The social sciences in health policy and practice

Sot Scr Med \ol 12 ?.o Pnnted ,n Gredt Bntaln

I I. pp IISi-1194.

1986

ilZT’-9536 Pergdmon

SECTION THE

SOCIAL

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Jcumdls Ltd

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SCIENCES IN HEALTH PRACTICE

POLICY

AND

GEERT VAX ETTEN’ and FRAM RUTTEN? ‘Staffbureau for Health Pohcy Development, Mmlstry of Welfare, Health and Culture. P 0 Box 439, 2260 AK Leldschendam and ‘Department of Health Economics. R~Jksunlvers~te~t Llmburg, P 0 BOY 616.6200

MD Maastncht,

The Netherlands

Abstract-In ttus paper the role of the social sciences m health pohcy and practice IS analysed The analylls focuses on the disclphnes of medical sociology and health econormcs. The authors attempt to descnbe the contribution of each of the two chsclphnes to health policy and health practice, firstly. be revle~mg their developments m the past two decades and secondly, by analysmg therr future perspecn\es Special attention m this descnption IS pald to the context of health policy It IS shown that there IS a prommencs of economists m present-day health servnzes research and the factors v,tuch are held responsible for this sltuatlon are analysed

INTRODUCTION

There IS evidence for a growing concern about the future mvolkement of the social sciences m health pohcy and practice. Clearly, the ways in which this concern has been expressed are different dependmg on the Issues Involved One of the central Issues IS the thorough reappraisal which sclentlfic research m general and social science research m particular IS undergomg m recent years after it had expenenced a tremendous growth smce the middle of the slxtles and the seventles As Blce [I] m his exhaustive review of the hterature on the utlhty of social science and health services research for pubhc pohcy indicated, the end of the seventles and the early elghtles marked the begmnmg of a stocktakmg by both policymakers and social sclentlsts to determme whether social science has m fact contributed materially to improved health pohcy Similar questlons can be raised from the point of view of health practice and an interesting example for the field of dental care has been gven by Davis [2] m his review of the impact of the social science on dentistry Another Issue which has been coming up recently IS the sometlmes severe cutbacks m fundmg for research m general and social science research m particular, due to the general reduction m government expenditure mcludmg for the health sector, which has caused pesslmlsm m the sclentlfic community about the future opportumtles for health research actlvltles Apart from concerns about the utility of the social sciences for health pohcy and practice on the one hand and about the restnctlon of research fundmg on the other hand, there 1s also some worry about the lack of orgamsatlonal strength and consequently of polttlcal Influence of the social sciences which otherwise could be used to mhlblt possible negative con-

sequences resultmg from the developments described above. In this paper we will present our view on the future mvolvement of social sciences m health pohcy and I I87

health practice, m particular m hght of the current health pohcy context m Western European countnes More specifically, we will provide separate descnptions for medlcal sociology and health economics In doing so we will for each dlsclplme bnefly analyse its role m health pohcy and practice m the past two decades and also analyse Its present posItIon m health research. From this analysis we will then descnbe the future perspectives for the two dlsclplmes and focus on the possible contnbutlon to health pohcles, dlstinguishing between three different levels of health policy: first, the natlonal level, second, the mternational level, and third, the developmg countries. In a concludmg paragraph we 41 present some issues for discussion In presentmg this case we will elaborate on the work of vanous authors, rn particular Blce [I] for the social science m general, Claus [3-j] and Cockerham [6] for medical sociology m Europe and the Umted States respectively No extensive reviews are aLalIable on the development of health economics

MEDICAL

SOClOLOC1

The development of medical sociology m Europe as well as m the United States has been thoroughly examined recently [3-61. It appears from these and other reviews that medlcal sociology is well established m a large number of countries. As Claus pomts out medical sociology m Europe ongmated from medicme, especially social medicine, whereas. according to Cockerham, the stimulus behmd the development of medical sociology m the Umted States came from academic sociology, and. unhke m Europe, was therefore linked with the mother dlsaplme. However, both authors consider the contemporary medical sociology, m both Europe and the Umted States, pnmanly as an apphed science Cockerham describes applied medlcal soc~olog>. as opposed to theoretical medical sociology, as “the use of soclologlcal knowledge and research methods to provide

