Health Service Change and International Health DivideAuthor(s): Sarah CurtisSource: Area, Vol. 25, No. 2 (Jun., 1993), pp. 197-198Published by: The Royal Geographical Society (with the Institute of British Geographers)Stable URL: http://www.jstor.org/stable/20003286 .

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Annual Conference 197

The innovation proved an undoubted success: part of that can be measured by the fact that the media picked up and reported on the debate on energy policy and flagged the regional assistance debate as an issue on which they will report once the government's proposals are published; part of it was reflected in the liveliness of the debates. Perhaps more sessions at annual conferences should experiment with such short, snappy and provocative presentations, with the opportunity of having longer general discussions. Whatever, I am extremely grateful to the speakers for having made so much of the opportunity into which they were volunteered.

Brian Robson University of Manchester

Health service change and international health divide The sessions organised by the Medical Geography Study Group (MGSG) at this year's confer ence were 'International Health Divides' and 'Geographical Perspectives on Health Service Change'. The Chairpersons for these sessions John Giggs (Nottingham); David Phillips (Exeter); Ellen Cromley (Connecticut); Sarah Curtis (QMW, London) presided over the presen tation of papers covering a varied range of topics and countries as diverse as Nigeria, the USA,

Eastern Europe, Italy, Britain and Portugal, illustrating the world wide relevance of medical geography and the expansion of research in the field to academic institutions in many different countries. However, the majority of the papers focussed on more developed countries and on health care organisation and delivery rather than on the geography of health. Only two papers were particularly concerned with the health outcomes of health care policy or delivery. Irene Brightmere (Derbyshire College of Higher Education) discussed prevalence of a specific disease, leprosy, and the association with treatment and prevention programmes, particularly in Nigeria.

Graham Moon (Portsmouth) discussed comparative trends in standardised mortality ratios since 1970 in Eastern European countries. Both papers highlighted the value of analysis over time as

well as space to illustrate the association between socio-economic and political conditions and the performance of modern medicine in reducing avoidable morbidity and mortality. Both cases illustrated stagnation and indeed of worsening in health outcomes under certain political and socio-economic conditions. Changes in health around the world continue to demonstrate the fragility and reversability of health improvements associated with processes of development.

Both papers also stressed health differences between countries and the importance of equity as an issue in the geography of health at the international scale.

The other papers were primarily concerned with the geography of health care. The use of health care and its relationship with health service organisation accessibility and appropriateness for users were particularly stressed by Sarah Harper (Royal Holloway), who discussed the use of hospitals as an unofficial source of respite care for frail elderly people, and by Paula Margarido (Universidade de Coimbra) who contrasted use of care by an urban and a rural population in Portugal. The preoccupation apparent in many western countries with cost containment in health care rationalisation of health facilities, with prioritisation of alternative uses for health care resources, and the importance of market forces in health care systems were reflected in the other papers in this session. Mark Rosenburg (Queen's University, Kingston, Canada) analysed changes in Canada in the role of Federal and Provincial Government associated with' the end of the second most expensive health care system in the world ' and questioned the degree to which ' rationalisation ' of hospital resources had followed geographical variation in population needs.

Mark Exworthy (Southampton) also emphasised the changes in central/local relations in the British National Health Service associated with health service change and the purchasing role. His analysis of the shifts in responsibility for purchasing of health care demonstrated some of the geographical dimensions of health care restructuring including the significance of scale and degrees of decentralization. Cosimo Palagiano (Universita di Roma) illustrated the difficulty of developing hospital care in the underprovided southern region of Italy due to polarisation of the growing private health sector in northern areas. The tendency for concentration in the indepen dent health care sector (also observed in other countries) was exacerbated in the Italian case by

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198 Annual Conference

the influence of trades unions and of local political patronage as well as traditional southern perceptions of hospitals as undesirable places of ' last resort '.

Another aspect of concentration of health services was highlighted by Ellen Cromley (Connecticut) and Gary Hart (Washington), who both presented papers on the closure of rural hospitals in the USA, where a quarter of rural hospitals have operating difficulties and over 500 closed in the 1980s. Cromley pointed to the ' risk factors ' associated with likelihood of closure. Although in some parts of the US, state policies had encouraged measures to protect access to care for rural populations, her analysis concluded that the policies were consistent with an acceptance by policy makers of the impact of forces of competition in regional health care

markets. Gary Hart was strongly critical of the quality of the literature on rural hospital closures which is often used to justify the trend. He catalogued many deficiencies in this literature including a failure to illucidate the long run processes associated with these closures. He suggested that more emphasis on these processes might cast new light on the ' rationality ' of the centralisation observed. British medical geographers may take note if they share concerns that internal health care markets in Britain have the potential to lead to domination of the system by the larger and most competitive hospital institutions!

Emphasis on process was also highlighted by Brian Massam (York University, Canada). He noted the increasing importance being attributed in Canadian Health Policy to' traceability 'and ' replicability ' of decisions with an associated focus on accountability. Accountability in health care planning requires that attention is given to ensuring representation of less empowered

members of society in processes of collective choice. Gavin Daker-White (QMW, London) drew attention to this problem in the context of assessment of user satisfaction with non-residential agencies for drug users. A qualitative approach highlighted the lack of effective methodologies to assess consumer satisfaction when consumers have low expectations of services, limited under standing of the health system and low self esteem. Ethical problems are raised in selecting ' representative samples' of respondents in such studies and in collecting information on their

experience of services.

Issues of access to care, spatial resource allocation, territorial equity and geographical differ ences in health outcomes are not new in geography, and the papers in this session showed that they are as relevant as ever to the debates and challenges being encountered in health and health care world wide. Medical geographers do seem, however, to be questioning some aspects of the conventional approaches to these issues and emphasising particularly the importance of social and political processes associated with the inherently geographical dimensions of change in health and health care.

Sarah Curtis QMW, London

Uneven development and the countryside The full-day session of the Rural Geography Study Group at this year's annual conference had 12 papers reflecting a wide-ranging focus on the processes and outcomes of uneven development in the countryside of Britain as well as selected overseas instances. Reviewing the session as a

whole, contributors looked at both the economic and the social impact of development processes and were unfettered in their definition of development. Paul Cloke (Bristol), moderately con strained by the funding bodies of the Rural Lifestyles Project in the results that he could report, suggested that the rural problems of accessibility, deprivation and disadvantage had reached the status of truisms to which policy-makers paid lip service. Arguing that people in similar socio economic cirumstances and in the same areas experienced and perceived rural life in different ways, he suggested that a qualitative, cultural approach to rural research was needed to counter balance the quantitative assessments of rural life chances. An emphasis on how people in the countryside spend their lives was also apparent in the paper from Charles Watkins (Nottingham), which examined patterns of church attendance amongst Anglican and non-Anglican denomina tions in five English dioceses. An essentially empirical paper, the results form part of larger interdisciplinary project concerned with the rural church. Robert Gant and Nigel Walford's

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