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This paper examines the impact of institutional change on patient care. Using panel data on obstetric deliveries from the state of California in the United States between 1983 and 2001, it develops and tests hypotheses predicting impacts of three features of institutional change-managed care insurance, changing professional controls and public attention to cost-control practices-on cesarean use and geographic variation in cesarean deliveries. It finds that managed care insurance promotes the diffusion of cost-effective patient care practices, reducing cesarean use and increasing variation. I found that over time, managed care patients experience continued lower use and reduced geographic variation as new practices become established. The combined effects of changing professional controls-the growing importance of clinical guidelines-and public attention to cost-control practices also diffuses cost-effective practices, increasing variation and decreasing cesarean use. Cesarean use increases and geographic variation declines in a period of managed care retreat in the late 1990s. The analysis extends prior research by documenting the impact of institutional change on health services use and variation and by suggesting that geographic variation is caused, in part, by the diffusion of new patient care practices

Substance use (SU) disorders adversely impact health status and contribute to inappropriate health services use. This qualitative study sought to determine SU-related factors contributing to repeated hospitalizations and to identify opportunities for preventive interventions. Fifty Medicaid-insured inpatients identified by a validated statistical algorithm as being at high-risk for frequent hospitalizations were interviewed at an urban public hospital. Patient drug/alcohol history, experiences with medical, psychiatric and addiction treatment, and social factors contributing to readmission were evaluated. Three themes related to SU and frequent hospitalizations emerged: (a) barriers during hospitalization to planning long-term treatment and follow-up, (b) use of the hospital as a temporary solution to housing/family problems, and (c) unsuccessful SU aftercare following discharge. These data indicate that homelessness, brief lengths of stay complicating discharge planning, patient ambivalence regarding long-term treatment, and inadequate detox-to-rehab transfer resources compromise substance-using patients' likelihood of avoiding repeat hospitalization. Intervention targets included supportive housing, detox-to-rehab transportation, and postdischarge patient support.

We argue in this paper that neighborhoods are highly relevant for the types of issues at the heart of regional science. First, residential and economic activity takes place in particular locations, and particular neighborhoods. Many attributes of those neighborhood environments matter for this activity, from the physical amenities, to the quality of the public and private services received. Second, those neighborhoods vary in their placement in the larger region and this broader arrangement of neighborhoods is particularly important for location choices, commuting behavior and travel patterns. Third, sorting across these neighborhoods by race and income may well matter for educational and labor market outcomes, important components of a region's overall economic activity. For each of these areas we suggest a series of unanswered questions that would benefit from more attention. Focused on neighborhood characteristics themselves, there are important gaps in our understanding of how neighborhoods change - the causes and the consequences. In terms of the overall pattern of neighborhoods and resulting commuting patterns, this connects directly to current concerns about environmental sustainability and there is much need for research relevant to policy makers. And in terms of segregation and sorting across neighborhoods, work is needed on better spatial measures. In addition, housing market causes and consequences for local economic activity are under researched. We expand on each of these, finishing with some suggestions on how newly available data, with improved spatial identifiers, may enable regional scientists to answer some of these research questions.

New York. London. Paris. Although these cities have similar sociodemographic characteristics, including income inequalities and ethic diversity, they have vastly different health systems and services. This book compares the three and considers lessons that can be applied to current and future debates about urban health care.

Highlighting the importance of a national policy for city health systems, the authors use well-established indicators and comparable data sources to shed light on urban health policy and practice. Their detailed comparison of the three city health systems and the national policy regimes in which they function provides information about access to health care in the developed world's largest cities.

The authors first review the current literature on comparative analysis of health systems and offer a brief overview of the public health infrastructure in each city. Later chapters illustrate how timely and appropriate disease prevention, primary care, and specialty health care services can help cities control such problems as premature mortality and heart disease.

In providing empirical comparisons of access to care in these three health systems, the authors refute inaccurate claims about health care outside of the United States.

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Levinson argues that BRT should be designed to complement and not replace rail lines when providing regional rapid transit. In his paper, he provides guidelines for a successful BRT system. He also identifies urban and suburban BRT opportunities in the New York region, along with already existing services.

On February 12th, 2008, Christine Quinn, Speaker of the New York City Council, took to the dais at the City Council Chambers to deliver the State of the City Address.  Towards the 17th page of an 18 page address, the Speaker’s remarks turned to public transit and the Mayor’s recently released PlaNYC initiatives.  While transit is generally a hot topic in New York, Mayor Bloomberg had made transportation a centerpiece of his second term and was spending the winter in a campaign to convince the State Legislature to approve a congestion pricing scheme in Manhattan to finance transportation capital projects. 