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ETTE~ and

information useful to health practitioners m lmprovmg health care, health orgamsattons in providmg more effective services. and to policy-making bodies for the purpose of developmg programs and policies intended to improve health conditions m society” (p. 1513) In this view applied medical sociologists are required to produce work relevant to patient care, medical education or health policy and therefore have a supporting role m relation to health practice, medical educatton and health policy. Claus [5] argued that applied medical sociology has different connotatrons. “In some countries, the emphasis is on providmg descriptive and evaluative research as tools for dectsion-makers m health car2 in various European countries In other countries, it means a more utilitarian and mterventionist approach m shapmg government pohcy and social welfare. In still other countries, it means defining health pnonties and implementing health policy and planmng An extenston of the applied nature of European medical soctologies is its focus on pohcymaking” (p 1594) The question arises here to what extent medical sociology has, m fact, been orientated to health policy and health practice The growth of medical soctology has generally taken place in the middle of the sixties and during the greater part of the seventies Among the major factors which have mfluenced this growth are the following. First, and most important of all factors are developments which have taken place at the un[cerSltles The development of medical sociology has been strongly linked wtth the social medicine and pubhc health movement, particularly m Europe Its major role was to support medical education and to teach sociology to medical students In various countries, such as Belgrum, The Netherlands and United Kmgdom social sciences had already been accepted m medical faculties m the first half of the sixties, and their position was more firmly established after formal regulations for the mtroductton of behavioural sciences in the medical curriculum had been laid down as was the case from the second half of the sixties such as m the Umted Kmgdom m 1968 and m the Federal Republic of Germany m 1970 Even today two-thirds of medical sociolossts are employed by umverslties [3, p 391 Within medical faculties sociologsts were also given a responsrblhty for research actlvmes, both in strengthening the generally weak research expertise of medical staff members employed m the department of social medicine, general practice and soctal psychiatry or m carrymg out independent research work themselves. Thus medical sociologrsts have contributed considerably to the establishment of a research tradition in these departments of medical faculties. However, most of this research work of medical sociologists has been within the framework of a ‘social eptdemiology’ tradttion focusmg on social aspects of health and diseases, and to a less extent on health care practices such as concermng the doctor-patient relationship, health centres or other worksettings m general practice, and various mstltuttons of social medicine such as occupational health care. Moreover, studizs m health practices to which

FROS

RLTTEE\I

medical sociologists had devoted themselves. were of a rather small-scale type Second. aftsr medical sociology had acquired the academic status and thus became mstitutionaltsed, it was in a position to receive additional fundmg sources. especially from the government other than through regular budgets to umversrties This gocernment jitn&g of msdical sociological research has been a maJor enabling factor m the development of medical sociology in Europe [3] Hoaev2r, tt is worth analysmg the natur2 of government funding Involved and its consequsnces for the research onentation of medical sociology in more detail In a previous discussion of the orgamsation and financing of health services research we distmguished three main funding sources [7] (1) universities through their regular budgets usually allocated by the Department of Education, (2) special research fundmg orgamsations such as the Medical Research Council m the United Kingdom. the German Research Foundation (Deutsche Forschungsgememschaft) in the Federal Republic of Germany, the Pure Research organisation of Scientific (ZWO/FUNGO) m The Netherlands and (3) Departments of Health responsible for national health pohcy In all three sources, biomedical and chmcal research are by far the two largest fields of expenditure in medical rrsearch Funds for soctal medicine, health services research and social science ressarch represent only a minor proportton. Based on a survey of IO member states of the European Medical Reseach Councils in 1979/1950. Poikolamen [S] estimated the Medical Research Counctls’ expenditure m community medicine at between Z and I?‘, of their total expenditure It IS also important to stipulate, contrary to common beliefs. that the dominant position of biomedical research IS also reflected m the pattern of research expenditure of most government Departments of Health With regard to specific research funding orgamsations, which are claimed to have given a strong impetus to the development of medical sociology in a number of countries, there arises the question of the research orientation developed within this framework In a case study of the development of medical sociology in the Federal Republic of Germany, Claus reported about the fundmg of medical sociological research by the Deutsche Forschungsgememschaft m the second half of the seventies and about its special focus on research related to illness behaviour HOWever, an unanticipated consequence of the focus on illness behaviour was that another field of research m which the structure of health care stands as a central issue was neglected [A. p 1161 Similar tendencies can be observed from the policies of comparable research funding organisations in other countries, which favour research proJects that have a strong medical base, also in the fields of social medicine and medical sociology Therefore. medical sociological research carried out within this framework follows the same social epidemiology tradition as described before with regard to research carried out from the regular budget of the umvsrsitles Since health services research projects have tended to be and still are almost systematically neglected by these special research

