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.
Abstract This chapter compares tax policies of Canada with other advanced democracies. It starts by establishing the facts about tax policies in Canada at the federal level, which are characterized by an equilibrium of relatively low tax with a high degree of tax progressivity. Then, the chapter explains the size and shape of taxation in Canada by presenting three complementary perspectives. It presents a functionalist perspective focusing on revenue needs, a distributional perspective highlighting the role of Canadaās majoritarian electoral system and system of interest group representation and the sectoral perspective focusing on the countryās growth model. The last section explains the role of federalism in shaping Canadaās tax policies and stresses interprovincial differences in tax policy choices. Overall, this chapter contributes to our understanding of the political economy of the financing of social policy in the context of a decentralized federation.
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
ā¢ A reform in 2023 introduced new criteria for allocating healthcare funding in Italy. ā¢ Socio-economic variables were included among the criteria for allocating funding across Regions. ā¢ 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. ā¢ 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 KerikmƤe, Åaban Ä°brahim Gƶksal, 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 āsocial dialogueā 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, workersā 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 ādo goodā. 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 āgoodā 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 āchange the worldā.
The new Law on Social Protection (LSP in further text) in the Republic of North Macedonia was adopted in 2019 as part of a social reform process in line with the key strategic goals within the social protection system. The main aspects of the new regulation focus on types, procedures and realization of social protection activities, the system, organization and institutional framework of social protection, as well as cadres, financing and oversight and other issues of importance for realization of social protection. The new LSP introduced many systemic changes which are reasonably interlinked in the text and provide for unhindered accomplishment of the key ongoing processes in social protection, such as deinstitutionalization, decentralization and pluralization in social services delivery. This article aims to identify impact and challenges related to implementation of the new social legislation, with focus on delivery and financing of social services. The content of this paper is a result of an analysis conducted in 2021 based on qualitative methodological approach and application of techniques of content analysis of relevant laws, bylaws, statistical data, reports, as well as expert interviews with representatives from relevant institutions ā Ministry of Labour and Social Policy, Institute for Social Activities and representatives from national social service providers (public and private).
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 āYellow Vestsā ( 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 āpopular politicsā, 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 peoplesā 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, Australiaās 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 ā 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 ā 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 ā 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 āconsumptogenic systemā. 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 āsocial vaccineā22 (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 Allianceās 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 ā 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 2008ā09, 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 2020ā21, 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 Bartlettās 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 providersā 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 āRetooling for an Aging Americaā (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. Scalesā (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 workersā 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 aidesā 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 āextraā 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 workersā accounts depict nursing assistants as a collective āwe,ā facing, on the one hand, the ātheyā of residents, largely drawn as passive recipients of care, and, on the other hand, the ātheyā 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.ās 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 āworkā 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.
This introductory article to the European Policy Analysis special issue on āPublic Policy Responses to COVID-19 in Europeā proceeds through four parts. Part I presents an abbreviated timeline of how the COVID-19 pandemic first emerged in China in late 2019, its recorded arrival in Europe in February, and the lockdown measures and public policy responses which followed during the first six months of 2020. Part II briefly reviews some of the contributions that an analysis of the public policy responses to COVID-19 in Europe might make to the debates in the social sciences. Part III briefly presents potential areas for future research that lie beyond the limited scope of this issue. Part IV introduces each of the fifteen contributions that follow. On 31 December 2019, the Wuhan Municipal Health Commission in Wuhan City, Hubei province, China, reported a cluster of 27 cases of pneumonia which were said to be linked to a wholesale fish and live animal market in the city. The first recorded cases of what would become known as coronavirus disease (COVID-19) and the virus that causes it (the severe acute respiratory syndrome coronavirus 2 -SARS-CoV-21) was confirmed in China in early January. The genetic sequence of the virus