“It’s only natural to look at our natural highways, our water ways... to move New Yorkers efficiently and sustainably.” Said Speaker Quinn,  “That’s why we are proposing and the Mayor has agreed to begin developing a comprehensive five borough, year-round New York City Ferry System.”   The Speaker explained that the idea for ferry service originated through a series of public hearings she held with her colleagues in the Council:

 “Soon after, we began exploring the concept of a pilot ferry service for the Rockaways…got a commitment from the Mayor to fund it…and that service should be up and running by this summer.


Two years and twelve days later, the rhetoric of the State of the City speech came crashing to an anti-climactic end, as a report in the Daily News announced the cancellation of the Rockaways service.  The ferry would cease operations at the end of March.  

Plans for a five borough Ferry System have not materialized, except for an East River ferry serving developments along the Queens/Brooklyn waterfront, currently with two sailings during the AM and PM peak hours is expected to offer more frequent service next year  The Rockaway route had not met ridership projections and was recovering only 15-30% of its operational costs from revenues collected at the farebox.   The failure of the Rockaway ferry service, combined with the cancellation of another newly opened ferry service between Yonkers and Lower Manhattan in 2009 has dashed the hopes of some who wished to exploit New York’s water resources to improve commuting options via ferries.  This has led to questions about the feasibility of expanding ferry service in New York City more broadly. 

As large sections of the New York City waterfront are reclaimed from decades of industrial land use, idyllic waterfront parks have been developed next to gleaming residential towers.  It seems only natural that ferries will soon serve a role in transporting residents and visitors to these new neighborhoods throughout the City.  However, recent experiences illustrate the many obstacles facing expanded ferry services in New York City 

We argue in this paper that neighborhoods are highly relevant for the types of issues at the heart of regional science. First, residential and economic activity takes place in particular locations, and particular neighborhoods. Many attributes of those neighborhood environments matter for this activity, from the physical amenities, to the quality of the public and private services received. Second, those neighborhoods vary in their placement in the larger region and this broader arrangement of neighborhoods is particularly important for location choices, commuting behavior and travel patterns. Third, sorting across these neighborhoods by race and income may well matter for educational and labor market outcomes, important components of a region's overall economic activity. For each of these areas we suggest a series of unanswered questions that would benefit from more attention. Focused on neighborhood characteristics themselves, there are important gaps in our understanding of how neighborhoods change - the causes and the consequences. In terms of the overall pattern of neighborhoods and resulting commuting patterns, this connects directly to current concerns about environmental sustainability and there is much need for research relevant to policy makers. And in terms of segregation and sorting across neighborhoods, work is needed on better spatial measures. In addition, housing market causes and consequences for local economic activity are under researched. We expand on each of these, finishing with some suggestions on how newly available data, with improved spatial identifiers, may enable regional scientists to answer some of these research questions.

The American Recovery and Reinvestment Act of 2009 has opened a window for implementing high-speed passenger rail operations in the U.S.  Because North America had never pursued high-speed rail as a national transportation priority, the planning framework for designing such services and linking them to the national transportation system was never created. An intermodal integration strategy will thus have to be developed in parallel with the designs for new high-speed train services, if these projects are to achieve their potential. Connecting these new high-speed passenger rail routes to airport, highway, and transit infrastructure and integrating train operations with aviation, transit and vehicular travel will facilitate future use of high-speed trains and enable high-speed rail supportive land uses to evolve. But designing tomorrow’s high-speed rail to fit into today’s air and surface transportation network would yield suboptimal results. A successful intermodal integration plan for high-speed rail will need to anticipate evolution in air and surface transportation modes that will adapt to the energy and climate challenges shaping future mobility.
 

Modern methods of fare collection have turned ticketing contracts into complicated information technology projects without necessary bringing all the disciplines of such systems. The high cost of updating or maintaining front line systems makes it very challenging to keep up with the rapid obsolescence cycles that the IT industry considers normal. It is challenging enough to build a system that offers some prospect of working. Wrapping these systems in long term, inflexible contracts with lenders and contractors opposed to making changes presents further challenges. London's experience with such a contract over the last decade offers some lessons for any transit system about to use a public private partnership (PPP) to build a ticketing system.

Collaborations between nonprofit and public sector organizations have become an increasingly important phenomenon in state and local public service delivery since the publication of the Winter Commission report in 1993. This article focuses on one of the less studied types of public–nonprofit collaborations, those in which philanthropic support from nonprofit organizations supplements the resources and activities of public agencies. Drawing on the case of "nonprofit-as-supplement collaborations" that support park services in New York City, this article documents the benefits and drawbacks associated with such collaborations. While they can provide increased resources and encourage management innovations, they also can lead to inequities in the availability and quality of services, the preponderance of particularistic goals over the broader public interest, and the politicization of previously bureaucratic decision making. The authors offer two strategies for public managers to realize more effectively the benefits yet mitigate the shortcomings of these collaborations.

