Quality issues for the National Bowel Cancer Screening Program (NBCSP)

Purpose: This two-part research project was undertaken as part of the planning process by Queensland Health (QH), Cancer Screening Services Unit (CSSU), Queensland Bowel Cancer Screening Program (QBCSP), in partnership with the National Bowel Cancer Screening Program (NBCSP), to prepare for the implementation of the NBCSP in public sector colonoscopy services in QLD in late 2006. There was no prior information available on the quality of colonoscopy services in Queensland (QLD) and no prior studies that assessed the quality of colonoscopy training in Australia. Furthermore, the NBCSP was introduced without extra funding for colonoscopy service improvement or provision for increases in colonoscopic capacity resulting from the introduction of the NBCSP. The main purpose of the research was to record baseline data on colonoscopy referral and practice in QLD and current training in colonoscopy Australia-wide. It was undertaken from a quality improvement perspective. Implementation of the NBCSP requires that all aspects of the screening pathway, in particular colonoscopy services for the assessment of positive Faecal Occult Blood Tests (FOBTs), will be effective, efficient, equitable and evidence-based. This study examined two important aspects of the continuous quality improvement framework for the NBCSP as they relate to colonoscopy services: (1) evidence-based practice, and (2) quality of colonoscopy training. The Principal Investigator was employed as Senior Project Officer (Training) in the QBCSP during the conduct of this research project. Recommendations from this research have been used to inform the development and implementation of quality improvement initiatives for provision of colonoscopy in the NBCSP, its QLD counterpart the QBCSP and colonoscopy services in QLD, in general. Methods – Part 1 Chart audit of evidence-based practice: The research was undertaken in two parts from 2005-2007. The first part of this research comprised a retrospective chart audit of 1484 colonoscopy records (some 13% of all colonoscopies conducted in public sector facilities in the year 2005) in three QLD colonoscopy services. Whilst some 70% of colonoscopies are currently conducted in the private sector, only public sector colonoscopy facilities provided colonoscopies under the NBCSP. The aim of this study was to compare colonoscopy referral and practice with explicit criteria derived from the National Health & Medical Research Council (NHMRC) (1999) Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, and describe the nature of variance with the guidelines. Symptomatic presentations were the most common indication for colonoscopy (60.9%). These comprised per rectal bleeding (31.0%), change of bowel habit (22.1%), abdominal pain (19.6%), iron deficiency anaemia (16.2%), inflammatory bowel disease (8.9%) and other symptoms (11.4%). Surveillance and follow-up colonoscopies accounted for approximately one-third of the remaining colonoscopy workload across sites. Gastroenterologists (GEs) performed relatively more colonoscopies per annum (59.9%) compared to general surgeons (GS) (24.1%), colorectal surgeons (CRS) (9.4%) and general physicians (GPs) (6.5%). Guideline compliance varied with the designation of the colonoscopist. Compliance was lower for CRS (62.9%) compared to GPs (76.0%), GEs (75.0%), GSs (70.9%, p<0.05). Compliance with guideline recommendations for colonoscopic surveillance for family history of colorectal cancer (23.9%), polyps (37.0%) and a past history of bowel cancer (42.7%), was by comparison significantly lower than for symptomatic presentations (94.4%), (p<0.001). Variation with guideline recommendations occurred more frequently for polyp surveillance (earlier than guidelines recommend, 47.9%) and follow-up for past history of bowel cancer (later than recommended, 61.7%, p<0.001). Bowel cancer cases detected at colonoscopy comprised 3.6% of all audited colonoscopies. Incomplete colonoscopies occurred in 4.3% of audited colonoscopies and were more common among women (76.6%). For all colonoscopies audited, the rate of incomplete colonoscopies for GEs was 1.6% (CI 0.9-2.6), GPs 2.0% (CI 0.6-7.2), GS 7.0% (CI 4.8-10.1) and CRS 16.4% (CI 11.2-23.5). 18.6% (n=55) of patients with a documented family history of bowel cancer had colonoscopy performed against guidelines recommendations (for general (category 1) population risk, for reasons of patient request or family history of polyps, rather than for high risk status for colorectal cancer). In general, family history was inadequately documented and subsequently applied to colonoscopy referral and practice. Methods - Part 2 Surveys of quality of colonoscopy training: The second part of the research consisted of Australia-wide anonymous, self-completed surveys of colonoscopy trainers and their trainees to ascertain their opinions on the current apprenticeship model of colonoscopy in Australia and to identify any training needs. Overall, 127 surveys were received from colonoscopy trainers (estimated response rate 30.2%). Approximately 50% of trainers agreed and 27% disagreed that current numbers of training places were adequate to maintain a skilled colonoscopy workforce in preparation for the NBCSP. Approximately 70% of trainers also supported UK-style colonoscopy training within dedicated accredited training centres using a variety of training approaches including simulation. A collaborative approach with the private sector was seen as beneficial by 65% of trainers. Non-gastroenterologists (non-GEs) were more likely than GEs to be of the opinion that simulators