was shared publicly on 11ā12 January shortly after the first death had been recorded in Chinaāthat of a 61-year-old man with underlying health conditions. By 13 January Thailand had recorded its first caseāthe first outside of Chinaāand by 20 January human-to-human transmission of the disease was confirmed by the Lancet medical journal (Chan et al., 2020). The first cases of COVID-19 in Europe were recorded in France and Germany on 24 and 28 January 2020, respectively. In each case, infections related to persons who had recently traveled from China. On 26 January, the Stockholm-based European Centre for Disease Prevention and Control (ECDC)āan independent EU agency responsible for strengthening Europe's defenses and preparedness against infectious diseasesāreported that there was āa high likelihoodā of cases being imported into those European countries with the greatest volume of people traveling to and from Wuhan and Central China (ECDC, 2020) and on 30 January the World Health Organisation (WHO) designated the outbreak of novel coronavirus a Public Health Emergency of International Concern (PHEIC) (WHO, 2020a). Over the coming weeks, several European countries implemented screening measures for travelers arriving from China and many airlines suspended flights to and from the region altogether in a bid to limit the spread of infection. On 04 February, a first major outbreak of COVID-19 was recorded outside of China on board the Diamond Princess, a British-registered cruise ship. The ship, along with its passengers and crew, was quarantined for almost a month in the Port of Yokohama in Japan. By mid-March, more than 700 of the 3,711 on board had tested positive for COVID-19, accounting for more than half of the recorded infections outside of China, and at least seven passengers died with the illness in the following month (Mallaparty, 2020). By mid-February, amid increasing cases of human-to-human transmission around the globe, the ECDC considered the risk for capacity in European healthcare systems to be overwhelmed by any outbreaks of COVID-19 at the peak of the influenza season (typically between November and April in the northern hemisphere, which includes Europe) to be ālow to moderate,ā while the risk to the health of visitors and residents in areas with elevated rates of infection to be high. On 22 February, in what was the first major case of community transmission in Europeāthat is, where infection was not associated with travel to an infected regionāItalian authorities reported clusters of COVID-19 across northern Italy in the regions of Lombardy, Piedmont, and Veneto. In a bid to better understand the nature of the virus, including its symptoms and methods of transmission, and the potential for prevention and containment, ECDC and WHO began a joint twelve-day mission to the region on 24 February. By the start of March, ECDC had identified the risk associated with COVID-19 infection in Europe to be moderate to high, based on the probability of transmission and the impact of the disease. On 08 March, the Italian government became the first in Europe to introduce restrictions on movement and to impose social distancing requirements in the country's most affected regions. The measures were extended to cover the whole country on 11 March as the reproductive rate of the virus increasedāthe same day the WHO declared the COVID-19 outbreak to be a global pandemic (WHO, 2020b). In the weeks that followed, most other European countries introduced similar public health measures in a bid to combat the spread of the virus. The suite of COVID-19 responses introduced by policy-makers across Europe was broadly similar, involving restrictions on economic activity, the promotion of social distancing, and the interdiction of large gatherings, and typically included the closure of schools, universities, and businesses that were deemed non-essential. While broadly similar in nature and design, the modalities, specificities, and duration of restrictive measures differed markedly, as did the timing of their introduction. Most European governments introduced legislative measures to underpin the measures by mid-March, including in France, Germany, and Spain, while a handful of governments opted not to, aiming instead to promote voluntary practices to halt the spread of the disease and to reach for āherd immunity,ā whereby society would gain immunity through widespread exposure, as occurred in Sweden and the United Kingdom (see Petridou, 2020; Colfer, 2020a. It is now clear that the introduction of lockdown measures across Europe early-on in the pandemic saved millions of lives (NIHR, 2020). Meanwhile, as the pandemic took hold, economic activity fell, supply chains seized up, and tax revenues dwindled. European and US stock markets reported historic losses throughout the first half of the year as the IMF predicted a deep recession in 2020 and a slow recovery in 2021, with global output projected to decline by almost 5% (Gopinath, 2020). At the same time, government expenditure on healthcare and social protection rose dramatically, as unemployment in the EU rose to 7.4% in August (Eurostat, 2020) and many workers were temporarily laid off. In what may be one of the most enduring structural changes brought about by the pandemic, up to 40% of the European workforce began working from home, at least in part, while many frontline workers in healthcare, transport, and delivery services were unable to do so (Ahrendt et al., 2020). At the time of writing (October 2020), there have been over 34 million recorded cases of COVID-19 and over 1 million deaths associated with the disease globally, of which more than 5 million cases of infection and more than 200,000 deaths have been in Europe. Over only a few weeks, the pandemic introduced fundamentally new economic, political and social realities across the globe. Government responses, and the nature of their implementation, present important questions and lessons for the practice and study of public policy. This episode has also laid bare the capacity, preparedness, and willingness of policy-makers in Europe