Many schools have experiential learning projects, often termed “capstones,” where
students combine theory and practice for the benefit of an outside agency. New
York University’s Robert F. Wagner Graduate School of Public Service (NYU
Wagner) has devoted a great deal of thought and effort to strengthening and
sustaining its Capstone program from the students’ perspective, and it has seen
significant improvement. But we knew less about whether the project work our
students performed was helpful to participating Capstone client organizations, as well as what factors made certain projects more successful from the clients’ point of view. In an effort to assess and understand this perspective, we undertook a post-project survey of recent Capstone clients. The results indicate very strongly that the services offered and tools created by our Capstone teams are useful to these outside agencies, and the feedback offers indications of how to increase the
value of these projects going forward.

Many policy problems require governmental leaders to forge vast networks beyond their own hierarchical institutions. This essay explores the challenges of implementation in a networked institutional setting and incentives to induce coordination between agencies and promote quality implementation. It describes the national evaluation of the Assuring Better Child Health and Development program, a state-based program intended to increase and enhance the delivery of child development services for low-income children through the health care sector, using Medicaid as its primary vehicle. Using qualitative evaluation methods, the authors found that all states implemented programs that addressed their stated goals and made changes in Medicaid policies, regulations, or reimbursement mechanisms. The program catalyzed interagency cooperation and coordination. The authors conclude that even a modest level of external support and technical assistance can stimulate significant programmatic change and interorganizational linkages within public agencies to enhance provision of child development services.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? Health Care Delivery in the United States, 8 th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed. With an easy to understand format and a focus on the major core challenges of the delivery of health care, this is the textbook of choice for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

Developing countries that were early, enthusiastic adopters of Primary Health Care often developed an extensive – but eventually dilapidated and under-utilized – network of public clinics at the grassroots. As paradigms and investment patterns of health sector reform have shifted, the question of what role these public clinics can meaningfully play, and how best to revitalize them, has become important in a number of countries. This paper evaluates the strategy taken by, and outcomes of, a major attempt in Vietnam to revitalize the grassroots infrastructure of primary health care against the backdrop of the country’s economic transition. The project’s substantial supply-side investments in infrastructure led to marginal increases in utilization and the quality of preventive health services  provided by the centers. But because the project failed to take adequate stock of broader, public sector-wide trends and reforms over the transition, the investments had little impact on the incentives, accountability patterns and capacities of clinic staff and the local authorities. Such institutional factors are heavily implicated, in Vietnam as elsewhere, in the substantial and often increasing disparities in service access and quality that continue to afflict transitional health sectors.

OBJECTIVES:

We examined the mechanisms by which living in a disadvantaged minority community influences smoking and illegal cigarette sale and purchasing behaviors after a large cigarette tax increase.

METHODS:

Data were collected from 14 focus groups (n=104) that were conducted during the spring of 2003 among Blacks aged 18 years and older living in New York City.

RESULTS:

A large tax increase led to what focus group participants described as a pervasive illegal cigarette market in a low-income minority community. Perceived pro-smoking community norms, a stressful social and economic environment, and the availability of illegal cigarettes worked together to reinforce smoking and undermine cessation.

CONCLUSIONS:

Although interest in quitting was high, bootleggers created an environment in which reduced-price cigarettes were easier to access than cessation services. This activity continues to undermine the public health goals of the tax increase.

Background: Access to timely and effective medical services can reduce rates of premature mortality attributed to certain conditions. We investigate rates of total and avoidable mortality (AM) and the percentage of avoidable deaths in France, England and Wales and the United States, three wealthy nations with different health systems, and in the urban cores of their world cities, Paris, Inner London and Manhattan. We examine the association between AM and an income-related variable among neighbourhoods of the three cities. Methods: We obtained mortality data from vital statistics sources for each geographic area. For two time-periods, 1988–90 and 1998–2000, we assess the correlation between area of residence and age- and gender-adjusted total and AM rates. In our comparison of world cities, regression models are employed to analyse the association of a neighbourhood income-related variable with AM. Results: France has the lowest mortality rates. The US exhibits higher total, but similar AM rates compared to England and Wales. Rates of AM are lowest in Paris and highest in London. Avoidable mortality rates are higher in poor neighbourhoods of all three cities; only in Manhattan is there a correlation between the percentage of deaths that are avoidable and an income related variable. Conclusions: Beyond the well-known association of income and mortality, persistent disparities in AM exist, particularly in Manhattan and Inner London. These disparities are disturbing and should receive greater attention from policy makers.