The socral scrences rn health pohcy and practtce fundtng orgamsatrons, thts fundmg source has not grven an opportumty for medtcal soctologcal research on health pohcy and health care practice When dtscussmg the nature of the research funded by government Departments of Health, one has to take Into account the changes m health pohctes whtch have occurred over the passed two decades. Tradmonally, the maJor responsibtlity of government Departments of Health was the protection of pubhc health, and tt 1s only since the stxttes-along with the creatton of the Welfare State-that the emphasis m government health pohcy in most countnes shifted to the provtsion of health services. Gradually, government mterventron m the health sector Increased as IS expressed by the rapid expansion of legislation related both to the plannmg of health services and to the health msurance schemes to guarantee adequate access mto these servrces. As a result government funding from the Departments of Health m research also increased, particularly m favour of health and health servrces research. However, two observattons should be made on this point Frrst, until the late stxttes the Increased government research funding by Departments of Health was predommantly geared towards social aspects of health and tllness and health indicators, mcludmg for mental health, m hne with their dominant interest n-r public health Thus the mam research work funded by the Departments m that perrod can also be labeled as socral eptdemrology A second observatton 1s that the decade of the seventtes has wttnessed the expansion of government responsrbtlity for the provrston of health services, especially m the field of plannmg [9] and later also in that of cost contatnment. These developments have created a large demand for health services research throughout the seventies, but there is evidence from vartous countrtes that economtsts since then have been much more mvolved m this type of health pohcy oriented research than has been the case with socrologlsts In fact, only a few large-scale medtcal SOCIOlogtcal studies exist which have been carried out in past I5 years wtthm the framework of the national health polictes. No major role has been played by medical socrologtsts m Important public pohcy issues like decentrahsation and regronahsatton, the dtffusron and utthsatlon of medical technology [lo] and health mformatron systems Thts lack of pohcy orrentatlon m medical soctological research can also be illustrated by the account of Claus m her recent analysts of medrcal soctologrcal research actlvltres m Europe. Among the most common topics of research reported from the medical soctologrsts m Europe were rllness and disease (about 45%) health care dellvery and mstrtuttons (25%) and health occupations (I%<) On the other hand. only 57; of the medical soctologrsts claimed to be mvolved m research related to health systems, health pohcy and health planning. After having revtewed the development of medrcal sociology m the past two decades, It can be concluded that medical soaology has indeed shown a tremendous growth for example m the number of its professronals. in its expanston to a great number of countrtes. in Its pattern of instttutionalisation in urnverstties. m its volume and subjects of research,

IIS9

and also m the volume of fundmg However. some negative observatrons have also been made such as the strong medical base underlying its research, focusing on socral eptdemtology and small-scale health care practice problems, tts funding mechamsms which have reinforced this research pattern. and finally, its lack of orlentatlon to major pubhc health policy Issues. HEALTH

