed to a consensus on the feasibility of scaling-up access to HIV treatment in low-resource settings, an issue that had been heavily debated among clinical, public health and development experts [2]. Since then, antiretroviral therapy coverage rose from 7% in 2003 to 42% in 2008, with especially high coverage achieved in eastern and southern Africa (48%) [3]. There are no longer doubts that access to ART results in a remarkable reduction in mortality, which may be as high as 95% in comparison to no intervention [4]. In addition, retention in care and treatment may exceed levels seen in the North: for example, a remarkable 79% of adults enrolled in the early stages of Botswana's antiretroviral therapy scale-up are alive five years later [5]. On a macro scale, Bendavid and Bhattacharya [6] found that after four years of the US President's Emergency Plan for AIDS Relief (PEPFAR) funding and support for ART, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, although trends in adult prevalence did not differ. Despite the community stigma, political denial and tensions between government policy and medical practice, South Africa with the largest number of HIV infected individuals is also home to the largest antiretroviral therapy program in the world with accelerating impact. In the Western Cape Province, six-month mortality among patients at an HIV treatment centre fell from 12.7% to 6.6% between 2001/2002 and 2005 as access expanded [7]. The recent statement, on World AIDS Day on December 1st 2009, about universal access to HIV care and treatment by the new South-African President, Jacob Zuma, raises hope that South Africa will henceforth assume a leadership role in the region [8]. However, scaling-up access to HIV treatment in Africa, home to two thirds of those living with HIV/AIDS, poses new and largely unexplored challenges in the delivery of a complex set of public health, medical and psychosocial interventions. The transition from an emergency response to robust and sustainable health services delivery systems for HIV is a work in progress. Building these systems must be mindful of cultural context and existing health systems in the affected communities. The most recent [9] report on the epidemic describes a highly varied picture of remarkable progress in some African countries and huge unmet needs in others. Access to treatment in Africa is often taking place in the context of fragile states, struggling with social, political and economic turmoil, where investment in healthcare systems has been limited. Particularly in resource limited settings, there is an unavoidable competition for infrastructure, resources and personnel between donor driven programs targeting specific diseases (ie. AIDS, TB and malaria) and long standing programs in primary care, maternal and infant health. The âMaximizing Positive Synergies Collaborative Groupâ (MPSCG), coordinated by WHO, has recently synthesized the existing evidence regarding interactions between disease-targeted programs and country health systems [10]. Although it concluded that this impact âon health outcomes and health systems, though variable, has been positive on balance and has helped to draw attention to deficiencies in health systemsâ, available evidence also pointed out that further improvements and efficiency gains are needed especially to strengthen the health workforce, align health information systems, and to reduce out-of-pocket payments for financing health-care expenditures. Operational research encompasses a broad range of investigation, primarily the evaluation of outcomes among the health programs. Systematic observation and analysis of data collected alongside ART programs can provide guidance to implementers and policy makers with the aim of achieving sustainable access to care. Critical in any operational research project is the development of partnerships and capacity building between the wide array of actors who contribute to deliver healthcare, including national health services, community based organizations and advocacy groups, national and transnational NGOs, as well as the international donor agencies on the one hand, and academic researchers and research organizations on the other [11]. There are certainly general principles of treatment that can be broadly applied and evaluated in Africa. But ultimately, in each context, it may be anticipated that the design of programs for access to ART will vary. Critical unanswered questions remain about how access to ART will impact social stigma, individual risk behavior and ultimately the course of the epidemic. Because of the heterogeneity of affected populations and societies, the psychosocial and behavioral consequences of ART access and methods to ensure adherence, retention and to provide sustained treatment across Africa are not likely to be distilled to a single set of best practices. Thus, in the face of the HIV epidemic in Africa, operational research is a process of âlearning by doingâ in each of the diverse contexts, sharing the outcomes and observations among countries and programs. A myriad of local evaluations of process and outcome may be the most flexible way to effect sustainable implementation of ART access and the development of robust medical and social responses to AIDS in various contexts across a continent. One regrets that in spite of significant investment in evaluation exercises, global health initiatives such as