Context The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) measure and report quality process measures for acute myocardial infarction (AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital's outcomes can be made from its performance on publicly reported processes.

Objective To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates.

Design, Setting, and Participants We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction (NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data.

Main Outcome Measures Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older.

Results We found moderately strong correlations (correlation coefficients ≥0.40; P values <.001) for all pairwise comparisons between beta-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures (correlation coefficients <0.40; P values <.001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates (P values <.001) but together explained only 6.0% of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI.

Conclusions The publicly reported AMI process measures capture a small proportion of the variation in hospitals' risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.

Public authorities play a major role in delivering public services. They supplement direct government agencies in three ways:

• Provide a business-like organizational structure for public services that are financed primarily by user fees and whose capital investments are self-financed through bonds supported by user fees.
• Provide a stewardship for major capital assets and make long-run investment decisions with some isolation from pressures of the electoral cycle.
• Provide a mechanism for taking advantage of federal tax benefits for economic development and other purposes that otherwise would be treated as private activities.

Authorities are intended to strike a balance between political accountability and political independence. Unlike heads of direct government agencies, governing boards of authorities are expected to be more independent of those who appoint them, to make difficult and unpopular decisions outside the arena of elected politics, and to be accountable to the public indirectly through reporting, transparency in decision-making and long-run performance. New York State makes extensive use of public authorities.

Objective: To use publicly available secondary data to assess the impact of Brazil's Family Health Program on state level infant mortality rates (IMR) during the 1990s.

Design: Longitudinal ecological analysis using panel data from secondary sources. Analyses controlled for state level measures of access to clean water and sanitation, average income, women's literacy and fertility, physicians and nurses per 10 000 population, and hospital beds per 1000 population. Additional analyses controlled for immunisation coverage and tested interactions between Family Health Program and proportionate mortality from diarrhoea and acute respiratory infections.

Setting: 13 years (1990-2002) of data from 27 Brazilian states.

Main results: From 1990 to 2002 IMR declined from 49.7 to 28.9 per 1000 live births. During the same period average Family Health Program coverage increased from 0% to 36%. A 10% increase in Family Health Program coverage was associated with a 4.5% decrease in IMR, controlling for all other health determinants (p<0.01). Access to clean water and hospital beds per 1000 were negatively associated with IMR, while female illiteracy, fertility rates, and mean income were positively associated with IMR. Examination of interactions between Family Health Program coverage and diarrhoea deaths suggests the programme may reduce IMR at least partly through reductions in diarrhoea deaths. Interactions with deaths from acute respiratory infections were ambiguous.

Conclusions: The Family Health Program is associated with reduced IMR, suggesting it is an important, although not unique, contributor to declining infant mortality in Brazil. Existing secondary datasets provide an important tool for evaluation of the effectiveness of health services in Brazil.

In a critical examination of some of the most topical and challenging issues confronting the public sector in developing counties in an era of globalization, the contributors to this book examine the potential and limits of managerial, fiscal and decentralization reforms, and highlight cases where selective use of some of the new management reforms has delivered positive results. A common thread that runs through the book is the challenges of capacity to improve public services. Looking beyond the past and the present into the future, the book provides lessons from the experience of implementing public sector reforms in developing countries.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? Health Care Delivery in the United States, 8 th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed. With an easy to understand format and a focus on the major core challenges of the delivery of health care, this is the textbook of choice for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

Health services research is, by nature, multidisciplinary, for it draws on the methods,concepts and theories of social sciences, which are relevant to the study of how the organization and financing of health services can improve the delivery of health care services (Gray, et al., 2003). While medicine and public health, too, are multidisciplinary enterprises drawing on such disciplines as molecular biology, physiology, anatomy, genetics, epidemiology and more, health services research departs from these disciplines in focusing not on the nature of disease and health but rather on the financing and organization of health systems.

So it is with urban health services research albeit that this field is more narrowly focused on health services in cities. The city focus has resulted in a large body of research on vulnerable groups, barriers to service access, public health clinics and community health centers. Likewise, it has led to important investigations of safetynet institutions, e.g. public hospitals and health centers, which serve a disproportionate share of uninsured and low-income patients. In addition, urban health services research has focused on a host of specific services associated with subpopulations suffering from TB, HIV/AIDS, drug addiction and other social pathologies that are typically associated with the "inner city."

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care?

Health Care Delivery in the United States, 8th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed.