ECOVOMICS

Health economtcs can best be descrtbed as the drsciplme of economics apphed to the topic of health and health servrces [I I] There are only a few theoretical concepts developed wtthm health economics itself, but the maJortty of research acttvlttes consists of the apphcatton of techniques. developed wrthm the broad drsctplme of economtcs, to the health sector. The development of health economtcs 1s generally beheved to have begun with the appearance of Arrow’s classtc arttcle [l2]. He draws attention to the phenomenon of ‘the uncertainty of the consumer tn the market for medical care’, and develops from that an interesting apphcatton of welfare economrcs to the health services sector From that moment on a slow, but steady development of theoretical notions n-r health economics can be observed As interesting areas m this respect one could mention the human capital approach [I31 the agency role of physlclans [l4], the demand for and effect of health insurance [15, 161 and the measurement and valumg of health status [ 171. A perhaps even more important stimulus for the development of this dtsclplme has been the continuing growth m the share of health expendttures m the gross national product of nearly all countnes Not only the sharp nse m health expenditures, but also the problem with respect to financing these expenditures m times of economtc stagnation, presented economists wrth an interesting new area for acttvrttes It took however quote some time before a constderable number of economsts got interested m the health field. In the United States, Canada and the United Kingdom one may already speak of a 20-30 year old tradition m health economrcs In the Umted States much empirtcal, econometric, work in health economics has been produced especially m the seventtes [18], while m England ongmally welfare economrst were attracted to thts sector and later some emprncal work developed, especially m the field of cost benefit and cost effectiveness analysts. Outside these few countrres activtties were limited until the mtd seventies. And still the number of health economtsts acttve in research m Europe IS relatively small Since there IS no systematic research on the influence of health economtcs research on health policy and practice, we WIII try m thts contrlbutlon to constder a number of examples of the Impact made be specific prolects and try to derive some general conclustons from these examples We wtll first concentrate on the impact of health economtcs on health policy at a macro level, as, for example, IS developed at the government level In this respect economtsts benefit from the fact, that economic Issues m health have been predominant in the last decade Important toptcs have been developments wtth respect to

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GEERT\A\ ETTE~ and FR~W RLTTE~

financing health care mcludmg the introduction of budgeting. the necessity of priority setting and how to implement policy chotces, options for curbing the demand for health care, the control of technological developments in tht health sector and recently the debate on competition in health care vs strict government regulation With respect to all topics mentioned here we would like to claim that health economists have playsd an important role in the public debate about these issues and that health economics research has been relevant m choosing among options for health pohcy In recent years a number of countries have seriously considered radical changes in the way of financing then health care systems In the late se\enttss a public debate on the mtroductton of Nattonal Health Insurance was held m the United States Many influential economtsts, among which Feldstem, ex-chairman of the Board of Economic Advisors to the president, participated in this public debate At the time a considerable amount of mon2y was invested in health economics research, and the most breath takmg act in this respect was the substdy for the ‘Health Insurance Study’ of the Rand Corporation (30 mtlhon dollars) [15] We will come back to this study later In the same period the discussion m the United Kingdom was arising on the question, whether financing of the health care system should be revised and based on the concept of social insurance, as the National Health Servtce. which is financed out of general revenues, was thought to be rather mefficient Economic analysis on the basis of mternational comparison showed, that the National Health Service did rather uell in terms of cost control, and the conservative government decoded to abandon the topic Also with respect to the particulars of health care financing, economists have made considerable contributions To illustrate that one could point at a recent change m financing hospitals under the (btlhon dollar) Medicare programme tn the United States Under this programme hospttals are now paid on the basis of ‘Diagnosis Related Groups’, a system developed by economists m New Jersey Furthermore, one can pomt at the dominant role of economtsts with respect to the mtroduction of hospital budgeting in France and m The Netherlands Much emptrical economic research has been devoted to establishing relations between subsectors m health car2 and to identifying options for substttutlon between health care facilities in order to help determining prioritlzs in the health care sector Espectally in the early seventies many research proJects were aimed at developing models of the health care system, to be used for pohcy purposes Although new insights into the functioning of the health care system were derived from these proJects. their actual impact on health pohcy seems to have been limited Often governments did not hate the legal instruments to impose political priorities on the sector. and especially behavioural relations of key actors tn the sector, strongly dependent on financial mcentrvestructures. appeared to be resistant to change With respect to curb the demand for health care economists have paid much attention to the rff2cts of ‘cost sharing’ In this resp2ct the formidable input in

