National Health Systems as Market Interventions MILTON I. ROEMER

r D ~ HE stucture and functioning of national health systems in the modern world are the result of long historical

i 2 developments in science and society. Advances in sci- t z , 5 ence made possible countless technologies for the pre-

vention of disease and for its treatment if prevention failed. Changes in society have fostered the application

of many of these technologies to the needs of people.

HEALTH SYSTEM EVOLUTION

From the earliest times, the provision of health service was regarded as a matter of value, warranting some sort of compensation. Like com- modities, health care was bought and sold in a market. When religious groups realized that some people were too poor to pay for care they obviously needed, charitable hospitals were established, and later dispen- saries. This was market intervention through the motives and resources of religion.

As industrialization developed, it was propelled by the profit incentives of capitalism. Science advanced, universities grew, cities multiplied, and a working class took shape. For workers, acute or chronic illness meant a loss of livelihood, against which sickness insurance could be a protec- tion. This was another market intervention by planned group action of working people, leading eventually to social security for health care in some 7o nations.

As doctors and other health care providers became more numerous, governments recognized the need for assuring their competence. Specified education became required for a license to practice -constituting one more strong intervention against free trade in the marketplace.

With vastly increased knowledge on prevention of disease, public health agencies were organized; they rendered environmental and per- sonal health services that could not be expected in the normal medical market. To provide comprehensive health care efficiently, furthermore, doctors and other personnel in scores of countries were brought together

6z

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ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 63

in teams stationed in health centers, as distinguished from individual practitioners functioning as small autonomous entrepreneurs.

The more complex that national health systems became, the more they called for planning. A hierarchial structure of activities was organized in nearly every country. Concepts of equity and social justice gradually came to replace a free market philosophy in decisions on many aspects of national health systems. Forty years ago, a conservative capitalist power, the United Kingdom, transformed comprehensive health service into a public good for everyone. Every other industrialized country has been moving, slowly sometimes, in the same direction. While marketplace values, of course, are still found in health systems -more in some than in others -the concept of health service as a social right has gained ascendancy in most countries of the world.

MEANING OF HEALTH SYSTEMS

What then is a national health system? It is the complex of activities intended to result in the provision of health services. A health service, in turn, is an action whose primary purpose is the protection or improve- ment of health. Food affects health, as does housing, clothing, or athletics, but health improvement is not their primary or principal purpose. Many features of living and of society, of course, influence health-probably even more than health services -as epidemiologists have known for a long time. On the other hand, many harmful effects of the physical or social environment can be prevented or ameliorated by appropriate health service.

Because of the countless determinants of health, besides health service, the World Health Organization emphasizes the importance of "intersec- toral collaboration" in the drive to achieve Health for All. Numerous sectors, such as agriculture, industry, employment, housing, education, even international relations, have enormous impacts on health. Health workers, therefore, must attempt to influence policies in all social sectors, insofar as they impinge directly on health. (See Figure I.)

Even within the health sector or health system (defined as the social machinery producing health services), the tasks are numerous and difficult. Most national health systems, at least in theory, have become motivated by concepts of social justice more profoundly than other sec- tors such as agriculture or housing. The implementation of principles of justice, however, may be difficult. We see the problem today in the incur- sion of for-profit investor-owned corporations into the field of hospitals,

FIGURE I

Determinants of Health

PHYSICAL SOCIAL ENVIRONMENT ENVIRONMENT

Geography, Climate, Education, Occupation, Food, Housing, Water, Income, Relationships,

etc. Urbanization, etc.

I~

r ~STATUS Age, Sex, Immunity, Genetic Background,

etc.

POPULATION'S PHYSICAL, MENTAL

and SOCIAL WELL-BEING

HEALTH SERVICES Health Promotion, Disease Prevention,

Treatment, Rehabilitation, etc.

ROEMER HEALTH SYSTEMS AS MARKET INTERVENTIONS 65 FIGURE 2

Model of a National Health System Showing its Components & Their Relationships to Health Status

----------------------------------------------_-------__________________z

w z M o

ORGANIZATIO

z~~~~~~~~~~~

long identified with non-profit or public sponsorship. The dependence of most countries, especially the less developed ones, on drugs produced by multinational corporations earning high profits, causes serious economic difficulties. Yes, even within strong national health systems, the dynamics of various component activities are complex.