Whatever his legacy as an architect of the war in Iraq, Defense Secretary Donald Rumsfeld has already earned a place in American bureaucratic history as one of its most ambitious organizational reformers. Rumsfeld is determined to complete a top to bottom overhaul of his department before he leaves office. Rumsfeld may be one of history's most ambitious reformers, but his actual impact is far from assured. He still faces intense resistance from the armed services, especially the Army, which has the most to lose in the movement to a much lighter military. And many of his proposals are either still under consideration in Congress or only in the early stages of implementation in the department. This is very much Rumsfeld's revolution to win or lose it is highly dependent upon his congressional support, which has ebbed and flowed with the fortunes of war, on the urgency of the war on terrorism, which continues to fade with memories of September 11, and on his relationship with the armed services, which has been shaken by the controversy surrounding the equipping of U.S. troops in Iraq. It also depends on his public reputation, which has dropped in the wake of the prison abuse scandals at Abu Ghraib and Guantanamo Bay. In October 2001, for example, the Harris Poll reported that 78 percent of Americans rated Rumsfeld's job performance as excellent or pretty good; by June 2005, the percentage had fallen to just 42 percent.

Four years after September 11th, public confidence in charitable organizations remains stuck at a contemporary low. According to a telephone survey of 1,820 randomly-selected Americans interviewed on behalf of NYU Wagner's Organizational Performance Initiative during the summer of 2005, confidence has held virtually constant since it bottomed out after months of controversy
surrounding disbursement of the September 11th relief funds. As of last summer, 15 percent of Americans said they had a great deal of confidence in charitable organizations, 49 percent said a fair amount, 24 percent said not too much, and 7 percent said none at all. Public views of how charitable organizations operate also remain unchanged. Only 19 percent of Americans said charitable organizations do a very good job running their programs and services, while just 11 percent said the same about spending money wisely. In addition, 66 percent of Americans said that charitable organizations waste a great deal or fair amount of money, while almost half said the leaders of charitable organizations are paid too much. If the past is prologue, these views will continue to drive higher levels of legislative and media scrutiny, which in turn, may further erode public confidence. The survey also suggests that rebuilding confidence must involve sustained investment in strengthening the capacity of charitable organizations to achieve measurable impacts toward their missions.

As a critical infrastructure sector, electricity enables numerous other critical infrastructures to function, and in many cases is the critical path for their operation. This is underscored by the fact that historically, electric power outages have played a central role in disruptions of many other infrastructures. As a consequence of the centrality of its role, electricity is potentially a key target for terrorist attacks. This case sets forth risks in terms of hypothetical alternative attack scenarios in the form of various grid configurations that are vulnerable based on both natural events in the U.S. and terrorism internationally as well as in terms of the odds that outages will occur and other characteristics of outages will change. Consequences are then identified based on hundreds of events and other records that portray the effects that electric power outages have on key public services and businesses. Economic accounting is conducted in terms of human premature death and injury and business loss for some of the key consequence areas, using a wide range of economic factors.

In a festschrift to Netzer-a public finance economist well known for his research on state and local taxation, urban public services, and nonprofit organizations-eight chapters apply microeconomics to problems facing urban areas and use statistical analysis to gain insight into practical solutions. The essays look at alternative methods of financing urban government, such as a land value tax and the impact of sales and income taxes on property taxation; at government expenditures, including housing subsidies; and at subsidies to nonprofit arts groups as well as the role of the nonprofit sector in providing K-12 education. Of interest to the fields of public finance, urban economics, and public administration.

In a festschrift to Netzer a public finance economist well known for his research on state and local taxation, urban public services, and nonprofit organizations eight chapters apply microeconomics to problems facing urban areas and use statistical analysis to gain insight into practical solutions. The essays look at alternative methods of financing urban government, such as a land value tax and the impact of sales and income taxes on property taxation; at government expenditures, including housing subsidies; and at subsidies to nonprofit arts groups as well as the role of the nonprofit sector in providing K-12 education. Of interest to the fields of public finance, urban economics, and public administration.

Given religious leaders' frequent opportunities to communicate to a large and receptive audience, political messages delivered during religious services have the potential to make a considerable impact on American politics-with particular significance for political education and mobilization. Social scientists routinely conclude that such messages are indeed disseminated, a claim we test in this study. Is it in fact true that church- and temple-going Americans regularly receive political messages from their ministers, priests, and rabbis during worship services? If so, what forms do these pronouncements take? How intense are they? Is this communication limited to messages from the service leader or does it come from other parts of the service, either informal or ritualistic? Existing empirical assessments of this topic depend heavily on survey research, asking congregants (or, less often, members of the clergy) about the frequency and content of political messages. Although such studies are certainly valuable, we approach religious political communications in a more immediate way: by observing them directly. Our conclusions are based on two waves of attendance at weekly services during 1998-1999, varying by religious tradition and denomination, region, and other dimensions. We find that "political" messages, broadly defined, are indeed delivered quite often. However, content analysis of these messages reveals that they typically address matters of social justice and rarely other types of political activity or belief, such as specific public policies or civic involvement (including voting). Political references during services only very occasionally constituted calls to direct political action on the part of the worshiper. Ultimately, our findings suggest that political content does occur relatively frequently during U.S. religious services, supporting the accounts of other social scientists. Our analysis offers new insight as to the content and nature of the political messages Americans are exposed to during religious services.

