世界経済・社会統計 = World development indicators

Trust: The Social Virtues and the Creation of Prosperity

With digital equipment becoming increasingly networked, either on wired or wireless networks, for personal and professional use alike, distributed software systems have become a crucial element in information and communications technologies. The study of these systems forms the core of the ARLES' work, which is specifically concerned with defining new system software architectures, based on the use of emerging networking technologies. In this context, we concentrate on the study of distributed systems which bring to life the vision of ubiquitous computing systems, also known as ambient intelligence.

반도체 공정 overview

The present report is submitted in response to General Assembly resolution 61/106, by which the Assembly adopted the Convention on the Rights of Persons with Disabilities and the Optional Protocol thereto. As requested by the Assembly, a brief overview of the status of the Convention as at 3 August 2007 is presented. The report also contains a brief description of technical arrangements on staff and facilities made necessary for the effective performance of the functions of the Conference of States Parties and the Committee under the Convention and the Optional Protocol, and a description on the progressive implementation of standards and guidelines for the accessibility of facilities and services of the United Nations system. Recent efforts of the United Nations and agencies to disseminate information on the Convention and the Optional Protocol are also described.

わかりやすい障害者の権利条約 : 知的障害のある人の権利のために = Convention on the rights of persons with disabilities

In 1978, when the Task Panel report to the U.S. President’s Commission on Mental Health emphasized the importance of improving health care and easing the pain of those suffering from emotional distress syndromes including loneliness, few anticipated that this issue would still need to be addressed 40 years later. In 2011, a meta-analysis on the efficacy of treatments to reduce loneliness identified a need for well-controlled randomized clinical trials focusing on the rehabilitation of maladaptive social cognition. We review assessments of loneliness and build on this meta-analysis to discuss the efficacy of various treatments for loneliness. With the advances made over the past 5 years in the identification of the psychobiological and pharmaceutical mechanisms associated with loneliness and maladaptive social cognition, there is increasing evidence for the potential efficacy of integrated interventions that combine (social) cognitive behavioral therapy with short-term adjunctive pharmacological treatments.

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Loneliness: Clinical Import and Interventions

Research on what has been termed global health is geographically uneven. Much of the published literature can be divided into two categories; that addressing issues which are truly global, such as climate change, pandemic influenza, and global health institutions and that addressing issues affecting low-income countries, especially those in sub-Saharan Africa and South Asia. By contrast, there is remarkably little on regions containing middle-income countries, such as the former Soviet Union, the Middle East and North Africa, and the Pacific Islands. Among middle- and low-income countries, a few, such as Bangladesh, Thailand, and Uganda, have been the subject of intensive research while others are almost absent from the literature.

In this study, we examine access to care and its determinants in the context of rapid and diverse change in the funding and delivery of health care in one of these neglected regions, the former Soviet Union, two decades after these countries gained independence. Each country has followed a different trajectory of health system change, and we seek to take a snapshot of access to services for those who believe they need care.

Now is an appropriate time to take stock. The first decade following independence involved a process of state building, as politicians struggled with a new reality in which the old political and economic dogma no longer applied. They all faced catastrophic financial problems and, in some, gross domestic product per capita has not yet returned to 1989 levels. Others recovered more rapidly, but this was often as a consequence of profits from oil, gas, and minerals that were concentrated in the hands of a few. Within the available resources countries varied in how much governments were willing to allocate to public budgets and, in turn, the priority they gave to the health budget (Kutzin, Cashin, and Jakab 2010) (Table 1). In those newly independent states most affected, the Semashko health system inherited from the Soviet Union virtually collapsed, as they were unable to raise the necessary funds, skilled health workers left, and pharmaceuticals and technology, now at world prices (or often higher, as the newly privatized distributors took their cut) became unaffordable (Rechel and McKee 2009). Some sought, with varying degrees of success, to implement new financing systems based on health insurance, while Azerbaijan, Belarus, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan essentially retained many of the features of the Soviet health system, although in the face of growing economic pressures (Figueras et al. 2004; Kutzin 2010). In many, out-of-pocket payments expanded to fill the space left by drastic reductions of state funds.



Table 1

Key Health System Indicators of the Study Countries (Various Sources, Most Recent Data Available)



They have also struggled to reform health care delivery, with health professionals coming to terms with new roles (Healy and McKee 1997) during the reconfiguration of an inefficient and increasingly obsolete health care estate (Healy and McKee 2002). There were many failures but also some successes, with a few countries managing to implement effective policies and achieve good results despite severe economic and institutional constraints (Kutzin, Jakab, and Cashin 2010; Rechel et al. 2011).