the ‘Health Insurance Study’ of tne Rand Corporation attracts most att2nnon This proJect consists of a large social expertment. under which people are offered different insurance policies to find out the effect of insurance on their health care consumption Many outstanding health economists are working on this proJect and the results are receiving aide attention [lj, 191 In The Netherlands, Van de Ven [I61 has analysed consumption patterns of pnvatsly insured consumers and hnked these with type and degree of cost shartng mcorporated in then insurance policies Since maJor results m this arsa of research have been acquired recently. one can not yet expect these to have an important mflusnce on current government policies There IS. however. an mcreasmg tendency to mcorporate elements of cost sharing in our social insurance systems within Europe [20] Our prediction is, that results of research on cost sharing WIII becomz mcreasmgly influential in government circles Most governments now have legal instruments to control and steer the diffusion of technological mnovattons, at least those which mvolve highly advanced technical equipment The Congress in the United States shows awareness of its responsibility in this respect and finances its Office of Technology Xssessment, which is very active in the field of health services In other countries steps ar2 made now to Insure, that policies with rsspect to ths introduction and diffusion of new technologies are sustamsd by thorough economtc analysis A final toptc. which IS bsmg debated vehemsntly among economists, IS the role of competition within health care [?I] From th2 begmnmg health economists have asked the question why the markst for health services does not produce accsptable results and how one should go about in undoing its deficiencies Outstde the United States. this debate IS not yet held at the political level. but the current sceps~s with respect to the potentials of government planning may alter this soon. It may be expected that economtsts, who are now nntiatmg studies on how to mcorporate market elements m resource allocatton tn the health care sector, will play an important role in advising goverments on this issue The impact of health econotmcs on health practice may be even more difficult to esumate than the impact on health pohcy Th2 economic management of health care mstitutlons and orgamsations se2ms to have improved considerably over the last decades More economists than sociologists ar2 active in day to day operations within health care units The mere effect that economists are playing an important role in managing the health care system is not sufTiclent to answer our question, the issue IS rather to establish whether economic techniques are frequently and properly apphed tn the various decisions on resource allocation in health practice Again. very few reports on thts matter are available A few developments however may provide some insight into the importance of using economic techniques m health practice In this respsct on2 can point to the increase of the for profit sector in the United States and Great Britain Most conspicuous is the Increase in the number of bsds in for profit hospitals and the extension of activities of for profit hospital

The social sciences in health policy and practice chams. Part of the success of these hospital chams IS clarmed to ongmate from the systematic application of economic techmquer to decisions on resource allocation m the hospttal sector But also outside the for profit sector economic tools are frequently used, e g. m relation to the development of competing orgamsattons such as Health Mamtenance Orgamsations. HMO-enrollment has grown at an average annual rate of 11% over the 1978-1983 penod [22]. The fact, that these and other competittve orgamsations use accountmg techmques more frequently, must have its influence on ‘traditional’ providers So tt may be expected, that economic analysts becomes more influencral in these environments. But also m government run systems, like the National Health Service m Great Bntam, economic analysis assumes a larger role This is stimulated by the government since decisions on resource allocation of a spectfic order of magnitude must be based on a thorough economic appraisal. Anne Ludbrook [23] undertook a small study to identify the situatton m which economic apprarsal should have been used but was not, and to obtain examples of attempts to use economic appraisal within the National Health Service and then degree of success It was concluded from the small survey, that indeed economic appratsals were undertaken although not frequently, and the author of the study was somewhat concerned about the quality of some of the economic appraisal exercises carried out. As a reason for the somewhat disappomting result it was pomted out that economrc appraisals are rather time consummg, and may therefore be less popular m management circles. Therefore, managers, who do not face strong mcentives to carry out economrc appraisals before taking decisions, may not use these techniques. In most health care systems important actors at the managenal level do not face clear mcentlves towards efficiency At the level of health care providers we seem to be still far from a sttuation, in which decision making IS systematically takmg into account economic aspects. There are expenments with chmcal budgetmg in England and Sweden, and orgamsatrons are being set up to promote mtegratron of economic and medical decrsion making, but we are still at the beginning of a development mto that direction. Recently, a scienttfic associatton for technology assessment has been mltlated, m whtch all relevant professtons are combmed, and this may perhaps mark the start of a development towards the mcorporation of economic elements mto medical dectsron makmg m day to day practice. Some general conclustons can be drawn Although the number of health economists active m research IS probably less than the number of medical soclologists, the former seem to have a more firm posttion m the health care sector than the latter. This may partly be explamed by the fact that many economists are working utthm the sector at various levels of dectsron makmg and this may foster the acceptabthty of research of economtc analysis Furthermore, economists have benefitted from the Increased attentton for cost contamment m health care It may be expected that economists will contmue to play an important role m the debate on how to develop and