I spoke of a health system as "the machinery producing health ser- vices," and in Figure 2 I have tried to show in a very simple model how this machinery operates. The "health needs" on the left are fed into the 5-part system, and the product emerging constitutes "health results" hopefully improvement. This is, of course, a great oversimplification, which requires more careful explanation.

HEALTH SYSTEM COMPONENTS

A more complete portrayal of the component parts of a national health system is shown in Figure 3. The most conspicuous feature of any national health system is the "organization of programs" that occupies the central

66 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989 FIGURE 3

National Health System: Components, Functions, and Their Interdependence

MANAGEMENT

Planning Administration

Regulation

RESOURCE PRODUCTION ORGANIZATION OF PROGRAMS SERVICE PROVISION

Manpower Ministry of Health--all levels Primary Health Promotion Facilities Other Public Agencies & Prevention

Commodities (drugs,etc) Voluntary Agencies Primary Care--treatment Knowledge Enterprises Secondary Medical Care

Private Market Tertiary Medical Care Rehabilitation

ECONOMIC SUPPORT

Governmental Revenues Social Security

Insurance (Voluntary) Charity

Personal Households Foreign Aid

conceptual box in this model. It is more logical, however, and I trust more lucid, if we start the analysis with the "production of resources," and then proceed through the steps that end with the provision of health services.

Production of Resources Essential for the operation of any health system are several basic resources which somehow must be produced or obtained. The manner in which these resources are acquired differs enormously among countries, but in their simplest form they include (a) health manpower, (b) health facilities, (c) commodities, such as drugs, and (d) knowledge. It may be noted that financing or money is not regarded as a resource; it is rather a medium of exchange, convertible into resources or services, as we will see.

The production of all resources requires inputs from various other social sectors, such as education, construction, manufacturing, and so

ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 67

on. The quantity and quality of resources in a health system depend largely, but not entirely, on the wealth of a country. Some relatively poor countries may develop abundant health resources because of a political will that assigns high priority to the health system.

Health manpower includes physicians, pharmacists, nurses, dentists, technicians, and scores of other types of personnel. With the growth of health technology and the expenditure of increasing shares of national wealth on health systems, the numbers and types of health manpower have expanded enormously. In the less developed countries, traditional healers (with or without some formal training) still play significant but declining roles. Almost all countries have also been making increasimg use of a great variety of medical assistants or community health work- ers -trained for relatively brief periods and working under supervision to extend primary health care to populations at relatively low cost.

Health facilities are also of many types. Historically oldest are general hospitals for treatment of the seriously sick, although their range of functions has steadily broadened. Special hospitals have been developed for the mentally ill, for leprosy patients, for maternity and women's disorders, for children, for general infectious disease, for military person- nel, and for other special purposes. While founded originally by religious groups, an increasing proportion of hospitals have become sponsored by units of govenment, by voluntary nonprofit organizations, and even by private entrepreneurs. The organized facility for ambulatory health ser- vice is much younger historically, but in recent decades it has acquired increasing importance. In most developing countries, in all socialist coun- tries, and in many industrialized and welfare-oriented countries, the health center or polyclinic has become the conventional setting for mod- ern ambulatory service.

Among health commodities required in every health system, drugs and vaccines are crucial. Over the centuries, drugs derived from nature- mainly from plants or animals -have gradually become replaced by chemically synthesized products. Large pharmaceutical companies, often linked to the chemical industry, have come to dominate the field. These firms, based in a few countries, are responsible for most of the drugs in the developing world -both those sold in pharmacies and those dis- pensed in hospitals and health centers. Because imported drugs are costly, drug expenditures may absorb 30 percent or more of a Ministry of Health's budget. The dynamics of medical supplies and modem diagnos- tic and therapeutic equipment are similar.

68 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989

Knowledge, the fourth resource, is produced by observation and re- search. The knowledge of the past, of course, is recorded in books, and most new knowledge is reported in journals or at conferences. Unfortu- nately new knowledge is often communicated slowly, especially in de- veloping countries and in the rural areas of all countries. Even when knowledge is available, its application in practice may be retarded by deficiencies in other aspects of health systems.