and elsewhere to respond to an unanticipated crisis as it develops. In particular, differing levels of capacity in healthcare and social protection systems became apparent as the crisis unfolded. The analysis of the onset of COVID-19, and the public policy measures mobilized in Europe in response to it, contribute to a range of related and overlapping debates in the social sciences. This includes as regards: the role of the state; how policy-makers respond to crises; the nature of political behavior; the legitimacy of public policy; and the future of the EU, to give only a few examples. COVID-19 has ushered in a new era of state-sponsored and state-directed activity around the globe, and the crisis has seen a changing and increasing role for public policy in the day-to-day lives of most Europeans. Arguably this episode provides an opportunity to assess the role and functioning of state institutions and programs in people's livesāand even to reimagine what the fundamental role of the state can be in the 21st century. The capacity of states to manage and oversee lockdowns, including by meeting the surge in demand for intensive care beds and personal protective equipment (PPE) in hospitals and care settings, as well as the enormous social protection costs associated with supporting citizens experiencing a sudden loss of income, was exposed during the initial months of the pandemic (Hassenteufel, 2020). This gave rise to debates about the prospect of fiscal burden-sharing between member states in the EU, as we shall see (Camous & Claeys, 2020; van Overbeke & Stadig, 2020). The early stages of the pandemic also tested the resilience of state institutions and their ability to function without permanent or stable governments following inconclusive elections, as was the case in both Belgium and Ireland. The pandemic in Europe also provided a number of examples of multicentric (Neuvonen, 2020) and multi-level governance in action as some states tailored responses to the specific needs and interests of different communities, regions, and devolved authorities, as was the case for example in Italy and the UK (see Colfer, 2020b; Malandrino & Demichelis, 2020). Building on this, an analysis of public policy responses to COVID-19 in Europe can contribute to the crisis management literature (Boin et al., 2017; BrƤndstrƶm & Kuipers, 2003; Drennan et al., 2014). For example, COVID-19 shows how a similar set of circumstancesāin this instance, the onset of a global health crisisācan be managed and framed differently across various polities and political contexts. For example, 't Hart (2014) argues that crises may be best understood as situational in nature, involving events and forces that are largely exogenous and temporary, or institutional in nature, involving factors that are more fundamental, intrinsic and deep-seated, and it is possible that a situational crisis could evolve into or merge with an institutional one. For example, in the case of Cyprus, lesson-learning from the early Chinese experience of COVID-19 is said to have allowed that country to prevent a situational crisis from morphing into an institutional disaster as the country's policy response prevented public services from becoming overwhelmed (Petridou et al., 2020). Relatedly, an analysis of public policy responses to COVID-19 can reveal much about political behavior, and how leaders deal with uncertainty, risk, and expertise. and are an of and risk and the is to what governments do Colfer, et al., during the functioning of institutions is tested and policy-makers make with uncertainty, time and levels of & Demichelis, 2020; with a crisis COVID-19, governments could a to an issue and to or or a for and political The pandemic presents to understand how and governments to or by on questions of and COVID-19 et al., 2020). The pandemic also questions about the role of in public policy. is between and public health and economic realities during a that on the of (see also and and van and that can present for policy-makers to in the and of a The to which public policy responses to COVID-19 were based on or economic and the to which or were to the in political across Europe and had a major on the nature and timing of COVID-19 can also reveal about how citizens respond to restrictive public policy and crisis are as or can become COVID-19, in some cases at it was clear with a initial restrictions were with by a of citizens and a the was recorded which & as the initial of the crisis gave to new and as states of for on economic and social activity began to in some et al., 2020). This was framed in by the to which are seen as & and the experience of the into the political by political and public risk over time, people can their first their of being infected (see 2020; et al., 2020). The public policy responses to the pandemic and fundamental in the of public in some to of the lockdown measures have been be it against or restrictions on public gatherings, for example, in Germany (see et al., 2020) or from for a different between economic and social as has been seen in (see & 2020). there is the of restrictions being to this an important for and (see 2020; 2020). COVID-19 as the EU had its of following the from the economic and social the crisis on many of Europe's and the of the UK to a few of the most the from the public health and social protection the pandemic it is clear that the introduction of measures at any time a of and of the prospect of and political in some of Europe's more (see 2020; 2020). the onset of COVID-19 has the role of and on the of workers to many including and 2020). the impact of COVID-19, the of the market and the of the was by the pandemic (Camous & Claeys, 2020). this, the EU to in the of to the regions affected by the crisis through the recovery from several northern member with The being the most the be from on markets by the Commission on of the EU and a fiscal at EU one of the most important in EU in a 2020b; 2020). This in to the and around the at a response to the and crises over the and an important for research and of the in this many more and in the