the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), PEPFAR or the World Bank still have limited contributions to effective operational research [12,13]. Operational issues in scaling up access to ART This supplement presents original results documenting the progress, as well as obstacles, in scaling up HIV treatment in Africa. Papers from Burkina-Faso and Cameroon are based on operational research carried out alongside the national ART programs of these two countries that have been directly supported by ANRS. Other papers present fruitful experiences from operational research in additional African countries (Botswana, Lesotho, Mozambique and South Africa) while one paper (Celletti et al., S45âS57) focuses on a multi-country effort associating four African countries (Ethiopia; Malawi; Namibia and Uganda) and Brazil. It must be noted that the paper by Bassett et al. (S37âS44) about initiation of ART in Durban, Kwazulu-Natal, South Africa, one of the epicenters of the epidemic, was awarded the joint International AIDS Society (IAS)/ ANRS âYoung Investigator Prizeâ for Operations Research at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, that took place in Capetown in July 2009. Finally, one paper (Jerome & Ivers, S73âS78) deals with rural Haiti, a non-African country, whose experience with ART in very deprived and vulnerable populations has been worthwhile for other low-resource settings. The process of improving and sustaining access to ART begins with surveillance and testing to understand the magnitude of the epidemic locally, and requires assessment and consultation with Ministries, healthcare providers, communities and stakeholders to identify the key operational issues in access. Access to ART begins with the effective implementation of voluntary testing on a scale not yet realized, effective post-test counseling, linkage to care, and has already led to monitoring, care and retention of 3 million people on ART in Africa. How to accomplish each of these tasks with health systems that are often insolvent and frequently understaffed is the focus of the papers presented in this supplement. All papers emphasize that advances in access to ART have only been made possible through implementation of innovative ways of delivering and monitoring care, and also illustrate some of these innovations. Clinical research programs continue to evaluate new, less toxic and potentially less costly drug cocktails, more effective monitoring algorithms and programs to reinforce and maintain treatment adherence that would be better adapted to the practical constraints of health systems with very scarce resources. Notably, the DART study results in Uganda and Zimbabwe suggest that some of the accepted guidelines for laboratory monitoring need careful reassessment [14], and the forthcoming results of the STRATALL study in Cameroon will evaluate the impact of the WHO public health approach to monitor ART at a decentralized level of care [15]. Similarly, the management of first-line ART is fraught with issues even in the choice of Non-nucleoside reverse transcriptase inhibitors (NNRTIs). Consideration of Efavirenz and Nevirapine as first line NNRTIs as described in the paper by Wester et al. (S27âS36) in Botswana reflect trade-offs among cost, potency, potential side-effects and concerns about teratogenicity and toxicity. These issues will continue to expand as additional drugs become available and as the price proposed by pharmaceutical firms for new first-line and for second-line regimens, as recommended by WHO, remain prohibitively high compared to those of the âoldâ generation of antiretroviral drugs [16]. It is estimated that at least 57 countries, mostly in sub-Saharan Africa, face crippling health workforce shortages, and there are simply not enough physicians and nurses on the ground to begin to address the magnitude of the HIV epidemic through traditional clinic based care. Rational redistribution of tasks between physicians and other healthcare personnel, and the introduction of community and family health aids and NGO volunteers, as medical officers, adherence counselors or treatment âbuddiesâ is a key part of the âtask-shiftingâ agenda articulated by WHO [17]. The multi-country paper by Celletti et al. (S45âS57), papers by Sherr et al. (S59âS66) on Mozambique, Jerome and Ivers (S67âS72) on Haiti and Ivers et al. (S73âS78) on the Haiti-Lesotho collaborative model detail the certain conditions that have to be fulfilled for the reorganization of clinical services under a task shifting model to be successful. One of the most innovative contributions of HIV programs has been to promote meaningful multi-stakeholder partnerships between governments, civil society and affected communities at the global and local levels. Civil society has critically important roles ranging from advocacy, demand creation, and service delivery, to policy-setting and providing oversight by emphasizing accountability to service users [18]. Papers by Desclaux et al. (S79âS85) on Burkina-Faso and Ivers et al. (S73âS78) on the south-south collaboration between Haiti and Lesotho illustrate how such involvement of civil society offer opportunities for creative operational research. Quite logically, it is the relationship between scaling up access to HIV treatment and health systems strengthening that bears the greatest scrutiny across most of the papers of this supplement. In a comprehensive