Organization of Programs In order to mobilize the several types of resources to achieve certain ends, they are typically organized into programs. As governments have as- sumed increasing responsibility for the general operation of health sys- tems, the major public agency to play this role has been a Ministry of Health or some broader body encompassing such a ministry. The initial functions of the Ministry of Health were usually to assure a sanitary environment and carry out other preventive activities. In time Ministries have come to operate facilities for medical care, to train personnel, to formulate and enforce technical standards, to do epidemiological surveil- lance, and to provide other forms of supervision of health services throughout a system.

In most countries, the geography and population require, for sound administration, the subdivision of the territory into provinces or states, and these in turn into districts or counties. The basic form of government in one country, such as Canada, may endow each province or state with great autonomy; in another country authority may be highly centralized; and in a third country one may find a balance between centralized and decentralized powers. Whatever the distribution of power, most Health Ministries seem to be trying to maximize the involvement of local au- thorities in health programs, while also maintaining at the top uniform national policies and standards.

Numerous other governmental agencies play roles in national health systems. Ministries of education are usually responsible for training physicians and certain other personnel. Social security programs, includ- ing health insurance, may be directed by a special ministry or be within another ministry, such as labor or social welfare. Ministries of labor look after occupational safety and health at workplaces. There may be special authorities for public works, social welfare, environmental protection, and for the "interior" -all of which are relevant to certain aspects of

ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 69

health. The military establishment of almost every country maintains its own medical service.

Still other organized programs function outside of government -usu- ally for quite focused purposes. Voluntary nonprofit agencies may con- centrate their efforts on certain diseases, such as tuberculosis or cancer; on certain population groups, such as children or the elderly; on certain services, such as blood banks or home nursing. Voluntary agencies may also operate health insurance programs. Associations of professional personnel often represent their members in negotiations with government and they monitor ethical behavior.

Still another form of non-governmental agency with a role in the health system is the industrial enterprise that provides health services for its workers and sometimes their families. Whatever may be the motive-to promote a healthy workforce, to paternalistically discourage unioniza- tion, or to reduce the insurance costs of worker's compensation for industrial injuries -such services are relevant in a health system.

Finally, the entire private market, in which medical care, drugs, and other health services are provided, must be considered part of this compo- nent of health systems. While not "organized" in the usual sense, private services are bought and sold through a process governed by supply and demand, price, and some degree of competition. The strength of the private market in a health system tends to be reciprocal to that of public programs; if Ministries of Health and other organized agencies are weak, the private market is usually strong, and vice versa.

Economic Support Supporting the development of all health resources, their organization into programs, and ultimately the provision of services, requires every national health system to have sources of economic support. To some extent in every country, private individuals finance health services, typi- cally for the treatment of personal health problems. Charitable donations are another source of support, and these may take the form of donated labor as well as money. Non-governmental or voluntary health insurance is another source of great importance in certain countries.

Under government, of course, general taxation is a source of economic support for the health system in all countries. The exact types of taxa- tion-on land, on income, on purchases, on selected products (e.g., al- cohol and tobacco) -vary widely in their use for health purposes. The

70 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989

political levels (national, provincial, local) at which they are collected, also vary in their relative importance. Everywhere tax revenues are used for general prevention, and in most countries also for health manpower training, for facility construction, for medical care of the poor, and for many other health purposes. With exceptions in certain African countries and a few others, the percent of all national health expenditures derived from public revenues has been rising. This has contributed to greater shares of total national wealth (gross national product or GNP) being devoted to the health sector.

Mandatory insurance or social security is a special form of government strategy contributing money to health system support in about 70 coun- tries. This method establishes one or more earmarked funds, which may only be used for financing the health care of persons who have made payments and, usually, their families. Because of their separate status, social secutity funds do not usually require parliamentary or governmen- tal decision for their use, nor do they compete with other programs of government depending on general revenues. Social Security may be con- ceived as organized self-help by workers and employers. For these reasons, the use of social security funds for health purposes has been politically attractive and has steadily broadened over the last century, protecting larger proportions of national populations for a wider range of health services.

In many countries, still another form of economic support for health systems-often for hospital construction and operation-comes from public lotteries. This gambling unfortunately attracts money dispropor- tionately from low-income people who can least afford to spend it. A final source of health system support is foreign aid, going to developing countries from international agencies or from certain affluent indus- trialized countries; as a percentage of the costs of national health systems in developing countries, these funds are seldom very large-usually well under 5 percent.