contributions in this special issue. are many more debates and that a analysis of this deal that the contributions in this issue on public policy responses to COVID-19 in Europe in the first six months of 2020. we that this issue can a on which future research can be research with a may on a range of and of for public policy that are not in in this issue. In the the impact of the pandemic on the and health of the and on the social that the of public policy as the impact of COVID-19 on the market and the future of The for this is by the role by frontline workers in society functioning throughout the pandemic and the increasing for many et al., 2020). to promote the health and of frontline workers and how to and an workforce be of The the pandemic changes how we and and how and are COVID-19 policy of as of personal are in new for example, with and The delivery of a one be one of the greatest in and future research how supply chains be to the needs of the COVID-19 Relatedly, restrictions on the prospect of the for and the potential to supply may new policy and that research might the impact of the pandemic has been differently across the are with the greatest social and health of COVID-19, while people and market deal with the recession in a and the prospect of economic and social and policy This special issue reviews public policy responses to COVID-19 in more than European countries in the first months of the coronavirus crisis from January to 2020. This includes the the WHO declared a pandemic on 11 March 2020, most European countries first introduced on social and economic activity that were to halt the spread of the virus, and governments began to restrictions from While in this issue presents a of how the initial stages of the COVID-19 crisis were by policy-makers across a range of different European countries and including Cyprus, France, Germany, Spain, the United and the as well as in China and at the of the reviews the public policy responses in countries and to the by policy-makers their and settings, and to to debates in the social sciences. The to this issue from a range of and including from political and public and are based in more than across Europe and The issue on a at the for European at in and most of the were at during the The of this briefly reviews each of the contributions that make up this special issue. Italy was one of the countries most affected by the outbreak of COVID-19, and became the first European country to both a and lockdown in the of the health Malandrino and how the response to the public health brought with it a high of the of along the government and the of by public The article shows how this and the and in this, the first the of between and authorities the of by The based on both political and public the of policy and case and for an of the Italian response to the crisis as a case in which the of institutional uncertainty, which in affected and how the COVID-19 crisis was in France by policy changes and in the public health argues that the response is at least by the of a health that of in which was as a and which to the of the agency to to and This health authorities were for the as by the of and intensive care beds the pandemic as well as by the large number of infections and in the The a that public policy responses in France, the of political and in the as the of and of for which did to The also the of the impact of COVID-19 on future health in France, and on the role of in the of health policy & 2020). the case of Spain, one of the countries affected by the pandemic in of rates of infection and The article the of the crisis for and the to the pandemic by on the political and structural factors that a more and response in that the public policy responses to COVID-19 in and the United their countries took different in the early stages of the The government to introduce restrictions on movement and social activity and introduced a lockdown on March in with most of the of Europe. Meanwhile, after a slow initial response with for the United Kingdom restrictions only on 20 March and became a in cases of analysis of cases different of the role of and how risk is by policy-makers that the to the Meanwhile, as the pandemic the responses to the pandemic in different of the UK as the leaders of the devolved governments different political on to introduce or This questions about the of in the and the and the public policy response to the pandemic in what see as in that country's crisis occurred elsewhere in the government to introduce measures to limit the infection rate and to while the on health and outside the and the country's lockdown the shows clear of as the to the lockdown was by economic following by interests in the most by for The that in institutional even by a state of as COVID-19 Europe with an While the virus to be in nature, not of government responses were largely governments in multi-level policy at the and In their Overbeke and at the crisis response in the and the to understand the impact of that on the political The that multi-level policy in both countries has up against the of to political In slow between the and governments the into while in the the of European institutions with fiscal policy has the of the EU fiscal in public The response to COVID-19 was to āherd without the of restrictive measures on economic and social not only from other European also from other countries that are and The that from an analysis of the case the the country to a response to the onset of the pandemic with most of the of Europe. the response to the pandemic in Sweden as the which to through an analysis of the of in the of public and the devolved governance that on public and public The that the between and in Sweden in an initial set of responses that was The response in with high political the and was to, than restrictive The with a that the response in for how initial policy response to COVID-19 the of with legislative by the The article first the between and the of the in the of COVID-19 policy. The analysis shows how during the state of about to and the of public This case is considered in the of multicentric and the for by government a in the in the conditions. 