evaluation of ART access through a national program in Cameroon, Boyer et al. (S5âS15) present analysis from the EVAL study where the quality and quantity of care at central, provincial and district levels was contrasted. This evaluation clearly shows that decentralization of ART delivery can increase equity in access for the poorest sectors of people living with HIV while maintaining clinical effectiveness, and even improving adherence and quality of life. Experiences in other African countries, like Uganda, suggest that even further decentralization of ART may be effective and cost-effective [19], but this needs more investigation and may differ according to each specific socio-economic and health systems context. Future challenges for long term sustainability of ART In this supplement, another paper on Cameroon by Marcellin et al. (S17âS25) provides compelling evidence that access to ART at higher CD4 levels reduces reported risk behaviors and can improve quality of life. This paper, and the one from Bassett et al. (S37âS44) describing considerable gaps in bringing and retaining people with AIDS into treatment in a well resourced program in South Africa, supports the recent revision of WHO guidelines [20]. These new guidelines increase the recommended CD4 count for starting treatment to 350 cc/mm3 (rather than the previous lower 200 threshold) and imply that an additional number of 5 million HIV-infected patients world-wide should be considered eligible for immediate access to ART. These papers, however, anticipate some of the new challenges and tensions that would logically derive from this extension of treatment eligibility and from the urgent need to revisit the relationship between HIV prevention and treatment. Despite the actions of many agencies and national health autorities, an estimated 1.9 million [1.6 millionâ2.2 million] new HIV infections occurred in sub-Saharan Africa in 2008. This high incidence, and consequent increase in unmet treatment needs over time, represents an additional key challenge for ART program scale up to remain feasible and sustainable [21]. The recognition that the speed at which people are infected exceeds the speed at which they can be put on treatment has been a powerful message to advocate for enhancing prevention efforts. Treatment programs offer many opportunities to strengthen prevention, through increased uptake of testing, viral load reduction in patients and models of âprevention counselingâ for and by positive people. These synergies should be fully recognized and monitored. As an illustration, in a paper on Cameroon in this supplement (Marcellin et al. [S17âS25]), patients not yet on ART reported more frequent inconsistent condom use compared to those on ART, confirming positive effects of intense patient-healthcare worker contact on behavior. (Re)-emphasizing and maximizing synergies between the ART roll out and prevention is essential and urgent but should be seen as a component of a comprehensive âTreatment and Prevention Combinationâ approach, including behavioral, social and structural interventions. Over the coming decade, the challenges of expanding, enhancing and sustaining treatment for the more than 22.4 million people living with HIV in Africa, will consume immense monetary, human and social resources. Evaluating the long-term outcomes of access to ART on a population level across diverse urban and rural and multiple cultural contexts in Africa present a formidable challenge. If the patterns of behavior and transmission observed in the North are any indication, large-scale access to care may increase transmission of drug resistant viruses [22]. The best way to prevent this will be the development of robust and affordable programs for retention, monitoring and management of ART by skilled providers and robust systems of care. Papers in this supplement support the optimistic view that innovative solutions can be found to tackle the multiple medical, public health, socio-economic and logistic issues related to long term sustainability of ART programs in Africa. Ensuring their financial sustainability through appropriate growth of domestic and international funding however remains a prerequisite for success, and this is far from guaranteed in the context of one of the worst economic crises the world has ever faced. Because overall demand has been higher than anticipated in the funding scenario of its previous replenishment, the Global Fund faces a resource gap for the period 2009â10 for the first time since its creation. Its future contribution to scaling up the response to the HIV epidemic will depend on the willingness of donor governments to provide significantly higher pledges for its next replenishment (2011â2013) than the 9.8 billion US$ obtained for the previous one (2008â2010) [23]. In the US, a debate is growing about whether or not a further expansion of PEPFAR would be the best use of international health funding [24]. Demonstrations, as presented in this supplement, contribute evidence-based advocacy in favor of sustainability of HIV/AIDS treatment and provide clear examples of how health systems are adapting to meet the challenges of HIV. Of course, we also present these examples to underscore the importance of continuing, flexible operational research and evaluation to maintain international and domestic funding, the life-blood of treatment access for millions in Africa, and around the world.