The relative proportions of these several sources of economic support influence health system policies in many crucial ways. Support from private individuals obviously channels resources, programs and services to those who have the money to spend, much more than to those with the greatest health needs. Fortunately for health system development, the share of national wealth (GNP) being devoted to all health purposes has been rising in almost all countries. Over the last half-century, it has been expanding in developing countries from z or 3 percent to 4 or 5 percent;

ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 7I

in developed countries it has risen from 4 or 5 percent to 8 or iO percent (in the United States to i i percent). Within those health expenditures, the proportion derived from government and other collectivized sources has also been increasing, implying an extension of principles of health equity. Even though private-market spending has risen in the last few years, the long-term trend has clearly been toward the public side.

Management A second form of support for the operation of a health system is manage- ment, which is meant to include several forms of social control-plan- ning, administration, regulation, and legislation. Each of these processes may be carried out with different degrees of rigor in various health programs. All four of them are operative to some extent in programs under both public and private auspices.

Planning may be done at central or local levels of health systems or at both levels with respect to different functions. It applies most often to the production of resources, but may also be applied to the development of organized health programs or the provision of specific services. In many ways, planning may be used to influence the performance of the private medical market.

Administration encompasses many functions -the exercise of author- ity, organization of resources, delegation of responsibility, supervision, communications, coordination, and evaluation. Sometimes the term "ad- ministration" is used interchangeably with "management," but-what- ever the terminology-the purpose is to mobilize human and physical resources to reach a goal with maximum efficiency and effectiveness.

Regulation involves the enforcement of certain standards of perfor- mance. It may apply in an organized program, but is used more often to monitor and control performance in the open market. Much regulation is by government -for example, surveillance over the method of manu- facturing drugs by a pharmaceutical company. It may also be non- governmental, such as the regulation of physicians' services by the or- ganized medical staff of a voluntary hospital. Despite much political rhetoric to the contrary, abuses in the free market of health care have led to increasing types of regulation in most health systems.

Legislation is the instrument of government used for crystallizing and clarifying health policy, so that it may become known to everyone. Whether a country is ruled by a parliamentary government, a military dictatorship, or some other political structure, various laws may be estab-

72 JOURNAL OF PUBLIC HEALTH POLICY * SPRING 1989

lished to govern the health system. These laws may facilitate the produc- tion of resources, authorize various programs, provide for social financ- ing of health services, control the quality of performance of health care providers, or prohibit behavior injurious to health.

Provision of Services

Operation of the four components of a health system just described leads to the final component: provision of health services to people. This in- cludes all forms of service-health promotion, disease prevention, diag- nosis, treatment, and rehabilitation. In terms of the complexity of the specific activity, the services may be designated as primary, secondary, and tertiary.

The types of personnel, facilities, work settings, and patient-provider relationships differ substantially among the health systems of countries. They differ also among various programs in one country. A health pro- gram addressed to poor people usually provides services in a manner quite different from conditions in a free private market serving the af- fluent. Health services for military establishments are provided through highly organized arrangements in all countries. In Latin American coun- tries with Social Security programs, covering perhaps zo or 30 percent of their population, the insured workers are typically provided services of higher quality than other persons served by Ministry of Health facilities.

Primary health care, according to WHO (World Health Organization) principles, includes a wide range of preventive services, along with the treatment of uncomplicated, common ailments. WHO does not intend "care"l to have its restricted meaning of "treatment." Since the Alma Ata Conference on Primary Health Care in 1978, almost all nations have adopted WHO's concept of primary health care (PHC) -to embrace all basic strategies of health promotion and disease prevention. The person- nel and setting for providing PHC, of course, differ greatly among coun- tries.

Secondary care has been variously interpreted, but I believe it should include specialized medical services to the ambulatory patient, relatively commonplace hospital care, non-medical specialist care (such as phys- iotherapy or prescribing eyeglasses), and low-intensity long-term care. Tertiary care refers to services requiring highly specialized skills and sophisticated technology, typically in a teaching hospital. Finally, rehabili-

ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 73

tation can provide services that help the disabled patient to return to a socially independent life.

Health services for certain populations, such as aborigines, or certain illnesses, such as mental disorders, are often provided under quite sepa- rate arrangements. Health resources and methods of program organiza- tion are usually quite different from circumstances in the rest of the system. Typically these services are more highly organized, publicly financed, and managed in a manner oriented to the special circumstances.