This period was extremely traumatic for those living in the region; they were plunged into uncertainty as the paradigm they had grown up with was abandoned (Field and Twigg 2000). New and unfamiliar institutional frameworks were put in place and those interacting with them had to learn the new rules (Lewis 2000). This was especially difficult for many users of health care, who inevitably include many of the most vulnerable in society who have the fewest economic and social resources.

A series of household surveys we conducted in eight former Soviet countries in 2001 as part of the Living Conditions, Lifestyles, and Health (LLH) project revealed the impact on ordinary people (Balabanova et al. 2004). In Belarus, which had rejected rapid economic reforms, people were still able to obtain health care without great difficulty (although it was clear even then that the same lack of reform was also causing the country increasingly to fall behind economically, raising questions about the sustainability of the system). By contrast, for those living in Armenia and Georgia, which in addition to more severe economic collapse had experienced major armed conflicts, the systems were clearly failing. Those who needed care were unable to obtain it and, when they were, largely paid out of pocket. Those who were already disadvantaged were experiencing the greatest problems.

In this study, we report the findings from a new wave of surveys undertaken in countries in this region in early 2010. Since our earlier surveys, things have changed considerably, although not in a consistent way. Most of the economies are growing, in some cases rapidly as a consequence of exploiting natural resources. However, the benefits have not been shared by all and while the share of households with income below the poverty line ($1.25 and $3) has fallen since the early 1990s, incomes are now much more unequal and inequalities continue to grow (World Bank 2010).

Many of the new institutions and practices introduced during the transition from socialism are now embedded in their societies, but reforms to health care financing have proven difficult to implement. Kyrgyzstan and Moldova (Kutzin, Jakab, and Shishkin 2009) have managed to introduce insurance systems with individual enrollment, risk pooling, and output-based payments, although some of these elements can be found in other countries (Kutzin 2010). People in the region now have much greater understanding about how their reconfigured health systems work, although the persistence of informal payments continues to create considerable uncertainty. Populations that were once isolated now have access to developments in the rest of the world, although not necessarily to the democratic systems they see elsewhere. Thus, we were unable to undertake surveys in Turkmenistan, where the government actively suppresses information on the health of its population (Rechel and McKee 2007), or Uzbekistan, which also seeks to control what is reported about it. Finally, the overall stability that has come about in the region remains susceptible to disruption, exemplified by our need to postpone our survey in Kyrgyzstan because of the civil disorder that erupted in early 2010 while the field work in Georgia was complicated in the aftermath of the conflict with Russia over South Ossetia and Abkhazia.

Our approach draws on the WHO framework that identifies the goals of a health system as not only to improve health but also to ensure responsiveness, fairness, and financial protection (WHO 2007). Access to necessary services is a core element of this concept and this is what we focus upon here. It is not possible, with only two studies only a decade apart, to attribute particular findings to specific reforms with any degree of certainty. Hence, our article is of necessity primarily descriptive.

Our focus is on a region of the world that has a number of specificities, in particular the historical legacy of communist rule for most of the 20th century, ending in political, social, and economic collapse. Nonetheless, we believe that some of our findings do have implications for countries elsewhere, including those emerging from major conflicts or large-scale political change.

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Health Care Reform in the Former Soviet Union: Beyond the Transition

The HiT profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The Ukrainian health system has preserved the fundamental features of the Soviet Semashko system against a background of other changes, which are developed on market economic principles. The transition from centralized financing to its extreme decentralization is the main difference in the health system in comparison with the classic Soviet model. Health facilities are now functionally subordinate to the Ministry of Health, but managerially and financially answerable to the regional and local self-government, which has constrained the implementation of health policy and fragmented health financing. Health care expenditure in Ukraine is low by regional standards and has not increased significantly as a proportion of gross domestic product (GDP) since the mid 1990s; expenditure cannot match the constitutional guarantees of access to unlimited care. Although prepaid schemes such as sickness funds are growing in importance, out-of-pocket payments account for 37.4% of total health expenditure. The core challenges for Ukrainian health care therefore remain the ineffective protection of the population from the risk of catastrophic health care costs and the structural inefficiency of the health system, which is caused by the inefficient system of health care financing. Health system weaknesses are highlighted by increasing rates of avoidable mortality. Recent political impasse has complicated health system reforms and policy-makers face significant challenges in overcoming popular distrust and fatigue in the face of necessary but as yet unimplemented reforms.