Objective
To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades.

Data Sources/Study Setting
Data were primarily derived from OECD Health Data 2001 and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (total n=504).

Study Design
Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression.

Data Collection/Extraction Methods
Secondary analysis of public-use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in-country experts.

Principal Findings
The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro-level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health.

Conclusions
(1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.

The public sector currently employs around 40 percent of all union members in the United States. Pressures for cost-effective and quality government services have placed new demands on the labor-management relationship. A fluctuating set of expectations about the appropriate responsibilities of government and a shifting political culture are severely testing the ability of the public sector to meet demands for increased accountability and expanded services. Especially in an age of knowledge workers, the traditional division between labor and management regarding leadership and work may no longer be viable. Going Public examines the forces affecting labor and management and the prospects for adopting service-oriented cooperative relationships as a key strategy for meeting the expanded demands on the public sector.

The management of international organizations is attracting growing attention. Most of this attention is highly critical of both the UN system and International NGOs. Sometimes, this criticism lacks depth or reflects insufficient understanding of these organizations, or is based on narrow, and sometimes biased, internal political concerns of a particular country. International relations theory has insufficiently studied the type of linkages that these organizations provide between international decision-making and Northern fundraising on the one hand, and practical action in the South on the other. As a result, current theory too rarely focuses on the inner functioning of these organizations and is unable to explain the deficiencies and negative outcomes of their work. While the authors identify and describe the pathologies of international organizations in, for example, international diplomacy, fundraising, and implementation, they also stress positive elements, such as their intermediary role. The latter form the basis for more efficient and effective policies and action that, in addition to some recent political trends also described in this volume, hold hope for a stronger functioning of these organizations in the future.

Examining cutting-edge issues of international relevance in the ongoing redesign of the South African local government fiscal system, the contributors to this volume analyze the major changes that have taken place since the demise of apartheid. The 1996 Constitution and subsequent legislation dramatically redefined the public sector, mandating the development of democratic local governments empowered to provide a wide variety of key public services. However, the definition and implementation of new local functions and the supporting democratic decision-making and managerial capabilities are emerging more slowly than expected. Some difficult choices and challenges commonly faced by developing countries must be dealt with before the system can evolve to more effectively meet the substantial role envisioned for local governments.

Like oysters on the half shell, some things are better when they're raw. In evaluating the performance of organizations and providing guidance for improving performance, however, raw performance measures, such as test scores or success rates, are often inferior to performance measures adjusted for client and environmental characteristics, or adjusted performance measures (APMs). Using examples from a variety of public services and data on public schools in Georgia, we compare the performance data generated by raw scores and by APMs. We conclude with guidance for constructing and using adjusted performance measures.

After the terrorist attacks on the World Trade Center in New York City on September 11, 2001, the ability to rapidly restore transportation, power, water, and environmental services to users was absolutely critical, especially to those involved in the immediate search, rescue, and recovery operations. What better way could infrastructure serve its users-both emergency workers and the general public-than to be able to respond quickly in a crisis? The ability to provide these services required a degree of flexibility, often unanticipated and unplanned, that only became apparent as the response efforts unfolded. The capability of basic infrastructure service providers to respond to public needs for transportation, energy, communication, water, sanitation, and solid waste removal after the September 11th attacks was to a great extent influenced by the flexibility of the initial infrastructure design and management functions to respond to normal system disruptions and to extreme, but not necessarily terrorist-related, events.

This book takes the conversation between bioethics and health policy to a new level. Moving beyond principles and normative frameworks, bioethicists writing in the volume consider the actual policy problems faced by health care systems, while policy-makers reflect on the moral values inherent in both the process and content of health policy. The result is a vigorous dialogue with some of the nation's leading experts at the interface of ethics and health policy. the book provides a history of the values implicit in U.S. health policy, a discussion of the federal and state roles in policymaking, an ethical examination of the social goals expressed through various policies, an analysis of the role of public opinion in the creation of health policy, and an exploration of the value of the private sector in health policy. In addition, the authors examine some of the major ethical controversies in health policy, such as the challenge of balancing ethical concerns with economic realities, the need to allocate scarce health resources, the call for heightened accountability, and the impact of various policies on vulnerable populations. The book concludes with an examination of the ethical issues in health services research, including the threats to privacy that arise in such research. To a greater extent than any previous volume, it establishes a strong connection between the disciplines of medical ethics and health policy.