BACKGROUND: The independent evaluation of the Cameroonian antiretroviral therapy (ART) Programme, which reached one of the highest coverage in the eligible HIV-infected population (58%) in Sub-Saharan Africa, offered the opportunity to assess ART outcomes in the context of the decentralization of HIV care delivery. MATERIALS AND METHODS: A cross-sectional survey (EVAL, ANRS 12-116, 2007) was carried out in a random sample of 3151 HIV-positive patients (response rate 90%) attending 27 treatment centres at the different level of the healthcare delivery (central, provincial and district), as well as in the exhaustive sample of doctors in charge of HIV care in these centres (response rate 92%, n = 97). Multivariate two-level analyses were conducted to assess the impact of the level of healthcare delivery on CD4 cell gains since initiation of treatment and adherence to treatment in the subsample of patients who were ART-treated for 6 months or more (n = 1985). RESULTS: District treatment centres were characterized by more limited technical and human resources but a lower workload. ART-treated patients followed up in these centres had significantly lower socioeconomic status. After adjustment for other explanatory factors, immunological improvement was similar in patients followed up at the central and district level, whereas adherence to ART was better both at provincial and district levels. CONCLUSION: Success in scaling-up access to ART in Cameroon has been facilitated by decentralization of the healthcare system. Long-term sustainability urgently implies better integration of this HIV-targeted programme in the global healthcare reform of financing mechanisms, management of human resources and drug procurement systems.
Conceived in the Bismarckian mould in response to The Social Question as it manifested
itself in the late nineteenth century, the Belgian welfare system followed a fairly conventional continental trajectory up until the worldwide economic recession of the early
1970s.
It was the same climate of social unrest during the recessionary 1880s that had led Ottovon Bismarck to institute the ïŹrst labour protection laws and social security provisions in
Germany that triggered the introduction of similar laws and provisions in Belgium. To
be clear, social security arrangements had by then already emerged on a voluntary basis,
usually within the context of mutual societies and such organizations, most of which had
a much broader purpose than providing social security. These mutual societies and organizations were organized along ideological lines, the Christian-Democrat and the Socialist
being the most prominent. The pluralist, decentralized and autonomous nature of social
security and social welfare provision did not change once the state started taking up a
regulatory and standardizing role. But out of a patchwork of arrangements emerged a
compulsory and increasingly universal system of social security and health care (Deleeck,
2001).
A long phase of incremental, though at times still erratic expansion of various, mostlyoccupationally segregated social security schemes culminated in the âSocial Pactâ of 1944.
Born in the exceptional atmosphere of solidarity and consensualism of the ïŹnal days of
the war, the Pact marked a consolidation of the welfare system. The Social Pact, while
extending compulsory social security coverage, conïŹrmed the subsidiary principle in the
sense that non-governmental organizations (i.e. unions and mutual societies) remained
responsible for the administration of beneïŹts. In addition, national agencies were created
for those not aïŹliated to such organizations. The role of the state remained, as before,
very much in a regulatory and complementary role.
The 1950s and 1960s were essentially a period of incremental expansion. Belgiumâssocial protection system came to maturity just before the economic crisis struck. With
the main social security pillars in place, by and large in the Bismarckian mould, all thathappened laws on
assistance (providing a minimum income guarantee to all citizens), the law on guaranteed
child beneïŹt (ensuring access to child beneïŹts all to those not covered under the social
security scheme) and the law on the guaranteed minimum pension (ensuring a minimum
pension for all pensioners).