Ukraine: Health system review.

BACKGROUND: Research suggests that the prevalence of loneliness varies between countries and that feeling lonely may be associated with poorer health behaviours and outcomes. The aim of the current study was to examine the factors associated with loneliness, and the relationship between feeling lonely and health behaviours and outcomes in the countries of the former Soviet Union (FSU) - a region where loneliness has been little studied to date. METHODS: Using data from 18,000 respondents collected during a cross-sectional survey undertaken in nine FSU countries - Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine - in 2010/11, country-wise logistic regression analysis was conducted to determine: the factors associated with feeling lonely; the association between feeling lonely and alcohol consumption, hazardous drinking and smoking; and whether feeling lonely was linked to poorer health (i.e. poor self-rated health and psychological distress). RESULTS: The prevalence of loneliness varied widely among the countries. Being divorced/widowed and low social support were associated with loneliness in all of the countries, while other factors (e.g. living alone, low locus of control) were linked to loneliness in some of the countries. Feeling lonely was connected with hazardous drinking in Armenia, Kyrgyzstan and Russia but with smoking only in Kyrgyzstan. Loneliness was associated with psychological distress in all of the countries and poor self-rated health in every country except Kazakhstan and Moldova. CONCLUSIONS: Loneliness is associated with worse health behaviours and poorer health in the countries of the FSU. More individual country-level research is now needed to formulate effective interventions to mitigate the negative effects of loneliness on population well-being in the FSU. Language: en

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Loneliness: its correlates and association with health behaviours and outcomes in nine countries of the former Soviet Union.

The HiT reviews are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. At independence from the Soviet Union in 1991, the Russian health system inherited an extensive, centralized Semashko system, but was quick to reform health financing by adopting a mandatory health insurance (MHI) model in 1993. MHI was introduced in order to open up an earmarked stream of funding for health care in the face of severe fiscal constraints. While the health system has evolved and changed significantly since the early 1990 s, the legacy of having been a highly centralized system focused on universal access to basic care remains. High energy prices on world markets have ensured greater macroeconomic stability, a budget surplus and improvements in living standards for most of the Russian population. However, despite an overall reduction in the poverty rate, there is a marked urban rural split and rural populations have worse health and poorer access to health services than urban populations. The increase in budgetary resources available to policy-makers have led to a number of recent federal-level health programmes that have focused on the delivery of services and increasing funding for priority areas including primary care provision in rural areas. Nevertheless, public health spending in the Russian Federation remains relatively low given the resources available. However, it is also clear that, even with the current level of financing, the performance of the health system could be improved. Provider payment mechanisms are the main obstacle to improving technical efficiency in the Russian health system, as most budget funding channelled through local government is input based. For this reason, the most recent reforms as well as legislation in the pipeline seek to ensure all health care funding is channelled through a strengthened MHI system with contracts for provider payments being made using output-based measures.

Russian Federation. Health system review.

This analysis of the United Kingdom health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. It provides an overview of how the national health services operate in the four nations that make up the United Kingdom, as responsibility for organizing health financing and services was devolved from 1997. With devolution, the health systems in the United Kingdom have diverged in the details of how services are organized and paid for, but all have maintained national health services which provide universal access to a comprehensive package of services that are mostly free at the point of use. These health services are predominantly financed from general taxation and 83.5% of total health expenditure in the United Kingdom came from public sources in 2013. Life expectancy has increased steadily across the United Kingdom, but health inequalities have proved stubbornly resistant to improvement, and the gap between the most deprived and the most privileged continues to widen, rather than close. The United Kingdom faces challenges going forward, including how to cope with the needs of an ageing population, how to manage populations with poor health behaviours and associated chronic conditions, how to meet patient expectations of access to the latest available medicines and technologies, and how to adapt a system that has limited resources to expand its workforce and infrastructural capacity so it can rise to these challenges.

Erica Richardson

Papers

Health Care Reform in the Former Soviet Union: Beyond the Transition

Ukraine: Health system review.

Loneliness: its correlates and association with health behaviours and outcomes in nine countries of the former Soviet Union.

Russian Federation. Health system review.

United Kingdom: Health System Review.