This report presents and examines a deceptively simple idea: That a large group of municipal employees, about 67,000 "non-managerial civilians," increase their workweek from 35 to 40 hours. The purpose of this change is to yield a substantial savings for the City and its taxpayers by enabling fewer workers to provide the existing package of public services.

A major issue on the national agenda in the United Kingdom is how to improve public services. There is no single, simple solution. A serious commitment to that goal will require additional resources and innovative leadership that can use the funding wisely. Such an effort also will require new organizational forms for the delivery of services. Alternatives to both traditional public bureaucracies and for-profit businesses are likely to be an essential component of designs for more cost effective public services. The Public Management Foundation (PMF) in London is a ‘think tank' that has begun to address the emerging need for new organizational structures. Their suggestion is to develop an entity that they call a ‘public interest company' (PIC). Such a body is proposed as one of many ways to help improve services: ‘Our collective point is that the way in which the British system allows organisations to deliver public services has been too restrictive and a far wider variety of organisational forms for public service delivery needs to be encouraged. The public interest company will be just one of these.'

Sound budget policy requires a clear understanding of the nature of fiscal problems and creative thinking in the design of solutions. The recent public debate about how to close
New York City's unprecedented budget gap falls short on both counts. The Citizens Budget Commission - a nonprofit, nonpartisan civic organization - has prepared this document to clear up a series of common misunderstandings that hinder the debate and to focus attention on the potential for significant savings by delivering City services more efficiently. The first part of the document identifies ten "myths" about the budget and provides the facts that dispel them. The second part presents five ideas that together
would save the City more than $1 billion annually. The ideas are based on research conducted by the Commission's staff and presented in greater detail in separate reports published by the Commission.

The United States cannot win the war on terrorism or rebuild homeland security without a fully dedicated federal civil service. Unfortunately, federal employees report that both the quality of their work life and their level of job satisfaction have declined since September 11. Fewer federal employees are coming to work for the right reasons, even fewer feel their agencies are providing the tools and training to do their jobs well, and even fewer still believe that their organizations are doing a good job at delivering programs and services

Urbanized and soon-to-be urbanizing areas are increasingly dependent upon infrastructure transmission and distribution networks for the provision of essential public resources and services for transportation, energy, communications, water supply, and wastewater collection and treatment. In large part, the increasing spread of population settlements at the periphery of cities and the increasing density and vertical integration of urban cores have increased reliance upon the connectivity that these networks provide. These infrastructure networks are, in turn, dependent upon one another, both functionally and spatially, in very complex ways, and that interdependence is increased as new capacity-enhancing infrastructure technologies are developed. The extent of these dependencies appears to be escalating, and that results in interactions among the systems and produces effects upon environments that are difficult to predict.

The quality of the environment in communities with large minority populations has been a growing concern particularly with respect to public health given the potential for greater
exposure among minorities and the lower availability of health services to address such exposures. A public health and environmental policy analysis is being conducted by the Institute for Civil Infrastructure Systems (ICIS) at New York University's Wagner Graduate School of Public Service (NYU-Wagner) to address some of these issues in the South Bronx. The Wagner School study is part of a larger project funded by the U.S. EPA about environmental issues in the
South Bronx, NY that aims to provide relationships among air quality, transportation, waste transfer activity, and demographic characteristics in the South Bronx.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? Health Care Delivery in the United States, 8 th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed. With an easy to understand format and a focus on the major core challenges of the delivery of health care, this is the textbook of choice for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

This report recommends a comprehensive reassessment of federal health policies, programs, and processes, including federal-state roles and relationships, and some immediate actions to promote and protect the nation's health and to provide leadership in world health. The report concentrates on the challenges facing the secretary of the U.S. Department of Health and Human Services (DHHS) as the head of the lead health agency in the federal government. The federal government is responsible for five main functions related to health policy: financing; public health protection; collecting and disseminating information about U.S. health and health care delivery systems; capacity building for population health; and direct management of services.

Unlike the current categorical, or highly specialized, approach leading to policies and programs addressing the needs of a specific population, illness, or organizational constituency, a new, comprehensive approach to policy for the 21st century should promote coordinated efforts across programs in order to achieve three goals:

* create conditions that lead to longer, healthier lives for all Americans;
* eliminate health disparities;
* protect communities from avoidable health hazards and help them to address their own health problems.

