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The utilization of the medical services and its relationship to morbidity, health resources and social factors
BOOKREVIEWS
403
There are obviously several sets of reasons, which would run something like this. As a method of evaluating difficult areas of linguistic function, the Semantic Differential appeals because it has a valid and theoretically sophisticated basis. Osgood did not look for an “instrument” which would satisfy some pseudo-scientific cannon, but for a method which would mirror a complex set of ideas about the importance of meaning in language in particular, and human behaviour in general. But, as well as that, it was a model of meaning whichfelt right. The symbolic processes in general had been having a pretty rough ride by psychologists up until this time. One was asked either to understand the delicate mysticism of the psychoanalytic theory of symbolism or else to be a Behaviourist Man and deny its importance-nay even its existence. Osgood’s approach had the rigour of the latter and the complexity of the former and so was assured of a qualified welcome. If something like this account is true, the success of the Semantic Differential is not at all surprising. Taken into account with the publishing of “Plans and the Structure of Behaviorl,” and the growth of interest in human communication, the Semantic DifferentiaI has contributed in no small way to the re-emergence of the symbolic process as an area of supreme importance in understanding human behaviour. It is only sad to add after all this that one of your reviewer’s contributions to the Semantic Differential method is included in the extensive bibliography-but with his name spelt wrongly. DOUGLASHOOPER, Ph.D. University of Bristol, Bristol, England.
THE UTILIZATION OF THE MEDICAL SERVICES AND ITS RELATIONSHIP TO MORBIDITY, HEALTH RESOURCES AND SOCIAL FACTORS by TAPANI PUROLA, KAI SIEVERS,ESKO KALIMO and KAUKO NYMAN. Research Institute for Social Security, Helsinki, 1968. PERSONSinterested in international health will find this English translation of a report first published in Finnish in 1967, a useful addition to the literature. Along with making information available on a nation not widely reported in English-speaking countries, it provides data for scholars interested in comparative study and research. The study was designed to obtain baseline data for a program of continuous research for health policy and planning in Finland following the implementation in 1964 of a sickness insurance scheme which broadened the previous program of national insurance for,hospital care to include physicians’ services, and general health care. It reports on health status and utilization patterns prevailing prior to the implementation of the sickness insurance plan. Subsequent studies are planned’ to gauge progress and problems in closing gaps and fulfilling national goals of equality of access to comprehensive high-quality health care. The report is organized into five parts. Part one deals with the objectives of the study. Part two provides an overview of the organization of the Finnish health system, along with supply and demand issues. Parts three and four report the results of a nationwide household
404
BOOK RFMEWS
interview survey of morbidity and utilization experiences. Part five contains a discussion of methodological and statistical considerations. Foreign readers will be especially interested in the brief description and analysis of the Finnish health care system found in part two. Finland is a parliamentary republic with central state administration operating through ministries and regional offices. For purposes of local administration the country is divided into 547 communes which, while supervised by the central government, possess considerable autonomy. Primary responsibility for initiating programs in health and other social services rests with the commune. As pointed out by the authors, “The fundamental tenet of the health services organization in Finland is the principle of local and regional responsibility”. The central governments maintain responsibility for overall planning, manpower training, and health statistics. While owned by local governments, hospitals are directly supervised by the central government. Hospitals are organized hierarchically according to levels of care. In terms of primary hospital services, the country is divided into 21 central districts with a population ranging from 100,000 to 950,000. Each district possesses a tertiary care hospital financed on a pooled basis by all of the communes in the district. Many districts also have one or more secondary or intermediate hospitals. The number of physicians in private practice is small. Private practice is largely part-time. Most physicians are employed by hospitals on a salary basis. Medical care outside of hospitals is primarily provided by public health physicians employed by the communes. Like many other countries, Finland has a severe shortage of physicians. The current ratio is one physician to 1300 inhabitants. The sickness insurance scheme covers all residents and pays for up to 75 per cent of the cost of health care. In addition, it provides compensation for 45 per cent of earnings lost due to sickness. Information