It was just after these ïŹnal pieces had been put in place that Belgiumâs social protectionsystem was challenged in a most profound way. Belgiumâs economy was particularly hard
hit by the oil price shocks and the subsequent economic downturn of the 1970s and
1980s. An early industrializer, Belgiumâs economy was still heavily reliant on manufacturing industry, much of which tended to be comparatively energy intensive and,
therefore, particularly sensitive to the energy price shocks. The share of industrial employment (including mining and construction) in total employment, which was still around
40 per cent in 1975, fell rapidly in the years thereafter, reïŹecting major structural
adjustments in steel, coal and textile industries. During the 1970s and also during the
1980s, Belgium recorded among the largest relative job losses in manufacturing industry
in the Organisation for Economic Co-operation and Development (OECD) area. The
consequences were particularly severe because entire cities and even regions remained
heavily dependent on industrial employment. The collapse in the demand for labour
occurred precisely at a time when many youngsters (the sizable post-war baby boom
cohort) and women were entering the labour market.
It was in this context that a massive increase in beneïŹt dependency, particularlyunemployment beneïŹt dependency, ensued. This happened in most continental European welfare states but virtually nowhere was it as dramatic, relatively speaking, as in
Belgium. Today Belgium still epitomizes continental Europeâs âwelfare without workâ
conundrum. Belgium spends more on unemployment beneïŹts, relatively speaking, than
just about any other EU member state (Table 2.1). While its unemployment rate is
around the EU15 average (Table 2.3), its employment rate remains among the lowest of
the northern continental European Welfare Systems. Around one in four people of
working age lives on some kind of replacement beneïŹt. While still enjoying a comparatively low poverty rate, Belgium has been slipping down the tables during the lastboth political as the
to move towards an âactive welfare stateâ, Belgiumâs corporatist system has not shown a
real capacity to deal with the root problems of sluggish job growth and persistent high
beneïŹt dependency. In addition, Belgium is facing some very particular problems owing
to its particular history of linguistic conïŹict, a problem exacerbated by regional economic
divergence.
This chapter sketches some of the key developments within Belgiumâs welfare systemover the past three decades and discusses the principal challenges facing it today.
Kenyaâs Constituency Development Fund (CDF) Act has been hailed as one of the most critical legislations and indeed one of the few landmark achievements of the ninth parliament and indeed of the NARC Government. Increasingly, however, concerns about the utilization of funds under this program are emerging. Most of them revolve around issues of allocative efficiency, rampant abuse and mismanagement in CDF operations, which has given rise to an increasing number of complaints from the public. \nHowever, while majority of CDF Committees countrywide are embroiled in acrimony and even legal battles, a few enjoy appreciation from their constituents and have even been recognized by various stakeholders for best management practices. These Committees have had excellent performances in the management of the funds towards the achievement of the intended purpose and as such have been able to attain real economic and resources decentralization. The question therefore is why some Constituencies are doing well in managing CDF. \nThe specific objective of the study was to assess the extent to which achievement of CDF objectives has been a success factor in the management of CDF in Gatanga Constituency, one of those that have been rated among the successful ones in the management of CDF. The study, which took place between June, 15 jmd July 31, 2009 adopted a cross sectional survey to meet its objectives. The population of interest was the various stakeholders in the CDF activities and the data collected was analyzed using descriptive and correlation types of data analysis. \nThe study noted that Constituents generally felt that if CDF was well managed, it would change the face of the country in terms of providing social infrastructure. The study also revealed that though majority of the constituents were generally satisfied with CDF management since it was established in the year 2004. However, management needs improvement in terms of both the projects and resources. Planning, organizing, compositions of CDF committees also require major improvement to bring about more successful completion of specific project goals and objectives. The CDFâs National Management Committee (NMC) and Ministry of Finance should also ensure committee compliance to laid out procedures for project selection. It is hoped that the findings of this study will inform national policy dialogues and reforms in the CDF management.