*> * *

This completes our analysis of the structure and functions of a national health system. We should now consider briefly the different types of system that operate in the world. Among the approximately i6 coun- tries on earth, no two systems are exactly alike, but one can understand them better by clustering the systems into certain major types.

DETERMINANTS AND TYPES OF HEALTH SYSTEMS

The combined characteristics of all five health system components define the type of health system found in each country. The determinants of these characteristics must be sought in past history, geography, culture, and other social conditions. Examined today, however, the health system can be identified quite well by two social features-economic and polit- ical. More precisely, the system is shaped by the wealth or economic level of the country and by the political ideology governing its health system.

The economic levels of countries can be quite readily scaled in terms of their gross national product (GNP) per capita. The GNP index tells us nothing about the distribution of income in a country, but this, in fact, is dependent on political ideology, which is a separate question. Countries with relatively high GNPs per capita are, of course, mainly industrialized, and those with low per capita GNPs are mainly agricultural. Deviation from this relationship has occurred in several petroleum-exporting coun- tries, which currently have relatively high GNPs without being indus- trialized.

The political ideology of a health system can be scaled along another axis, yielding a matrix of systems portrayed in Figure 4. The scaling of this dimension is not so readily achieved as that of the economic level, but I believe it is valid to base it on the degree of market intervention in the operation of the health system -ranging from minimal to maximal.

Market intervention replaces, in effect, the "unseen hand" of free trade

74 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989 FIGURE 4

Types of National Health Systems Classified By Economic Level & Health System Policies

ECONOMIC HEALTH SYSTEM POLICIES (Market Intervention) LEVEL (GNP per Capita)

Entrepreneurial Welfare-Onented Universal & Socialist & & Permissive Comprehensive Centrally Planned

United States West Germany Great Britain Soviet Union Affluent & Canada New Zealand Czechoslovakia

Industnalized Japan Norway

1 ~~~~~2 3 4

Thailand Brazil Barbados Cuba Philippines Egypt Nicaragua North Korea

Developing & South Africa Malaysia Transitional

5 6 7 8

Ghana India Sn Lanka China Bangladesh Burma Tanzania

Very Poor Nepal

9 10 11 12

Gabon Libya Kuwait Saudi Arabia

Resource - Rich

13 14 15 16

and competition with planning; it replaces individual purchases with group financing; it replaces isolated vendors with teams of providers; and so on. In a word, it replaces entrepreneurial autonomy with social organi- zation, and this may occur to varying degrees.

Even with the relatively simple classifications used in Figure 4, the i 6 conceptual cells may be sufficiently distinct to clarify how the main types of health system work. In all but one of the I 6 cells the names of various (3 I) countries are given, simply as examples. If every country in the world

ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 75

were placed in one or another cell, some cells would doubtless contain many countries and others only a few. Moreover, the countries in various cells would change from year to year, as economic and political influences modified their health systems.

To explore the matrix in Figure 4 somewhat further, we may consider simply the scaling along each dimension. Thus, economically the top row refers to countries with GNPs of $ ooo per capita or more per year. The second row refers to countries with annual GNPs per capita between $ ooo and $5oo. The third row refers to countries with under $ oo GNP per capita per year. The resource-rich countries all have relatively small populations and per capita GNPs of more than $5,ooo or even $2o,ooo per year.

The gradations along the political dimension cannot be so quantita- tively precise. The "Entrepreneurial" colunm refers to countries in which most of the health system, as reflected in overall expenditures, operates through a private market. Government's role in the system is relatively weak. In the second column for "Welfare-oriented" countries, market intervention has been substantial with respect to the financing of the system. Health care for most, nearly all, of the people is a public respon- sibility. A private medical market continues, however, and much govern- ment money is spent on payments to private providers.

In the third column for countries with "Universal and Comprehensive" health systems, government has intervened in the market even more extensively. Both the financing and the provision of health services have become highly organized. The total population has become entitled to virtually complete health service as a civic right at least to the extent of available resources. The fourth column for socialist countries refers to health systems which have been almost completely removed from market dynamics. Government has become responsible for all health services; all health resources, physical and human, have come under government control. Private buying and selling of health care has not been prohibited, and it exists, but to a very small degree.