1191

implement a policy towards a more efficient health care provision. It seems even more important, however, to increase the use of economtc principles m day to day medical practrce to really achieve efficiency, medical declston making must become also economtc decision making. In other words, an mtegration of medicme, epldemlology. ethics, soctology and economics should be founded to set standards of medical dectsion makmg Thus. the economists ~111 have to learn to cooperate utth other disclplmes and help to bndge cloughes between dlsciphnes. This ~111 by no means be easy. FUTURE

PERSPECIWES

In this paragraph we shall review the future perspectives of medical sociologrsts and health economists, both at the national and the mternattonal level. With regard to the national level we will draw the attention to the changes anticipated for the health sector and their possible tmphcattons for socral SCIence research. After that we will look into the posstble contribution of medical sociology and health economtcs to the acttvltles of the World Health Orgamsatron, especially m the European Region, and m those of the European Economic Community, as well as to health pohcy and practice in developing countries. The nattonal level In this section we ~111 look mto the changes that will likely occur m health policy and practice and their relevance for medical sociological and health economics research These changes will reflect the growmg awareness that the possibtlities for governments to determine developments within the health care sector are limited, that the effectiveness of medical care tends to decrease when investments m the health care sector increase at a fast rate, and that the responstbtltty of the ctvihans for their own health status and that of then relatives should be stressed. First, in vtew of these changes one can expect that governments will gradually shift the emphasis from health services to health conditions of the population. Moreover, studies show that the social and economic environment as well as hfestyles are among the main determinants of health The recogmtlon that health problems often ongmate m other sectors of society, has strong policy implications since It not only demonstrates the necessary emphasis on health promotion and prevention but also underlines the need for cooperation between different policy sectors such as employment, housmg and education m order to achieve an improved health status of populattons One major area of medical sociologrcal research should therefore be health promotion and disease prevention, patterns of hfestyle, the environmental contexts of health both in terms of the behavtour of populations and of the social structure of public admmlstration. Second, the focus on health will also affect the measures of intervention to the extent that more emphasis will be placed on the outcome of these measures Thus, major policy instruments applied to the health sector such as planning and management,

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GEERT LAL ETTES and FRAX RLTTE~

cost control and health information. will not only be dtrected to input measures as has been the dominant approach until today. but also to output measures In other words. more attention will be paid to the evaluation of health activities In terms of improved health Important tmphcattons for medical soctological research will be a greater concern for areas hke health status and health impact assessment, health indicators, health perceptions and patient satisfaction. For health economics research this opens a whole new and almost mexhaustable area for cost-effectiveness studies and assessment of new technologies, m which health economists must learn to cooperate with physicians and epidemiologists Third, the focus on health will also draw the attention of health workers and health policy-makers to specific groups of the population, m particular the emerging dependency groups [24] the elderly, the handicapped and the chronically ill, which have mcreased largely as unintended consequences of improvements m health and social conditions Research tmphcatlons for medical sociology m this field relate to important areas lrke the development of measurement tools for the assessment of the charactertsttcs and the needs of these groups of patients suffertng from physical and mental dtsabihttes and social handicaps, e g m terms of cogmtive, psychological and social functtonmg apart from physical functlonmg Economists and sociologsts together should analyse existmg support services m the community and evaluate experiments with new facilities for these groups As financial limits will be placed upon faciltttes for these dependency groups the cost-effectiveness of vartous support programmes will have to be assessed, which requtres new ways of data collecting m such manner that detailed consumptton data can be linked to mdivtdual patients But also the provision of health care itself yet needs a lot of attention from both dlsclphnes as tt 1s still far from being efficiently orgamsed and benefits are often distributed very unequally Apart from the topics for research mentioned above a promlsmg area is that of evaluating government policies m general and specific pohcy measures m particular. In the Umted States a tradition seems to have been estabhshed m the field of program and policy evaluation using sometimes elements of pohtical economics. Since major changes m some European health care systems are to be expected, this field calls for further exploration by both economists and sociologists It can be concluded that there will be changes in the research needs of the health sector, m which medical sociology and health economics can play an tmportant role In particular, these research needs will mcreasmgly be expressed by the policy-making mstltutions both at the national level and local, decentrahsed level. However, in order to guarantee the future mvolvement of medical sociology in health and health care research, the policy orientation of medical SOCIology needs to be strongly improved A second remark relates to the funding opporturnties for social science research. The focus on health rather than on disease, and more m particular the emphasis on the environmental context of health developments would also requtre constderable