reported on morbidity includes: (1) number of restricted activities days and days of bed confinement, (2) sickness causing bed confinement, (3) sickness giving rise to most recent visit to a physician, (4) prevalence of chronic conditions, and (5) prevalence of other sicknesses. Among other things, the results showed that rural residents experience more sickness than persons living in urban areas; women have more sickness than men, and the prevalence of sickness increases with age. Compared with data from the United States and Denmark, the relationship between sickness and age was found to be much stronger in Finland. The number of restricted activity days, was found to be greater for men than for women. This differs from both Denmark and the United States where the relationship is the reverse-i.e., women experience more restricted-activity days than men. Data reported on utilization includes: (1) utilization of health services by age, sex and residence, (2) sickness expenditures, (3) income, availability of care, and utilization of health services, and (4) sickness expenditures by income and distance to nearest physician. Generally speaking, the results showed that persons most in need of health care (the poor and persons living in rural areas) were less apt to get care than persons of less need. Utilization increased with age and was heavier for women than for men. Rural families were found to spend about 5 per cent of their income for health care as compared to 2 per cent for urban families. In Finland the cost of drugs appears to be a more important problem than in the United States. The cost of medicines accounted for 58 per cent of the out-of-pocket cost of Finnish families as compared with 24 per cent for United States families. Utilization of physicians’ care was found to increase with income, with decreasing distance to a physician, and with increasing number of physicians in place of residence. Low income families were found to use more prescription drugs than high income families. And length of hospital stay was found to increase with the supply of physicians and hospital beds.
BOOK
-VIEWS
405
Because responsibility for writing each of the parts varied among the authors, the report suffers in matters of organization and style. It is marked by considerable unevenness and inconsistency. As recognized by the authors, the report is somewhat fragmentary in structure and many sections are difficult to read. The language is heavily laced with social scientific and quantitative jargon, most of which, in the opinion of this reviewer, is unnecessary. Moreover, the original report was abridged considerably. Data on individual disease and family health care expenditures have been reduced and an analysis of intergovernmental problems in the organization of health services has been omitted in the translated edition. These changes are regrettable in that the subject matter cut back was perhaps the most interesting to readers in the United States and other English speaking countries. As it now stands, a disproportionate emphasis is given in the report to methodological and statistical issues, quite familiar to persons knowledgable about the operation of household-interview sickness surveys. It would have been better had much of the technical discussion been eliminated instead of the discussion on individual disease, family health care expenditures, and intergovernmental problems. While the document constitutes an important addition to the international health care literature, it is not recommended reading for anyone but persons with specialized interest and the fortitude for reading through technical reports. ROGER M. BATTISTELI.A, Ph.D. Cornell University, Ithaca, New York.
PRIVACY,
FREEDOM
AND
RESPONSIBILITY
by M. C. SLOUGHand CHARLESC.
THOMAS.232 pp., price not given. THIS timely book is published as a monograph in The Bannerstone Division of American Lectures in Behavioral Science and Law. The author, M. C. Slough, is presently engaged in the private practice of law and as a municipal judge in St. Marys, Kansas. Previously he served as Professor of Law and Dean of the University of Kansas Law School, and as Professor of Law at the University of Texas. The major theme of this book is the right to privacy, i.e. the right to be let alone. Such a seemingly simple theme, however, turns out to be extremely complex. This is so because while the need for privacy among mankind is universalistic, perhaps instinctually based, the meaning of privacy for individuals is particularistic. The poet Hesoid in “Works and Days” advises “Invite the man that loves thee to a feast, but let alone thine enemy”. Jefferson Davis in his first message to the Conferate Congress in March 1861 appealed, “All we ask is to be let alone”. In Part I of “Paracelus”, Robert Browning extols “Ay, tell the world”. In Part V of the same poem, one reads the lament “I give the fight up: let there be an end, a privacy, an obscure nook for me. I want to be forgotten even by God.” Privacy denotes many things. For Hesiod it meant not only the right to be away from your enemies, but also the right to be with those you love. Implicit in Browning’s work are at least two meanings. There is the right to share one’s hopes and sorrows with everyone. There is also the right to be completely and totally isolated--even from God. For Davis,