This paper examines the financial crisis in light of the local economic development and sets out some policy recommendations. Local economic development is a process in which the local authorities cooperate with the public sector, business community, and NGOs, in order to create more appropriate environment for economic development and for unemployment decreasing. The last months saw the world economy facing to the worst financial crisis in history, causing unprecedented drop in demand and sales and recordâbreaking unemployment levels worldwide. No country can escape certain economic and social consequences from the global financial crisis. The main research question is the following: How does the gobal crisis affect local governments? The local governements are facing several problems such as: higher unemployment and social needs at the community level, pressure for increased spending, difficulties of investment financing, need of deferring maintenance. Then, the paper sets some policy recommendations adressed to the following aspectâ what should and can local governments do? The crisis offers some chances for change in the context of strengthening the role of local governments.The central government will rely on local governments to bring policies rapidly to bear on the economy. This could and should intensify the intergovernmentaldialogue and it could also lead to strengthening fiscal autonomy of municipalities. Improving the competitiveness at the local level and developing a strong local economy can help the country cope with the effects of the global economic slowdown. Local government units should improve their competitiveness to attract more investments and to develop their local economy. Given that the responsibility of assisting the national government in mitigating the impact of the crisis through stimulation of the local economy are given to local governments, this paper aims to discuss issues related to enhancing local economic development and fiscal decentralization as a means of improving overall service delivery in the country, in the context of global economic and financial crisis. Local governments may also be succesful in the promoting productivity locally in order to enhance the countryâs competitiveness in anticipation of a greater role in global trade during the recovery in the next few years. The special focus of this paper has been given to the case of local economic development in the Republic of Macedonia.
Open access
Regional Development and Management Studies
Regional Development and Policy
Hungarian Social, Economic and Educational Studies
A proxy signature scheme enables a proxy signer to sign messages on behalf of the original signer. In this paper we propose an efficient proxy signature scheme based on RSA signature scheme, which divides the document M into m blocks and adds some redundant bits to each message block. We also give a kind of algorithm of the zero-knowledge proof of proposed digital signature. This algorithm has characteristics which has little computation, high reliability, and easy to be realized. The proposed signature scheme satisfies the secure requirements and is efficient.
This article focuses on the debate over the usefulness of foreign aid, beginning with books by Jeffrey Sachs and William Easterly, combined with the more recent contributions of Dambisa Moyo and Paul Collier. Political Elasticity (PE) theory is put forward to facilitate our understanding what has to happen for countries to economically develop. In so doing, the theory attempts to reform terminology, including such words as corruption, democracy, decentralization, and power. Also introduced is the concept of political software, referring to the quality of relationships between leaders and followers. The case studies presented, dealing, first of all, with solid waste management in Lagos, Nigeria, and, secondly, with agricultural production in Ghana, are intended to illustrate the effect of software deficiency on urban and rural life. This is followed by comparison of Bangladesh and Vietnam, suggesting that from below (including microcredit programs) advocated by Muhammad Yunus, is not enough to enable countries to escape extreme poverty unless (as in Vietnam) leaders are motivated enough to engender the social energy necessary to do so. At the conclusion, the experience of the World Bank is presented, indicating various reasons why it has not been more successful in bringing about development and suggesting an alternative approach intended to be motivational, rather than charitable. Key Words: Foreign aid; Political elasticity theory; Political software; Bangladesh; Ghana; Nigeria; Vietnam; World Bank. Introduction There has been an interesting debate going on regarding the usefulness of foreign aid. Until recently, the debate has been dominated by Jeffrey Sachs and William Easterly. Professor Jeffrey Sachs of Columbia University, as chairman of the UN Millennium Project, is generally considered to be the world's leading advocate of more foreign aid. His arguments, as presented in his 2005 book, The End of Poverty: Economic Possibilities in Our Time, can be summarized as follows: (a) many of the poorest countries of the world are caught in a poverty trap (including very heavy debt burden) requiring significant foreign aid, together with debt relief, to escape; (b) the rich countries, particularly the United States (which spent $450 million on the military in 2004, as against only $ 1 5 billion for foreign aid), could be far