Sheena Asthana

Community participation in HIV prevention: Problems and prospects for community-based strategies among female sex workers in Madras

The concept of strengthening community action within the context of HIV prevention is gaining popularity among health circles, with organizations such as gay volunteer groups in the U.S. providing positive evidence of the potential role of community participation in HIV/AIDS prevention and care efforts. Care must be taken, however, in assuming that participation can easily be achieved among all high-risk groups. This paper examines problems and prospects for participation in HIV prevention strategies among commercial sex workers (CSWs) in Madras. Based upon the experiences of a pilot project established by the Tamil Nadu State Government AIDS Cell and WHO, it finds that the organization of the commercial sex trade in Madras is not highly conducive to collective action. Identifying factors that have frustrated attempts to promote community-based strategies in the city, the paper suggests that this approach is unlikely to succeed unless there are significant changes to the institutional arrangements that keep sex workers in a position of subordination and exploitation.

Partnership Working in Public Policy Provision: A Framework for Evaluation

Partnership working has emerged as a key feature of New Labour’s approach to social policy. However, although the theoretical benefits of partnership have been well rehearsed, agencies charged with fostering partnerships lack “evidence” about how best to proceed in bringing about organizational change. This paper describes the development and implementation of a practical approach to capturing the strategies that can be used to establish, strengthen and sustain local partnerships. To this end, it presents a conceptual framework for the evaluation of partnership working and demonstrates the application of the framework to an investigation of partnership working in Cornwall and Isles of Scilly, and Plymouth Health action zones.

School Performance, School Effectiveness and the 1997 White Paper

ABSTRACT The rhetoric of the 1997 White Paper, Excellence in Education, appears to mark a ‘rediscovery’ of the role played by contextual factors in influencing the quality and performance of schools. Despite this, the policy initiatives outlined in the White Paper remain wedded to the idea that school improvement can take place largely independently of contextual constraints. This paper argues that this survival of a perspective more in keeping with New Right thinking reflects the continuing dominance of the School Effectiveness Research (SER) paradigm. Providing a methodological critique of SER, we argue that the focus on the use of prior attainment data in the measurement of the ‘value added’ by schools has deflected attention from studies of how patterns of school performance reflect underlying patterns of social advantage/disadvantage. Reviewing a growing body of work which demonstrates how schooling serves to reinforce existing patterns of social advantage, we conclude that genuine and widespread sch...

What works in tackling health inequalities? : pathways, policies and practice through the lifecourse

Introduction Part one: The research and policy context of health inequalities: Researching health inequalities The National Policy context Part two: Health inequalities pathways, policies and practice through the lifecourse: Early life and health inequalities: research evidence Early life: policy and practice Health inequalities during childhood and youth: research evidence Health inequalities during childhood and youth: policy and practice Inequalities in health behaviours and the life trajectories of children and youth: research evidence Inequalities in health behaviours and the life trajectories of children and youth: policy and practice Health inequalities during adulthood: research evidence Health inequalities during adulthood: policy and practice Health inequalites during older age: research evidence Older age: policy and practice Part three: Tackling health inequalities: developing an evidence base for public health: Towards a new framework for evidence based public health.

Geographies of need and the new NHS: methodological issues in the definition and measurement of the health needs of local populations

For a variety of purposes it is increasingly necessary to establish the health needs of local populations. Following a critique of existing proxies of need, this paper presents and evaluates an alternative which draws upon epidemiological evidence concerning the age, sex and social class distribution of morbidity in order to estimate the prevalence of specific conditions in designated populations. By way of demonstrating the insights to be gained through the use of these indicative prevalence rates, the paper considers the treatment of ischaemic heart disease in a sample of 539 practices and presents evidence regarding the significance of deprivation and rurality in determining health service use relative to needs.

What's in a number? Commentary on Gorard and Fitz's ‘Investigating the determinants of segregation between schools’

This paper seeks to critique the methodology utilized by Gorard and Fitz in their work on changing levels of social segregation between schools. Demonstrating the extent to which their ‘Index of Segregation’ is determined by overall levels of free school meal entitlement, this paper argues that their Index does not, as is claimed, reveal how patterns of school enrolment have changed over time. Their dismissal of the polarization hypothesis is thus contested on methodological grounds, but also with reference to both the wealth of previous, largely qualitative, studies cataloguing the detrimental consequences of marketization and our own conceptualization and empirical analysis of trends in free school meal entitlement. The paper concludes that, notwithstanding Gorard and Fitzs claims, the polarization debate is far from settled. The need to understand whether and how market processes advantage some individuals and groups at the expense of others remains of central policy significance.

Evaluating Partnership : The Role of Formal Assessment Tools

Partnerships are increasingly seeking tools that enable stakeholders to reflect on their own effectiveness, benchmark the status of their partnership and provide a framework for development. Drawing on the evaluation of two Health Action Zones, this article focuses on the use of one such formal assessment tool, adapted from the Nuffield Partnership Assessment Tool and the Verona Benchmark, to explore the contribution of formal tools to our understanding of partnership. It outlines some key methodological limitations and stresses the continued importance of an understanding of context alongside any measurement of partnership effectiveness. It is suggested that formal assessment tools can be extremely valuable in terms of the learning that can result both from the process itself and from the outcomes of the assessment. However, as a stand-alone device they are open to misinterpretation and unlikely to foster development other than in those partnerships prepared to invest the necessary resources in a broad-based evaluation.

The pursuit of equity in NHS resource allocation: should morbidity replace utilisation as the basis for setting health care capitations?

Although the English NHS has been described as a world leader in pioneering methods of distributing expenditure in relation to population needs, concerns about the legitimacy of using the current utilisation-based model to allocate health service resources are mounting. In this paper, we present a critical review of NHS resource allocation in England and demonstrate the feasibility and impact of using direct health estimates as a basis for setting health care capitations. Comparing target allocations for the inpatient treatment of coronary heart disease in a sample of 34 primary care trusts in contrasting locations in England, we find that a morbidity-based model would result in a significant shift in hospital resources away from deprived areas, towards areas with older demographic profiles and towards rural areas. Discussing the findings in relation to a wider policy context that is generally concerned to direct more health care resources towards the poor, the paper concludes by calling for greater clarity between the goals of health care equity and health equity. Whilst the former demands that the legitimate needs of demographically older populations for more health care resources are acknowledged, the goal of health equity requires real political commitment to resource broader social policy initiatives.

Schools, Pupils and Examination Results: contextualising school 'performance'

This article seeks to demonstrate the extent to which school-level performance in the General Certificate of Secondary Education (GCSE) is underpinned by variations in the socio-economic background of pupils. Using a postcode-census method of profiling the socio-economic characteristics of school populations, the study analyses the examination performance of 259 schools in 12 local education authorities (LEAs). Describing an Ordinary Least Squares (OLS) multiple regression model which accounts for 64% of between-school variance in the GCSE performance of non-selective schools, the paper concludes (1) that uncontextualised performance statistics are fundamentally flawed, and (2) that policies directed at school improvement must acknowledge and address underlying constraints on school performance.

Deprivation, demography, and the distribution of general practice: challenging the conventional wisdom of inverse care.

It is generally believed that the most deprived populations have the worst access to primary care. Lord Darzis review of the NHS responds to this conventional wisdom and makes a number of proposals for improving the supply of GP services in deprived communities. This paper argues that these proposals are based on an incomplete understanding of inverse care which underestimates the degree to which, relative to their healthcare needs, older populations experience low availability of primary care. Many deprived practices appear to have a better match between need and supply than practices serving affluent but ageing populations. However, practices serving the oldest and most deprived populations have the worst availability of all.