changes m the orientation of research funding orgamsattons. especially in that more support should be given to the various disciplines of the health sciences In other words. It is not so much the total volume of resources available for medical and health research which IS of concern. but rather the funding mechanisms underlymg the research policies in the health sector The European level The WHO Regional Officefor Europe has been very active in bnngmg together health economists. health policy-makers and health practittoners m various workshops exploring economic issues m health care NOW a number of mternational research efforts are being undertaken and programmes on health economics teachmg are bemg set up [X] The Regional OBice has also initrated cooperanon with medical sociologists m a more structured way in 1980, when it brought together a group of medical sociologists The aim of the meetmg was to consider the contribution which soctologlsts might make to the decelopment and implementatton of the WHO regional programme with as its major components disease prevention and control, promotion of environmental health, development of comprehensive health services and, finally, research. planning and human resources and health mformatton. This programme has been developed within the framework of the regional strategy for attammg health for all by the year 2000 It is obvious that the WHO strategy also calls for a reorientation of medical research stnce the focus of policy IS on the social and environmental aspects of health, which requires the mvolvement of soctal science research apart from the traditional biomedical research Thus, a wide range of research areas can be identrfied for social science research related to issues hke health status especially the mequahty m health status of population groups. health mdicators, and health care for example in areas like primary health care, health care for the elderly, the handicapped and the chromcally ill, mental health care, health education, health systems research and research on how to foster a more meaningful participation m plannmg and declstonmaking At the orgamsatlonal level the cooperation with could be expanded m the scientists social following ways. the contmuatton of the parttclpatron of medtcal soclologtsts and health economrsts m the European Advisory CommIttee for Medical Research (EACMR), the mam advisory body on research to the Regional Committee In recent years the EACMR has taken n-ntlatrves m developing the research components of the regronal strategy and the regional programme, m promotmg the further development of the management and the structure of health pohcy research, and finally, m supporting the preparatton of textbooks on the methodology of health servfces research [27], the establishment of collaborating centres for medical sociology and health economics, the partlctpatton of medical sociologists and health

The soctal scrences in health pohcy and practice economtsts consultants

m the various programmes, or as researchers

etther

as

The begmnmg of the coordmatton of medical research at the level of the European Econorwc Commumr~ dates back to the early seventies when m 1972 a Commtttee on Medtcal and Public Health (CRM-Comite de la Recherche Medicale) was set up as the advtsory body to the Commisston. In 1978 the Counctl of >lnusters of Health allowed the nuttatton of medtcal and pubhc health research under the EEC-treaty. Smce then three multtannual programmes were set up, for the pertods 1978-1981 (first programme), 1980-1982 (second programme) and 1982-1986 (third programme). The overall atm of the programme IS to increase the effictency of the research efforts m the member states through the mobihsatton of avatlable research potential of parts of nattonal programmes and its gradual coordination at the EEC-level CRM IS supported by four working groups spectahsed m the following research areas. btomedtcal engmeenng, medical biology, eptdemtoiogy and health servtces research. In the past decade malor emphasis in the research activities of CRM has been on the medical and engineenng aspects, and tt was not until 1980 that the special aorkmg group on health servrces research was established In 1984 the first author of this paper was appomted chairman of this working group. Among the major research projects of the programme of the workmg group on health services research are the followmg. the evaluation of pre-, pen- and postnatal care delivery systems a comparative study into the blockages to pathways through the health and social servtces for the elderly; health and avotdable deaths, the evaluation of integrated noncommumcable diseases control and prevention programmes, an analysis of health plannmg systems; the study of cost contamment measures; health status assessment, the role of primary health care; the evaluation of residenttal versus community mental health servtces; and finally, three projects with regard to health technology assessment, one on the methodology of economic appraisal, another one of the regulatory mechamsms for the diffusion and control of medtcal technology, and the third one on the interand mtra-country vanations in the utilisation of medical technology. The research programme of the working group on health services research carned out since the beginmng of the eighties, has allowed the participation of medtcal sociological research centres m a variety of prolects Yet, the contnbution from medical soctologists to the research programme has been relatively small One of the reasons for this presumably is the predommance of medical dtsctplmes, mcluding from soctal medtcme, m this field of research. However, another important factor is the lack of professional commumcatton between medical sociologists of different European countries, a small interest m the cooperatton m common and international research acttvittes, the lack of an mternational network of medtcal soctological research centres and, finally, the absence of an mternattonal organisation of medical sociologists This great amount of ethnocentrism, for