more generous; (c) much foreign aid is undermined by tariffs and subsidies, making it, for example, impossible for African farmers to compete in exporting cotton, corn, and peanuts; (d) the Millennium Development Goals (elementary education, nutrition, antimalarial bed nets, safe drinking water and sanitation, improved cooking stoves, and minimal levels of infrastructure) can be financed within the bounds of official development assistance already promised; (e) poor countries need trade plus aid; (f) foreign aid allocation should be determined by real needs, rather than by extraneous considerations; and (g) explanations for the failure of foreign aid (e.g., inadequate democracy or excessive corruption) have been exaggerated or misunderstood. William Easterly's The Elusive Quest for Growth: Economists' Adventures and Misadventures in the Tropics, appeared in 2001, Since then, he has become leading critic of foreign aid and especially of the taken by Jeffrey Sachs and the UN Millennium Project. Hs criticism led to an early retirement from the World Bank, where he had been senior research economist for more than sixteen years, before becoming professor of economics at New York University and senior fellow at the Center for Global Development. Foreign aid has not been complete failure, according to Easterly's 2006 book, The White Man's Burden: Why the West's Effort to Aid the Rest Have Done so Much III and So Little Good. Since 1965, life expectancy in the typical poor country has risen from 48 years to 68 years; enrollment in primary school has reached 100 percent and in secondary school, 70 percent; and there has been dramatic fall in infant mortality. âŠ
In response to the mandates in the MINER Act of 2006, the National Institute for Occupational Safety and Health (NIOSH) conducted refuge alternatives research that included characterizing the utility, practicality and survivability of refuge chambers and outby safe havens. NIOSH also prepared and delivered a report to Congress in late December 2007 that summarized the findings of the research, included recommendations concerning the design and performance specifications for refuge alternatives, and focused on specific information that could inform the regulatory process on refuge alternatives. This paper highlights NIOSHâs research and recommendations concerning refuge alternatives, survivability evaluations of refuge chambers and presents a brief review of the current deployment of refuge chambers in underground coal mines in the U.S. The research has lead to the conclusion that refuge alternatives have the potential for saving the lives of mine workers if they are part of a comprehensive escape and rescue plan and if appropriate training is provided. Introduction The U.S. coal mining industry experienced an increase in fatalities during 2006 when 37 miners perished in the nationâs underground coal mines. Nineteen miners perished in three disasters: 12 miners perished in a methane explosion at the International Coal Group, Sago Mine, two more miners died in a fire at the Aracoma Coal Co., Alma No. 1 Mine, while another methane explosion resulted in the loss of five more miners at the Kentucky Darby, LLC, Darby No. 1 Mine. This reversed the downward trend of fatalities that had taken place during the previous 21 years (Fig. 1). The causes of all the underground coal mine fatalities in 2005, 2006 and 2007 are listed in Table 1. Table 1 illustrates that fewer fatalities occurred in 2005 and 2007 than 2006 with the goal of zero fatalities as desirable. The Mine Improvement and New Emergency Response Act of 2006 (MINER Act), PL 109-236, was passed in response to this increase in fatalities resulting from the three mine disasters that occurred in 2006 (United States, 2006). Section 13 of the Act â Research Concerning Refuge Alternatives, specifies NIOSHâs responsibilities with respect to refuge alternatives. Section 13, subsection (a) of the Act states that âThe National Institute for Occupational Safety and Health (NIOSH) shall provide for the conduct of research, including field tests, concerning the utility, practicality, survivability and cost of various refuge alternatives in an underground coal mine environment, including commercially available portable refuge chambers.â Subsection (b)(1) then states that âNot later than 18 months after the date of enactment of this Act, the National Institute for Occupational Safety and Health shall prepare and submit to the Secretary of Labor, the Secretary of Health and Human Services, the Committee on Health, Education, Labor, and Pensions of the Senate, and the Committee on Education and the Workforce of the House of Representatives a report concerning the results of the research conducted under subsection (a), including any field tests.