In This Issue

The first three articles in this issue concern the use of health services research to inform public policy. The issue begins with On Being a Good Listener: Setting Priorities for Applied Health Services Research, by Jonathan Lomas, Naomi Fulop, Diane Gagnon, and Pauline Allen. In the face of constrained resources, organizations that fund health services research must decide what research to support. Lomas and colleagues describe two broad approaches to setting such priorities. Technical assessments rely heavily on data, while interpretive assessments seek consensus from a set of relevant participants. The authors argue that when setting priorities for health services research, an interpretive approach that involves the research’s potential users should be used. This should increase the likelihood that the research will address important practical problems and that the results will actually be applied to the organization, delivery, or use of services.

In the listening model that Lomas and colleagues describe, important stakeholders are involved in a multistep process for setting priorities for health services research. The authors describe and analyze two substantial exercises, one in Canada and one in England, in which the listening model was used with apparent success. The question for future research is whether and how the resulting set of user-driven research priorities will affect the acceptance and use of research results by policymakers, managers, heath professionals, and the public.

Collaborations between state agencies and academic researchers also can contribute to the policy process (Wickizer et al. 2001). Debbie Chang, Alice Burton, John O’Brien, and Robert Hurley provide a detailed example of such a collaboration in their article, Honesty As Good Policy: Evaluating Maryland’s Medicaid Managed Care Program. The subject raises two contentious topics: managed care and federal-state relations. The stakeholders include elected officials and executive agencies at the federal, state, and local levels; advocacy and watchdog groups; various types of health care providers and their trade associations; health plans; Medicaid beneficiaries; and taxpayers. In addition to describing the methods and findings of the evaluation, Chang and her colleagues review the steps taken to give the evaluation credibility with this set of stakeholders. They draw important lessons about making complex programs understandable, about investments in systems to gather data and conduct analyses, about the combined value of quantitative and qualitative approaches, about building flexibility into a program evaluation, and about the credibility benefits of disclosing both good and bad findings. In the Maryland example, these factors combined to enhance public support for Medicaid managed care.

Chris Ham, Ruth Kipping, and Hugh McLeod also provide an account of an evaluation of a health care innovation in their article, Redesigning Work Processes in Health Care: Lessons from the National Health Service. The innovation was to address the British National Health Service’s (NHS) endemic problem of queues for hospitalization by persuading physicians to book hospital admissions at the time that treatment decisions are made. The “booked admissions” program was the first in a series of quality improvement programs in the Blair government’s reform of the NHS. This seemingly simple change had numerous ramifications, including requiring physicians to lessen their control over their own work and their ability to generate paid work outside the confines of the NHS. The challenge was to persuade physicians to participate.

Ham and his colleagues focus their analysis of the booked admissions program on facilitating and inhibiting factors. Organizational change is particularly difficult in what Mintzberg (1983) calls professional bureaucracies, in which control resides with professionals who deliver the services. The booked admissions case is instructive. The degree of success in the pilot sites in which the program was initiated varied greatly. Ham, Kipping, and McLeod examine the difficulties of implementing and sustaining quality improvements in the NHS, and they identify factors that may account for the differences across sites, concentrating on the supportiveness of the local context and the methods by which the change was introduced. Along the way, they offer a useful account of recent quality improvement initiatives in the NHS.

In The Labor Market Consequences of Race Differences in Health, John Bound, Timothy Waidmann, Michael Schoenbaum, and Jeffrey Bingenheimer use U.S. Census data to examine whether and how racial disparities in health status are related to differences in employment, earnings, and household income. Although many racial/ethnic disparities in health status have been documented and much research has been done to shed light on their causes (Institute of Medicine 2002), the consequences have received much less attention. In this article, Bound and his colleagues report that disparities in health are a source of economic disadvantage, particularly for blacks and Native Americans. Health disparities are an important source of inequality in American society, contributing substantially to these groups’ disadvantages in employment rates and participation in public transfer programs. Health disparities, however, contribute more modestly to these groups’ disadvantage in earnings and household income.

Policy responses to fetal harm resulting from substance use by pregnant women have often been framed in terms of a conflict between the interests of the fetus and the rights of the woman. In their article, Reciprocal Obligations: Managing Policy Responses to Prenatal Substance Exposure, Peter Jacobson, Gail Zellman, and Chris Fair argue for an alternative approach. Rather than treating the problem as a matter for the criminal justice system, as has occurred in some cases, they advocate a public health approach aimed at prevention and treatment. Their proposed model rests on the notion that the state (representing the fetus) and the pregnant woman have obligations both to the fetus and to each other. They contend that once a woman has decided not to terminate her pregnancy, both she and the state must act in the best interest of the fetus. In the presence of substance usage that could damage the fetus, the state has an obligation to make drug treatment available, and the woman has an obligation to accept a referral to such treatment. After describing this approach, the authors offer a set of guidelines for use by policymakers in regard to interventions to prevent harm from prenatal substance use.

Bradford H. Gray
Editor, The Milbank Quarterly


Institute of Medicine. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academies Press.

Mintzberg, H. 1983. Structure in Fives: Designing Effective Organizations. Englewood Cliffs, N.J.: Prentice-Hall.

Wickizer, T.M., G. Franklin, R. Plaeger-Brockway, R. Mootz, and D. Drylie. 2001. Improving the Quality of Workers’ Compensation Health Care Delivery: The Washington State Occupational Health Services Project. Milbank Quarterly 79(1):5–33.

Author(s): Gray, BH

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Volume 81, Issue 3 (pages 359–361)
DOI: 10.1111/1468-0009.00041-i1
Published in 2003