1193

which Claus [3, pp 65, 841 has also found evidence, mhibtts the actual parttctpatton of medical sociologtsts m the mternattonal research work, not only wtthm the framework of the EEC, but also m that of the WHO. The de~elopmg countrres Health problems in the deueloprng countries have for a long time drawn the attention of social SCIenttsts, though considerable variations can be observed over the past four decades both m the type of dtsciplmes mvolved and the SubJects of research covered For example, Btbeau [28] in his revtew of the current and future issues for medical social scientists in developmg countries m general, and van Etten [29] m his analysts of the African literature have shown that until 1970 two broad categories of studies have predommated first. those concerning the indigenous medical systems, which has been the traditional field of anthropologists, and second, those related to social and cultural factors in health and diseases which subject has attracted the attention of medical investigators, apart from anthropologists, and later also sociologists. However, the emergence of pressing health problems m the developmg countries, the inadequate performance of then modem medical institutions which ortgmated from the colonial penod, as well as the functionmg of the broader pohttcal and social context m which the health system was operating after independence, called for a reorientation of the medical social sciences m developing countries. As from the mid seventies one can observe new approaches m medical social sciences applied to the problems in developing countries, and the major of these approaches relate to the followmg research areas: (1) the health status of the population which is interpreted as part of general political and soctoeconomic development; (2) the functtonmg of modern medical mstituttons which subject had almost been neglected amongst social scientists; (3) various aspects of the health systems, especially m the field of planning, and the evaluation of health policies [30], (4) the mdigenous systems of medicine, which recently has also been supported by the WHO. In this context, the participation is worth mentioning of social scientists m the UNDP/World Bank/ WHO Specral Programme for Research and Trarntng m Tropical Diseases, which has also established, in 1979, a scientific working group on social and economic research The two main research objectives of this working group are (1) to determine the impact of social, cultural, demographic and economic conditions on disease transmission and control; and (2) to promote the design and use of cost effective and acceptable disease control programmes and policies. In the implementatton of this programme, several research groups m social and economic research from African, Asian and Latm American countnes as well as Western countnes are mvolved. It can be concluded that at the mtematlonal level social scientists can contnbute considerably to the development and evaluation of health pohctes and health care delivery systems. However, their actual mvolvement will depend, among other things, on

GEERT VAV ETTE~ and FRAU RLTTE~

1 I94 thstr interest m mternatlonal onentatlon of their research to cope with the cornpetItIon of medical

and

health

cooperation, the pohcy and finally. their ability for fundmg

In the field

s

research 9

ISSUES FOR DISCUSSION

This paper raises a number of Issues which need further discussion Topics for such dlscusslon would include (1) How to enlarge the impact of medlcal sociology and health economics on health pohcy and practice3 How to increase the pohcy orientation of medical sociology and health economics? (2) How to influence pollcles of national medical research councils and of Departments of Health in order to increase the allocation to social science research? (3) How to orgamse internationally and how to get mvolved m mternatlona! research programmes and international research poilcy forums? (4) The study of health pohcy and practice call for a multi-dlsclplmary approach what problems can be foreseen m this respect and how can they be solved3 What does this mean for the infrastructure of research centres? (5) With regard to evaluation studies would it be possible to agree on a standard protocol for evaluating diagnostic and therapeutic routines as well as medical technology m health care provIsIon What tools have to be developed further? (6) Which research topics are important for fundmg seen from a societal point of view? What contnbutlons may be expected from health services researchers (both medlcal sociologists and health economists)? (7) Is there a need for fundamental research within both disciplines and what areas need to be covered m this respect? (8) Considering the lack of mformatlon on the development of health economics, there is a need for such reviews m various European countries; existing reviews of medical sociology may serve as an examp!e REFERENCES

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