TRENDS

These comments on the major types of health system in the world are inevitably over-simplifications. There are some exceptions to any generalization, and yet the matrix may help to put some order into numerous national health systems that otherwise appear like a jungle.

Of course, no health system is static; every system is continually chang-

76 JOURNAL OF PUBLIC HEALTH POLICY * SPRING I989

ing. This is in response not only to economic and political forces, but also to changes in the demography of the population, the capabilities of technology, urbanization, increased involvement of people in public af- fairs, and many other social circumstances. The effect of these pressures is to drive virtually all health systems in the direction of greater organiza- tion. This applies to all five components of health system structure.

With mounting government support, the production of health re- sources -manpower, facilities, and knowledge -is expanding. Ratios to population of hospital beds, doctors, nurses, and others are rising. The production of drugs by private industry is increasing due to strengthened economic support to purchase them, even though this support is mainly from public sources.

Organized programs are growing under both public and private aus- pices. Economic support is becoming more collectivized, mainly through government revenues, but in some countries (France, West Germany, Latin America, Middle East, Japan, South Korea, Philippines, etc.) largely through social insurance. Private spending is also increasing in certain countries, both developed and developing.

Management is certainly becoming more sophisticated, especially in planning, regulation, and legislation. The provision of services in nearly all countries is shifting from solo practitioners to organized teams of health personnel, working usually in clinics or health centers, as well as in hospitals.

Some people fear that all this organization yields impersonality and insensitivity to the feelings and needs of each person. Bureaucracy is, indeed, a hazard of any large organization. The benefits, however, in accessibility to health care, in quality assurance, in economy, and in equity are of overriding importance. The increasing organization of health systems is helping more people to obtain those benefits. The chal- lenge is to achieve Health for All without sacrificing the personal interests of any human being.

Acknowledgment: This paper is based on a Rosenstadt Lecture, presented at the University of Toronto (Toronto, Ontario, Canada), March I 5, I98 8.

ABSTRACT

National health systems have developed in all countries; their features have been shaped largely by organized interventions in the free market of health service.

ROEMER * HEALTH SYSTEMS AS MARKET INTERVENTIONS 77

Any health system can be characterized through analysis of five major compo- nents: (i) its production of resources, (2) organization of programs (including a residual private market), (3) sources of economic support, (4) modes of man- agement, and (5) patterns of providing services. The diverse types of health systems in the world may be categorized in a matrix derived from two dimen- sions: (a) the economic level (four steps), and (b) the political ideology of the health system, scaled (also four steps) from highly entrepreneurial (minor market intervention) to socialist (nearly complete market intervention). Every national health system would fit into one of the i6 cells of this matrix, although positions change as a result of economic and political dynamics.

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Issue Table of ContentsJournal of Public Health Policy, Vol. 10, No. 1 (Spring, 1989), pp. 1-142Front Matter [pp. 1-4]Guest EditorialTime Will Reveal Our Primitive Priorities [pp. 5-6]

An Agenda for Public Health [pp. 7-18]"The Future of Public Health": The Institute of Medicine's 1988 Report [pp. 19-31]The Cigarette Advertising Broadcast Ban and Magazine Coverage of Smoking and Health [pp. 32-42]Development of Behaviorally-Based Policy Guidelines for the Promotion of Exercise [pp. 43-61]National Health Systems as Market Interventions [pp. 62-77]The Health Status of Cuba: Recommendations for Epidemiologic Investigation and Public Health Policy [pp. 78-87]DocumentsComments on the Institute of Medicine's Report: "The Future of Public Health": United States Conference of Local Health Officers [pp. 88-94]NACHO's Response to the IOM Report: "The Future of Public Health": National Association of County Health Officials [pp. 95-98]Health Care in Rural America: The Crisis Unfolds: Joint Task Force of the National Association of Community Health Centers and the National Rural Health Association [pp. 99-116]

From Our Corresponding EditorsTowards Public Sector Goals: New Zealand's Recent Experience in Health Services Reorganization [pp. 117-122]

CommunicationGovernment Procurement Leverage [pp. 123-125]

Book ReviewsReview: untitled [pp. 126-129]Review: untitled [pp. 129-131]Review: untitled [pp. 131-134]Review: untitled [pp. 134-136]Review: untitled [pp. 136-137]Review: untitled [pp. 137-139]

Back Matter [pp. 140-142]