403
There are obviously several sets of reasons, which would run something like this. As a method of evaluating difficult areas of linguistic function, the Semantic Differential appeals because it has a valid and theoretically sophisticated basis. Osgood did not look for an “instrument” which would satisfy some pseudo-scientific cannon, but for a method which would mirror a complex set of ideas about the importance of meaning in language in particular, and human behaviour in general. But, as well as that, it was a model of meaning whichfelt right. The symbolic processes in general had been having a pretty rough ride by psychologists up until this time. One was asked either to understand the delicate mysticism of the psychoanalytic theory of symbolism or else to be a Behaviourist Man and deny its importance-nay even its existence. Osgood’s approach had the rigour of the latter and the complexity of the former and so was assured of a qualified welcome. If something like this account is true, the success of the Semantic Differential is not at all surprising. Taken into account with the publishing of “Plans and the Structure of Behaviorl,” and the growth of interest in human communication, the Semantic DifferentiaI has contributed in no small way to the re-emergence of the symbolic process as an area of supreme importance in understanding human behaviour. It is only sad to add after all this that one of your reviewer’s contributions to the Semantic Differential method is included in the extensive bibliography-but with his name spelt wrongly. DOUGLASHOOPER, Ph.D. University of Bristol, Bristol, England.
THE UTILIZATION OF THE MEDICAL SERVICES AND ITS RELATIONSHIP TO MORBIDITY, HEALTH RESOURCES AND SOCIAL FACTORS by TAPANI PUROLA, KAI SIEVERS,ESKO KALIMO and KAUKO NYMAN. Research Institute for Social Security, Helsinki, 1968. PERSONSinterested in international health will find this English translation of a report first published in Finnish in 1967, a useful addition to the literature. Along with making information available on a nation not widely reported in English-speaking countries, it provides data for scholars interested in comparative study and research. The study was designed to obtain baseline data for a program of continuous research for health policy and planning in Finland following the implementation in 1964 of a sickness insurance scheme which broadened the previous program of national insurance for,hospital care to include physicians’ services, and general health care. It reports on health status and utilization patterns prevailing prior to the implementation of the sickness insurance plan. Subsequent studies are planned’ to gauge progress and problems in closing gaps and fulfilling national goals of equality of access to comprehensive high-quality health care. The report is organized into five parts. Part one deals with the objectives of the study. Part two provides an overview of the organization of the Finnish health system, along with supply and demand issues. Parts three and four report the results of a nationwide household
404
BOOK RFMEWS
interview survey of morbidity and utilization experiences. Part five contains a discussion of methodological and statistical considerations. Foreign readers will be especially interested in the brief description and analysis of the Finnish health care system found in part two. Finland is a parliamentary republic with central state administration operating through ministries and regional offices. For purposes of local administration the country is divided into 547 communes which, while supervised by the central government, possess considerable autonomy. Primary responsibility for initiating programs in health and other social services rests with the commune. As pointed out by the authors, “The fundamental tenet of the health services organization in Finland is the principle of local and regional responsibility”. The central governments maintain responsibility for overall planning, manpower training, and health statistics. While owned by local governments, hospitals are directly supervised by the central government. Hospitals are organized hierarchically according to levels of care. In terms of primary hospital services, the country is divided into 21 central districts with a population ranging from 100,000 to 950,000. Each district possesses a tertiary care hospital financed on a pooled basis by all of the communes in the district. Many districts also have one or more secondary or intermediate hospitals. The number of physicians in private practice is small. Private practice is largely part-time. Most physicians are employed by hospitals on a salary basis. Medical care outside of hospitals is primarily provided by public health physicians employed by the communes. Like many other countries, Finland has a severe shortage of physicians. The current ratio is one physician to 1300 inhabitants. The sickness insurance scheme covers all residents and pays for up to 75 per cent of the cost of health care. In addition, it provides compensation for 45 per cent of earnings lost due to sickness. Information reported on morbidity includes: (1) number of restricted activities days and