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An intriguing aspect of the current picture is that alliances are developing between the public and private sectors. In the past, the public county councils Sweden and Denmark and central hospital districts Finland have purchased certain elective surgical procedures particularly coronary bypass operations from the private Nordic hospital sector Saltman and von Otter, Although this volume may well grow in the new contract-based purchasing environment, a converse but complimentary trend also has begun to emerge. In Sweden, private insurers who want to expand their underwriting business have begun to negotiate contracts with publicly operated hospitals to provide inpatient clinical services for private patients Dagens Nyheter, e.

At least initially, the public hospitals expect to offer better amenities—private rooms, better food—but insist that they will maintain the same clinical services for public and private patients alike. Swedish hospitals, particularly in over-bedded Stockholm, appear to be interested because of the likely end of queues for elective procedures coupled with their need, as public firms, to attract additional revenue in order to remain open.

Current movement toward planned market models in the Nordic countries, although impressive in design, has yet to be fully tested in application. As the dates for implementation of several key proposals suggest, and the present soft character of many contracts further underscores, the final outcome of this reform process may not be known for some years. In particular, the extent to which the pursuit of heightened efficiency and performance is compatible with continued maintenance of social values like equity and comprehensiveness remains to be seen.

The capacity of contracting within publicly operated health systems to achieve efficiencies greater than the added transaction costs that accompany them also has yet to be demonstrated Saltman and von Otter, ; Bartlett, Whether unrestricted patient choice of physician and hospital can be maintained, should the contracting process evolve from soft to hard agreements, is another unknown. Further, insufficient regulation of private providers in Sweden suggests that some policymakers have not yet recognized that greater reliance on private health care providers will require much the same level of direct governmental oversight although different in focus in order to maintain acceptable standards of service.


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Major new initiatives also will be required to develop and disseminate information sufficiently detailed to enable patients to utilize their freedom to choose their provider effectively Saltman, The shift to contract-based or privately provided hospital inpatient services may affect the current high level of patient trust of physicians in the Nordic region and the consequent low level of malpractice suits.

Several additional factors loom on the policy horizon.

Recent decisions in Sweden July and Finland November to apply for membership in the European Community may have a variety of financial and organizational implications for their health sectors, reflecting an expected macroeconomic convergence concerning tax levels i. These externally generated pressures will likely be exacerbated by the current Northern European recession, particularly in Finland where a substantial structural adjustment following the loss of Eastern trade is expected to result in a 15 to 20 percent reduction in the national budget for health care Jansen, Another factor is the growing interest by fiscally hard-pressed Nordic governments, like national governments elsewhere in the industrialized world Organization for Economic Cooperation and Development, to be published , in off-loading a portion of current health care spending onto lower-level governments and onto private business and individual budgets.

This trend can be seen in recent Dagmer negotiations in Sweden and the projected 5-year phase-out of part of the Hiltunen block grant system in Finland, in increased copayments for primary care visits in Sweden and the current revisiting of this subject in Finland, in the elimination of occupational health subsidies to industry in Sweden, and, more long term, the establishment in Sweden of a national government inquiry to explore the feasibility of establishing a social insurance based financing system for health care.

Finally, it should be noted that the changes under way in the health sector also are beginning to be felt in other sectors of the social welfare system. Discussions about making the Swedish day care and educational system more responsive to parents also are taking place, and are likely to be replicated in Finland as well in Denmark, private schools and day care facilities already are administered as one part of the public system.

Thus, the conceptual issues under consideration in the health sector should be seen as part of a broader debate about renewing the entire social sector of the Nordic welfare state. Viewed in international context, emerging Nordic health care reforms are equally as important for what they will not change. In contrast with the ongoing debate about market mechanisms among policymakers in the United States, all mainstream health sector actors in the Nordic Region explicitly accept the highly delimited degree to which competitive forces can be appropriately applied to health care systems Saltman and von Otter, Among the elements of these three Nordic countries' health systems which will remain as before are the following:.

Universal access —All major political parties continue to be committed to the right of every citizen to receive comprehensive health services, and to do so independently of personal ability to pay for care. Predominantly public ownership —Despite rapid growth in some areas of private sector activity, the service delivery structure remains overwhelmingly public well over 90 percent, for example, in Sweden , and several reforms currently under way are intended to strengthen and reinforce the publicly operated system.

Single source financing —The introduction of competitive forces has been confined to the production side of the delivery system. What little interest exists in changing financing arrangements in Sweden is focused on developing a uniform social insurance system Federation of County Councils, , not a United States Enthoven and Kronick, or Dutch Dekker-style van de Ven, competitive financing structure. Expanded primary and preventive services —All national and regional Sweden and Denmark governments remain committed to expanding primary, preventive, and social care services, a commitment which will be reinforced by recent changes in the financial responsibilities of local political boards in Stockholm and Dalarna counties, and in Finland's emerging municipally-based contracting system.