't (2014) of et the public policy response to a situational the authorities lessons from the Chinese experience to prevent the onset of the virus from into a institutional The between situational and institutional 't Hart is that the events that are largely considered exogenous temporary, while institutional crises more intrinsic institutional and a that is brought into during a The lessons the authorities from the Chinese experience of COVID-19 the impact of the of and the of in the response The article with on what this might for public et at the cases of and and how leaders and policy-makers may to or in of uncertainty, and political a by and it with from BrƤndstrƶm and the article the factors the of of and the of public policy responses to the COVID-19 crisis in The the in the political and with for political as leaders to public political and public health during the Meanwhile, on that in the early of the more governments were better to than their the lockdown measures are to and economic and social activity is more at a and this might be in a global pandemic that public and In and across the pandemic a in The by governments to a is to introduce fiscal policy policy to be limited to a of market a of willingness by governments to be exposed to market fiscal policy this This occurred in the of the public policy response to COVID-19 not government that fundamental and EU governments have as travel and to citizens from Central and European countries could not COVID-19 in this European and the between and in those a on the case of and with to and the the and that policy and argues that systems a role in policy as for policy and as for from one occurred to a country's the economic and political of the COVID-19 crisis for the states of the on and and this article how factors the sudden in brought about by the the of of and the of fiscal to from the EU, and other of and in the early months of the an of the between government and EU in the this article argues that while in the in the fiscal risk state and the on et at the of assess public for COVID-19 in The first the during the first weeks of restrictions and on from the how public for the most important has been In so the article on the of the social and political of the on the article the to which the measures were seen as or not by a of this is important for policy-makers as the to which a policy is seen as people that policy. The analysis shows following initial widespread for the lockdown measures in March, for on economic and social activity The onset of COVID-19 many of the and economic the and the measures by the European institutions in the initial stages of the pandemic and were to the of the economic crises as The article first reviews how institutions the European Central its programs and the European to member This and political which the for a and institutional a first a fiscal with between countries and This to be for This article this issue by on what this might for the future of Europe.
Over the last decade, the term āgig economyā 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 āon-demand workā:11 Prassl 2018, p. 11. workers22 Throughout this article, we deliberately speak of āworkersā 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 āgigā, 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 āremoving frictionā in labour markets, and unlocking efficiency gains as āunproductive human capitalā is āset freeā.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 workerās 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 ageāa job with a fixed number of hours, worked in set shifts, in one place, and for a predetermined salary (call this āstandard employmentā)ātowards work that is contracted at short notice on the basis of current demand (call this āgig workā).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 arrangementsālike on-call workers, contract workers, and freelancersāmade 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 ātoo-big-to-failā banking can enhance local economiesā 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 2012ā2015 in three sectors ā metalworking, food, banking and finance ā 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 workersā and/or the firmās 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 ā in those countries showing similar levels of advanced practice ā 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 quasiāmarkets in the Danish Public Employment service has been promoted, altered, and reāregulated over a period of 10 years. It was in 2002 when quasiāmarkets have been created by using the instrument of contractingāout employment services to private providers. Seen from the perspective of policymakers at the national level, contractingāout 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, contractingāout 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 reāmodeled again by replacing standardized national tendering with a decentralized, partnershipābased and dialogueāoriented approach, where services are developed in joint efforts between purchaser and provider. All in all, the development of quasiāmarkets 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 ļ¬rst conversation excerpted above took place in an era when for-fee provisioning of health care services was ļ¬rst being established as a central feature of Russiaās broader, post-Soviet health care reforms. The second statement took place over a decade and a half later in the United States, just months after the Congress passed and President Obama signed historic legislation mandating comprehensive health care reform aimed at increasing coverage and aļ¬ordability. Despite their separation in time and space, these excerpts reveal a common cultural contradiction that plays out in contexts of market-oriented health care. These two health professionals simultaneously conļ¬rmed and rejected an approach to the exchange of health care as analogous to the exchange of any other consumer service, an approach captured in the aphorism āyou get what you pay for.