â This document summarizes NIOSHâs refuge alternatives research that was included in the report to the U.S. Congress. The concept of utilizing refuge chambers dates back as far as 1912 when the U.S. Bureau of Mines advocated the building of refuge chambers to fight mine fires (Rice, 1912) in the main sections of mines (Paul et al., 1923). In the late 1930s and early 1940s, some small refuge chambers had been established in some coal mines in the central states and these chambers saved lives (Harrington and Fene, 1941). In addition, the Harwick Coal and Coke Co. built a number of large refuge chambers in the Harwick Mine. These chambers were 23-m(75-ft-) long, 2.4m(8-ft-) high and 3.3-m(11-ft-) wide, cut out of the coal and connected to the surface by two boreholes to provide air, communications, food and water (Harrington and Fene, 1941). More recent research efforts were completed under contract for the U.S. Bureau of Mines starting around 1970 and extending into the mid-1980s. Five major contract efforts were completed between 1970 and 1983 that addressed mine rescue and survival, the design of explosion-proof bulkheads, post survival and rescue research needs, and guidelines for rescue chambers. As a result, one refuge chamber was constructed and is still located in NIOSHâs Bruceton Safety Research Coal Mine (Fig. 2). In general, these contract efforts did not point to any one specific component that would ensure survival during a mine disaster but stressed that survival is a collaboration of subsystems. The subsystems that make up the overall survival strategy include escape, rescue, communications, breathable air and barricading (refuge). NIOSHâs recent research on refuge alternatives was limited to underground coal mine applications. Historically, the use of refuge alternatives has been more prevalent in underground metal/nonmetal mines. The underlying differences between mining sectors are significant and practices in one sector cannot be generalized to the other. Even so, the findings from this research may be useful for metal/nonmetal application. The research efforts summarized in this document involved a number of activities. First, a literature search was performed to identify the findings from any past research on refuge alternatives and topics related to mine refuge and mine disasters, escape and mine rescue. Visits were made to mines, nationally and internationally, and meetings were held with mining experts from labor, industry and government in the U.S., Australia and South Africa to collect information on refuge alternatives, specific refuge regulations and to discuss contemporary issues associated with refuge alternatives. Several contract efforts were completed that examined existing U.S. and international practices, regulations and refuge products. However, these efforts revealed very little information related to coal mining refuge applications, while identifying several knowledge and technology gap areas. In response, a major research contract was awarded to address the gap areas, including guidance for locating and positioning refuge alternatives and establishing specifications for chambers and in-place shelters1. 1The gap areas were identified at the end of the international survey effort, which was performed during July through October 2006. The technical part of the contract to address these areas was completed at the end of October. The actual contract award, conducted in compliance with the Federal Acquisition Rules, was made in March 2007. Work on this contract will continue through 2009. The contractor was able to provide key inputs for the preparation of the report to Congress. Concurrently, NIOSH researchers examined nonminFIGURE 1 Underground coal mine fatalities 1987-2007 (Bauer Kohler, 2009.
This article descriptly and qualitatively explains aspects concerning decentralization. The meaning of decentralization as well as its concept, its form, its factors determining its success, and the method to measure the degree of fiscal decentralization are discussed in the article. Decentralization concerns many aspects; fiscal, politics, administration and system of goverment, economy, social aspect and so on. Generally, there some types of decentralization; political decentralization; administrative decentralization (deconcentration, devolution, delegation or institutional pluralism), fiscal decentralization. The success of decentralization depends on its design, the process of implementation, political supports at the level of decision making at every level of government, popular support, readiness of goverment administration, isntutional development and human resources, mechanism of coordination for improving the perfomance of bureaucrats, the change of value system and bureaucracy's attitude in meeting the expectation of public service. The dimension of fiscal decentralization can be measured among other thing by looking at the contribution of local revenue to regional revenue. By doing so, the perfomance of regional finance can be observed comprehensively. The higher contribution to regional revenue and the higher the ability of a region to finance its own progam will show the positive perfomence of local finance.
The essay provides support to the hypothesis that financing of provincial public spending through national transferences leads to overspending. We rest on persuasive economic and politicoinstitutional arguments. Fiscal illusion and the Leviathan model help to explain the overspending. And cartelization of tax collection helps to explain why governors are so reluctant to decentralize this task. We conclude that a fiscal organization closer to that of a confederation would be desirable. Two ways of organizing fiscal relations between the Nation and the provinces are considered. One way consists of paying for national spending by means of periodic provincial transferences; control of public spending by tax-payers would be the greatest possible in this scenario, though leaving national financing in provincial hands could be a risky affair. Another way consists of allowing the Nation some taxing power and incorporating constitutional restrictions as regards the kinds of public goods the national government is permitted to provide.