The continued commitment to a socially responsible health system can be summarized by the following overview included by the Swedish Ministry of Health and Social Security in its proposal to establish a national commission:.

The Nordic reform process is very much in the initial phases of development. How present changes will play out and what final shape these new planned markets will take are yet to be determined. What is clear, however, is that major reform is under way, fundamental principles are by-and-large being preserved, the existing publicly operated systems are beginning to respond to the pressures they confront, and the outcome could well be stronger, more flexible, and more responsive publicly operated health systems in the Nordic region in the not-too-distant future. The author would like to thank all those who provided facts and figures for this article.

He is also indebted to Casten von Otter, Ilkka Vohlonen, and the Review's anonymous reviewers for their comments on previous versions of this article.


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  6. These stressed improvements in mortality and morbidity, health-related lifestyle changes, enhanced environmental monitoring and controls, and more comprehensive access to and participation in health services. Reprint requests: Richard B. Saltman, Ph. National Center for Biotechnology Information , U. Health Care Financ Rev. Richard B.

    Copyright and License information Disclaimer. Copyright notice. This article has been cited by other articles in PMC. Abstract Health care systems in Sweden, Finland, and Denmark are in the midst of substantial organizational reconfiguration. Introduction This article reviews current reform experiments and proposals that reflect the search for a new, specifically Nordic planned market approach to the delivery of health services.

    Searching for a new paradigm Health care systems in Sweden, Finland, and Denmark 1 are well reputed for their commitment to values of equity and social justice Anderson, Current reforms The present profusion of health reform projects and proposals in the Nordic countries can be grouped into two basic categories—changes taking place predominantly inside the existing publicly operated systems, and changes concerning predominantly the private finance or delivery of health services. Contracts Perhaps the most striking change in these three Nordic health systems is the growing emphasis on contracts inside the public sector.

    Cross-boundary initiatives As fully articulated welfare states, Nordic societies provide their citizenry with a wide range of social as well as health-related benefits. Patient choice A third set of reform initiatives in publicly operated Nordic health systems concerns the introduction of patient choice of physician and treatment site.

    Public sector physicians Reforms in the status of physicians in the Nordic countries reflect frustration with compensating doctors on a percent salaried basis. Private finance and provision The private sector has played only a very minor role in these three Nordic health systems for more than a generation. Future issues Current movement toward planned market models in the Nordic countries, although impressive in design, has yet to be fully tested in application.

    Among the elements of these three Nordic countries' health systems which will remain as before are the following: Universal access —All major political parties continue to be committed to the right of every citizen to receive comprehensive health services, and to do so independently of personal ability to pay for care. Acknowledgments The author would like to thank all those who provided facts and figures for this article. Footnotes 1 The absence of Norway and Iceland reflects the author's lack of empirical research experience in these two countries. References Anderson O. Can There be Equity?

    New York: Wiley; Stockholm: Federation of County Councils; a. Personal communication. Calltorp, J. Didricksen F. Funding and organization of health services and medical care. New York: Praeger; New England Journal of Medicine.

    Federation of County Councils. Stockholm: Federation of County Councils; Changing the Payment System of General Practitioners. Utrecht: Netherlands Institute for Primary Health care; A Strategy for Labor. Boston: Beacon Press; London: Institute for Economic Affairs; Health Series No. Remunerating General Practitioners in Western Europe. Aldershot: Avebury Press; Oxford: MacKeith Press; Health Statistics in the Nordic Countries: Organization for Economic Cooperation and Development.

    Stockholm: Arbetslivscentrum; Medborgarnas Makt.

    Rosenthal M. Growth of private medicine in Sweden: The new diversity and the new challenge. Health Policy. Economic incentives influence ecological restoration and depend on laws and policies in each country. Our analyses suggest that habitat types determine the methods of ecological restoration, whereas socio-economic drivers are more important for the decisions concerning the timing and location of restoration. To improve the understanding, planning, and implementation of ecological restoration, we advocate increased cooperation and knowledge sharing across disciplines and among countries, both in the Nordic countries and internationally.

    An obvious advantage of such cooperation is that a wider range of experiences from different habitats and different socio-economic conditions becomes available and thus provides a more solid basis for developing practical solutions for restoration methods and policies. Key words: economic incentives; habitats; land use pressure; northern Europe; regional scale; restoration efforts. If accepted for publication, your response will be hyperlinked to the article.

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    To submit a response, follow this link. To read responses already accepted, follow this link. The strategy could also provide data and tools for climate change adaptation work at the regional level where potential Nordic cooperation could make a difference compared to those efforts currently taking place e. A joint approach to climate change adaptation could also strengthen the Nordic position towards other regions e. Baltic Sea Region and countries e.