ā When the Russian clinic chief backtracked to assert, āI canāt do bad work,ā she implicitly contested the widespread assumptions in health policy circles that physiciansā āinterestā in the outcomes of their work is derived solely from how well they are paid.1 For Valentina Pavlovna and many Russian doctors, at stake in the issue of whether women who paid actually obtained a superior quality of care was nothing less than their sense of professional pride and dedication. She had spent her entire career in the Soviet socialist model of free and universal health care, which charged physicians with the obligation of providing competent care to all patients for free as a matter of professional integrity. Yet she was reincarnating her clinic based on the popular notion that physiciansā expertise and dedication was only available if bought.2 Still, when asked directly about whether she endorsed inequalities of care based on ability to pay, she found herself unable to condone this practice as ethically acceptable. The US dental studentās statement is telling in that he phrased his perspective through caveats ā āIām not saying Iām like that, or anybody else in here is ā¦ but [the get-what-you-pay-for mentality is] kinda ingrained in people when they purchase anything.ā Implicitly, he denied that, as a health care professional, he would provide compromised care to the poor ā an admission that would seem to violate professional integrity if not also formal ethics. Yet at the same time, he suggested it would be reasonable for health care users to expect to receive worse quality care if they obtained those services for free or through reduced fees. Health policy planners and analysts would do well to contemplate this ambivalence characterizing the relationship between usersā fees, professionalsā integrity, and the presumed unequal quality of medical care. This ambivalence, I will show, stems from mixed cultural messages and uncertain criteria about entitlement, or about what diļ¬erent groups of physicians and patients are seen to deserve. Tacit understandings about entitlement are linked with actorsā expectations of their own and othersā obligation and responsibility; these understandings in turn shape the kinds of claims perceived as legitimate, and the resulting silences that characterize certain kinds of need; they also work as logics shaping the ways providers conceptualize their career choices and daily work practice. Indeed, cultural visions regarding various groupsā legitimate scope of entitlements and their related responsibilities stand in relation to each other in a systematic way and shape daily practice. Anthropologists refer to this interrelated set of concepts and practices as moral economies, or āconsensual assumptions about reciprocal obligationsā (Minkler and Cole 1997: 40), understanding āeconomiesā here to involve the circulation of goods, both material (such as money and beneļ¬ts) and non-material (such as dignity, integrity, entitlement, and social standing) ā and noting how these various types of goods are often intertwined. We analyze the ways in which moral economies serve as the implicit conceptual backdrop against which certain cultural practices are reproduced without question as āthe right thing to do,ā while other practices may be protested against as representing betrayals of justice or the violation of fairness (Thompson 1971). My goal in this chapter is to introduce the framework of moral economies to the study of health care policy planning and analysis in Russia and the United States. More speciļ¬cally, I suggest that eļ¬orts to improve access to care by addressing physician workforce issues have not adequately conceptualized the ways health providersā experiences, aspirations, and strategies are embedded in moral economies that deļ¬ne (if ambivalently and with contradictions) professional and patient entitlement and obligation. Examining the moral economies of health care and professional work through which providers in Russia and the United States make sense of their career decisions and daily practice will bring new and important insights into the challenges of increasing access to underserved populations. Both Russia and the United States have great needs to extend access and improve the quality of health care. The particular characteristics of these two countriesā health care systems and system needs are dramatically diļ¬erent: whereas Russiaās problems of access stem from gaps in what is supposedly a universal model of free health care, the USAās system of work-based insurance structurally ensures that tens of millions of citizens will face barriers to access because of lack of health care coverage.3 Russian health care reforms have focused on introducing new ļ¬nancing mechanisms while facilitating the emergence of private and semi-privatized services; in the USA, contrastingly, new health care reforms aim to extend insurance coverage and enhance the capacity of community-based, publicly funded clinics for rural and urban residents excluded by the market-based, private health care system. While these diļ¬erences are immensely important, it is also notable that, in both contexts, workforce issues entail a key part of eļ¬orts to address existing needs. In particular, health planners in both countries recognize that access and quality of care are intensely aļ¬ected by the situations and actions of physicians. Yet in neither context do planners recognize how physiciansā entanglement in access and quality of care issues is related to the moral economy of health care. This essay highlights the ways Russian and US physiciansā career decisions and daily practices regarding patient access to their services are aļ¬ected by culturally shaped notions of professional entitlement and patient worth, as well as the perceived symbolic worthiness of particular sectors of health care vis-Ć -vis the system as a whole. All of these are dimensions of the moral economy of health care. The section that follows examines the ways Russian health policy planners and analysts have deļ¬ned (and ignored) problems of access as