In the absence of universal coverage and an effective primary care delivery system for vulnerable populations, hospital emergency departments (EDs) are the ultimate safety net for many patients. This is especially true in New York City, where nearly 75 percent of ED visits in 1998 were for nonemergent care, or for emergent care that could have been treated in a doctor's office.1 Another 7 percent of visits required care in the ED, but were for potentially preventable conditions such as acute flare-ups of asthma or diabetes. New Yorkers who rely on EDs lack continuity in their health care and end up using costlier services. Why do so many patients depend on hospital emergency departments for primary care? Do they seek emergency care immediately, or do they have time and opportunity to obtain care at a doctor's office or neighborhood clinic? Do these patients have a usual source of care other than the ED? Do they have any contact with the health care system prior to their ED visit? Does insurance status, race, ethnicity, national origin, or gender have an influence on ED use?

To answer these questions, the Center for Health and Public Service Research at New York University conducted face-to-face interviews with 669 emergency department patients ages 18 to 55 at four hospitals in the Bronx.

This report focuses on the cost-effectiveness of the policies of the New York State Department of Correctional Services, and makes four recommendations for achieving operational savings without diminishing public safety. These recommendations are: (1) to extend the reach and effectiveness of tested alternatives, such as boot camp and the CASAT program; (2) to develop new alternatives for additional inmate groups; (3) to reengineer the parole system; (4) to create an enhanced research and development unit.

Increasingly, nonprofit, for-profits, and public organizations have been cooperating in producing and distributing a wide range of goods and services. In many cases, the partnerships have arisen from the recognition that different activities are best suited to different governance structures. Yet, working through a cross-sectoral partnership can bring with it complicated managerial issues. This article explores partnering in two important sectors: higher education and welfare reform. In both areas, cooperation across the sectors is widespread and follows lines of comparative advantage. At the same time, there is ample evidence in our cases of classic transactions costs in implementing cross-sectoral partnerships. The article explores ways in which organizations deal with problems of opportunism and imperfect information in contracting across the sectors.

This book addresses a seemingly simple question: Just how many people really work for the federal government? Official counts show a relatively small total of 1.9 million full-time civil servants, as of 1996. But, according to Paul Light, the true head count is nearly nine times higher than the official numbers, with about 17 million people actually providing the government with goods and services. Most are part of what Light calls the "shadow of government"-nonfederal employees working under federal contracts, grants, and mandates to state and local governments. In this book--the first that attempts to establish firm estimates of the shadow work force-- he explores the reasons why the official size of the federal government has remained so small while the shadow of government has grown so large.

Light examines the political incentives that make the illusion of a small government so attractive, analyzes the tools used by officials to keep the official headcount small, and reveals how the appearance of smallness affects the management of government and the future of the public service. Finally, he points out ways the federal government can better manage the shadow work force it has built over the past half-century.

This book is a collection of 18 essays by health services researchers that analyze Medicaid managed care, its historical context, its implementation in several states, its applicability to disabled and other special needs populations, and its potential for monitoring quality and provider performance.

Examines the provision of police and education services using a new method of indexing quantities of local public services that isolates movements in shadow prices and quantities in expenditure data. Effects of public services on public characteristics; Link between expenditures between 1982 and 1983 and quantities of education and in prices of public services.

The Budget 2000 Project recommends actions that will reduce the cost of government in New York by between $12.8 and $19.7 billion, amounts large enough not only to balance the budgets of the Two New Yorks, shift the local government costs of public assistance and Medicaid to the State, and fund salary increases for workers who assist in the restructuring, but still leave at least $9.3 billion to improve New York's competitiveness by investing in the infrastructure, enhancing services and cutting taxes.

Understanding more about the psychological state of persons notified of human immunodeficiency virus (HIV) infection is critical for designing notification and counseling programs that will have the most positive effect. Methods. The subjects were blood donors who had been notified of HIV infection by the New York Blood Center. A nurse elicited a medical history, performed a limited medical examination, and asked the subjects to complete a questionnaire that included questions about drug use, sexual behavior, and psychological characteristics. The subjects completed another questionnaire approximately 2 weeks later. Results. The average depressive symptom scores for both men and women were substantially higher than scores typically found in representative population samples. More than a quarter of the men and more than a third of the women reported seeking psychological or psychiatric services in the first few weeks following notification. Conclusions. Anticipating and meeting individuals' psychological needs may be necessary if HIV screening programs are to address effectively the needs of persons infected with HIV.

Suggests a method of indexing local public services using community characteristics to allow the isolation of movements in prices and quantities from expenditure data. Differences in individual production functions for commodities where both private goods and community characteristics are inputs of production; Impact of government activities on community characteristics and production.