days of bed confinement, (2) sickness causing bed confinement, (3) sickness giving rise to most recent visit to a physician, (4) prevalence of chronic conditions, and (5) prevalence of other sicknesses. Among other things, the results showed that rural residents experience more sickness than persons living in urban areas; women have more sickness than men, and the prevalence of sickness increases with age. Compared with data from the United States and Denmark, the relationship between sickness and age was found to be much stronger in Finland. The number of restricted activity days, was found to be greater for men than for women. This differs from both Denmark and the United States where the relationship is the reverse-i.e., women experience more restricted-activity days than men. Data reported on utilization includes: (1) utilization of health services by age, sex and residence, (2) sickness expenditures, (3) income, availability of care, and utilization of health services, and (4) sickness expenditures by income and distance to nearest physician. Generally speaking, the results showed that persons most in need of health care (the poor and persons living in rural areas) were less apt to get care than persons of less need. Utilization increased with age and was heavier for women than for men. Rural families were found to spend about 5 per cent of their income for health care as compared to 2 per cent for urban families. In Finland the cost of drugs appears to be a more important problem than in the United States. The cost of medicines accounted for 58 per cent of the out-of-pocket cost of Finnish families as compared with 24 per cent for United States families. Utilization of physicians’ care was found to increase with income, with decreasing distance to a physician, and with increasing number of physicians in place of residence. Low income families were found to use more prescription drugs than high income families. And length of hospital stay was found to increase with the supply of physicians and hospital beds.
BOOK
-VIEWS
405
Because responsibility for writing each of the parts varied among the authors, the report suffers in matters of organization and style. It is marked by considerable unevenness and inconsistency. As recognized by the authors, the report is somewhat fragmentary in structure and many sections are difficult to read. The language is heavily laced with social scientific and quantitative jargon, most of which, in the opinion of this reviewer, is unnecessary. Moreover, the original report was abridged considerably. Data on individual disease and family health care expenditures have been reduced and an analysis of intergovernmental problems in the organization of health services has been omitted in the translated edition. These changes are regrettable in that the subject matter cut back was perhaps the most interesting to readers in the United States and other English speaking countries. As it now stands, a disproportionate emphasis is given in the report to methodological and statistical issues, quite familiar to persons knowledgable about the operation of household-interview sickness surveys. It would have been better had much of the technical discussion been eliminated instead of the discussion on individual disease, family health care expenditures, and intergovernmental problems. While the document constitutes an important addition to the international health care literature, it is not recommended reading for anyone but persons with specialized interest and the fortitude for reading through technical reports. ROGER M. BATTISTELI.A, Ph.D. Cornell University, Ithaca, New York.
PRIVACY,
FREEDOM
AND
RESPONSIBILITY
by M. C. SLOUGHand CHARLESC.
THOMAS.232 pp., price not given. THIS timely book is published as a monograph in The Bannerstone Division of American Lectures in Behavioral Science and Law. The author, M. C. Slough, is presently engaged in the private practice of law and as a municipal judge in St. Marys, Kansas. Previously he served as Professor of Law and Dean of the University of Kansas Law School, and as Professor of Law at the University of Texas. The major theme of this book is the right to privacy, i.e. the right to be let alone. Such a seemingly simple theme, however, turns out to be extremely complex. This is so because while the need for privacy among mankind is universalistic, perhaps instinctually based, the meaning of privacy for individuals is particularistic. The poet Hesoid in “Works and Days” advises “Invite the man that loves thee to a feast, but let alone thine enemy”. Jefferson Davis in his first message to the Conferate Congress in March 1861 appealed, “All we ask is to be let alone”. In Part I of “Paracelus”, Robert Browning extols “Ay, tell the world”. In Part V of the same poem, one reads the lament “I give the fight up: let there be an end, a privacy, an obscure nook for me. I want to be forgotten even by God.” Privacy denotes many things. For Hesiod it meant not only the right to be away from your enemies, but also the right to be with those you love. Implicit in Browning’s work are at least two meanings. There is the right to share one’s hopes and sorrows with everyone. There is also the right to be completely and totally isolated--even from God. For Davis,