they set about reforming their contemporary health care system. Mainstream discourses emphasize that barriers to access stem from doctorsā demands for illegal payments from patients; and reforms focus on raising physiciansā salaries. I then draw on my ļ¬eldwork, and more recent doctorsā blog-postings, to argue that low salaries alone do not explain physiciansā willingness to demand payments from patients ā physicians draw on cultural and symbolic understandings of how medical work is and should be valued; they make social assessments of what kinds of persons they are treating, what kinds of care these patients deserve, and what these patients should oļ¬er in return for medical treatment. Such culturally embedded calculations, which often remain tacit or discussed through providersā jokes, stories, and the like, play a signiļ¬cant role in shaping the tenor and character of professional work. In other words, improvements in access and quality do not result mechanistically from increased funding and higher salaries ā because material issues alone do not capture the notions of entitlement and responsibility through which physicians make sense of their daily work practices. We need to see material remuneration as part of the broader symbolic messages that the state and patients communicate regarding the value of medical work and diļ¬erent forms of expertise; in turn, the actions of physicians can be seen as commentaries on the varying social worth of diļ¬erent patient groups, the perceived legitimacy of certain kinds of diseases, and their sense of what experts owe to patients, the state, and themselves. I then turn to the US context, where health care reforms aim to promote physiciansā and dentistsā willingness to work in primary care and with underserved populations. Obamaās reforms increase the funding for, and work opportunities in, primary care as a way of recruiting new graduates, while medical and dental schools undertake programs to cultivate studentsā commitments to ācommunitiesā and āserviceā. Yet public health clinics not only pay less, they also represent lower symbolic value relative to private practice. Market-based health care orients itself to the interests of consumers ā those who pay for care ā whereas recipients of public welfare services are deemed āfailed consumersā, expected to be grateful for charity and not entitled to make demands. My ļ¬eldwork with dental students reveals how the disparate social worth of private and public clinics, their populations, and the meanings of work in each sphere get conveyed to new practitioners in training. Although committed faculty struggle to insist that under-served populations deserve high quality care, the structural organization of health care often confounds this message. Increased funding and pedagogical attention to the plight of the underserved importantly acknowledge the countryās gaping inequities, but these reform eļ¬orts do not substantially subvert the moral economy of market-based medicine; such radical change would require the cultural acceptance of dramatically new calculations of clinician entitlement and the social worth of public health ā a vision of clinicians as indebted to society for their training and opportunities, and a notion that all patients, regardless of social background, are entitled to high-quality services and dignity. The issue of health care access ā ensuring that all patients who need medical care can receive it ā is complexly intertwined with the transitions from a Soviet health care model to a post-Soviet one, whose ļ¬nancing procedures and legal guarantees are still being worked out some two decades after the collapse of the socialist system. Health care reforms are currently an oļ¬cial state priority, one of the 2006 National Projects that Putin established to reform governance and bring legitimacy to the state in the wake of several decades of massive cynicism towards decaying government services. The 1990s had witnessed an unprecedented public health crisis, characterized by skyrocketing rates of premature male mortality, plummeting fertility, the alarming spread of infectious disease, from tuberculosis to HIV, and more. While these indicators reļ¬ected the simultaneous conļ¬uence of multiple socio-economic disruptions and rapid cultural transformations, the Russian government also attributes part of the health care crisis to the poor funding and poor performance of the health care system itself (Ministerstvo 2009).4 Citing the ongoing declining population numbers and extraordinary high rates of mortality, throughout the 1990s conservative and nationalist critics of market reforms accused the Yeltsin government of causing the āgenocideā of the Russian people, which, they claimed, was ādying outā due in part to widespread unemployment, poverty, and a loss of social stability and values. Following this era, Putin built widespread legitimacy for his administration, in part through funneling portions of state revenues from higher oil prices into tangible beneļ¬ts for citizens, especially through the partial revival of the stateās withered system of social support. In the National Project for health care, these investments included increased funding to improve primary care, raise health care providersā salaries, build new medical clinics, and develop innovative methods and technologies ā all represented as signiļ¬cant initiatives to improve the quality and accessibility of medical care (Antonova 2007: 191). Given the fact that the Soviet health care system had one of the highest ratios of doctors to population in the world and a system of universal coverage, it is somewhat ironic that the country has been and continues to be plagued by serious problems of access at present. My ethnographic research and analysis of health policy debates in the 1990s found that barriers to access were created not only by ļ¬nancial need, but by pervasive cultural dynamics too: providers evaluated patientsā social worth by assessing their apparent education and ācultural levelā, as well as the type of condition patients had. Even at present, patients with HIV and other STIs face shaming and prefer to seek care at specialized AIDS centers rather than mainstream clinics (Bendina 2009). Exclusionary tactics against those deemed to have a ālow level of cultureā are common, with the result that patients who felt berated distrusted the medical professionals and were reluctant to use their services (Rivkin-Fish 2005). Rusinova and Brown (2003) found that access to care depended on the networks and social skills that patients were able to deploy to maneuver around bureaucratic obstacles and pervasive mistrust. Patientsā strategies, and their success in obtaining high quality services, differed according to their social strata and the related social and cultural capital they could mobilize. My research further explored the speciļ¬c ways in which patientsā strategies and networking aļ¬ected providersā sense of personal obligations to provide especially attentive care. Close acquaintance relations facilitated access not merely to medical services, but even more importantly, to trustworthy, satisfying relations with providers. The acquaintance relationship in turn helped physicians, as they were more likely to have their expertise acknowledged and valued when they shared a personal connection with patients (Rivkin-Fish 2005). Certainly, personalized relations compromised the possibility of equity in health care; yet the perceived ethical character of these relationships, and the kinds of (inadequate) solutions they achieved to the problems of mutual distrust and enmity between doctors and patients, have not been addressed in policy debates, which often caricature these relations as simply exploitative and extortionist. Until the late 1990s, many Russian health providers expressed great ambivalence about the introduction of fee-based health care, seeing required monetary payments as unethical and creating compromises in professional integrity. Physicians trained during the Soviet era described entering medicine as a calling, an arena in which scientiļ¬c knowledge could be applied in an apolitical career that provided humanitarian-oriented workers with the satisfaction of saving lives. The ļ¬nancial remuneration was less than in other professional ļ¬elds, but the sense of mission was invaluable. Yet, as Russian society underwent broader shifts driven by the profoundly transformative ubiquity of consumer culture, professionals began to redeļ¬ne cultural expressions of self-respect, and their expectations for a digniļ¬ed middle-class lifestyle transformed: markers of success (or failure) now became read in the clothing one wears, the mode of transportation one takes, the holiday destinations one chooses, the state of disrepair or remodeling of oneās apartment. The signiļ¬cance of oneās professional occupation became increasingly interpreted on the basis of whether it enabled culturally emerging aspirations to consume expensive goods. Male physicians told me their marriages were threatened because they were committed to practicing medicine in public hospitals and not demanding money from the poor; women physicians described being able to continue with their career only because they had ārichā husbands who agreed to support their āuncompensatedā calling. Many worried about how they would fund their childrenās higher education as tuition payments were becoming more common. The economic crisis that medical professionals confronted was thus experienced as at the same time a piercingly unjust material deprivation, a traumatic source of life-altering interpersonal loss, and a cruel attack on the social value of their professional role. The focus of health care reforms as early as 1993 centered on creating new ļ¬nancing models that would decentralize and shift the ļ¬ow of resources away from the state as a monolithic funder. Policy makers roundly celebrated ideas of competition, fee-for-service, and salary diļ¬erentiation for performance as solutions to the problems created by the Soviet system, almost never considering how market mechanisms in health care would aļ¬ect access to care for the poor and socially marginalized or providersā own well-being. A brief examination of the actual realities wrought by this new ļ¬nancing model reveals both the ideological character of these reforms, and their narrow, mechanistic understanding of the social dynamics that shape access to care. In the new ļ¬nancing system, employers and municipal governments were required to make contributions to quasi-governmental health insurance funds (OMC). Each of Russiaās eighty-nine regions (except Chechnya) has its own fund, a situation that contributed to decentralized policies and signiļ¬cant variation across the country. The employer payroll tax for medical insurance of workers was set at 3.6 percent, an amount that both insurance fund directors and chief doctors decried as severely low, as reported in Judyth Twiggās survey conducted in 2000 (2002: 2260). Municipal governments made contributions on behalf of the non-working population. They determined their payments on a per capita basis, with the amount decided by each individual region (Twigg 2001: 204). The federal government was also to continue payments to health care, but the amount was small and expected to gradually diminish as an overall percentage of health care ļ¬nancing (Curtis et al. 1995: 760). In the year following Russiaās ļ¬nancial crisis of 1998, the funding for health care as a proportion of GDP dropped by 30 in to in by it had to of GDP (Ministerstvo the per capita paid by regions was the actual throughout the Russian from a low of per capita paid in the of to a high of per capita in (Ministerstvo In the early that, in many the funds were with private insurance is to the of patients and quality (Twigg Even at that time, doctors and other critics the of insurance funds and private insurance which represent an of have been expressed that these were payments for the health care system for personal in In somewhat that insurance to be facilitating the of insurance but the mechanisms and that employers were not the amount they Indeed, to reforms as early as et al.