are beneficial for colonoscopy training (χ2-test = 5.55, P = 0.026). Approximately 60% of trainers considered that the current requirements for recognition of training in colonoscopy could be insufficient for trainees to gain competence and 80% of those indicated that ≥ 200 colonoscopies were needed. GEs (73.4%) were more likely than non-GEs (36.2%) to be of the opinion that the Conjoint Committee standard is insufficient to gain competence in colonoscopy (χ2-test = 16.97, P = 0.0001). The majority of trainers did not support training either nurses (73%) or GPs in colonoscopy (71%). Only 81 (estimated response rate 17.9%) surveys were received from GS trainees (72.1%), GE trainees (26.3%) and GP trainees (1.2%). The majority were males (75.9%), with a median age 32 years and who had trained in New South Wales (41.0%) or Victoria (30%). Overall, two-thirds (60.8%) of trainees indicated that they deemed the Conjoint Committee standard sufficient to gain competency in colonoscopy. Between specialties, 75.4% of GS trainees indicated that the Conjoint Committee standard for recognition of colonoscopy was sufficient to gain competence in colonoscopy compared to only 38.5% of GE trainees. Measures of competency assessed and recorded by trainees in logbooks centred mainly on caecal intubation (94.7-100%), complications (78.9-100%) and withdrawal time (51-76.2%). Trainees described limited access to colonoscopy training lists due to the time inefficiency of the apprenticeship model and perceived monopolisation of these by GEs and their trainees. Improvements to the current training model suggested by trainees included: more use of simulation, training tools, a United Kingdom (UK)-style training course, concentration on quality indicators, increased access to training lists, accreditation of trainers and interdisciplinary colonoscopy training. Implications for the NBCSP/QBCSP: The introduction of the NBCSP/QBCSP necessitates higher quality colonoscopy services if it is to achieve its ultimate goal of decreasing the incidence of morbidity and mortality associated with bowel cancer in Australia. This will be achieved under a new paradigm for colonoscopy training and implementation of evidence-based practice across the screening pathway and specifically targeting areas highlighted in this thesis. Recommendations for improvement of NBCSP/QBCSP effectiveness and efficiency include the following: 1. Implementation of NBCSP and QBCSP health promotion activities that target men, in particular, to increase FOBT screening uptake. 2. Improved colonoscopy training for trainees and refresher courses or retraining for existing proceduralists to improve completion rates (especially for female NBCSP/QBCSP participants), and polyp and adenoma detection and removal, including newer techniques to detect flat and depressed lesions. 3. Introduction of colonoscopy training initiatives for trainees that are aligned with NBCSP/QBCSP colonoscopy quality indicators, including measurement of training outcomes using objective quality indicators such as caecal intubation, withdrawal time, and adenoma detection rate. 4. Introduction of standardised, interdisciplinary colonoscopy training to reduce apparent differences between specialties with regard to compliance with guideline recommendations, completion rates, and quality of polypectomy. 5. Improved quality of colonoscopy training by adoption of a UK-style training program with centres of excellence, incorporating newer, more objective assessment methods, use of a variety of training tools such as simulation and rotations of trainees between metropolitan, rural, and public and private sector training facilities. 6. Incorporation of NHMRC guidelines into colonoscopy information systems to improve documentation, provide guideline recommendations at the point of care, use of gastroenterology nurse coordinators to facilitate compliance with guidelines and provision of guideline-based colonoscopy referral letters for GPs. 7. Provision of information and education about the NBCSP/QBCSP, bowel cancer risk factors, including family history and polyp surveillance guidelines, for participants, GPs and proceduralists. 8. Improved referral of NBCSP/QBCSP participants found to have a high-risk family history of bowel cancer to appropriate genetics services.

Sir Neville Howse (VC), Private John Simpson Kirkpatrick and Private Martin O’Meara (VC) and their contributions to Australian military medicine

Medical personnel serving with the Defence Forces have contributed to the evolution of trauma treatment and the advancement of prehospital care within the military environment. This paper investigates the stories of an Australian Medical Officer, Sir Neville Howse, and two stretcher bearers, Private John Simpson (Kirkpatrick) and Private Martin O’Meara, In particular it describes the gruelling conditions under which they performed their roles, and reflects on the legacy that they have left behind in Australian society. While it is widely acknowledged that conflicts such as World War One should never have happened, as civilian and defence force paramedics, we should never forget the service and sacrifice of defence force medical personnel and their contribution to the body of knowledge on the treatment of trauma. These men and women bravely provided emergency care in the most harrowing conditions possible. However, men like Martin O’Meara may not have been given the same status in society today as Sir Neville Howse or Simpson and his donkey, due to the public’s lack of awareness and acceptance of war neurosis and conditions such as post traumatic stress disorder, reactive psychosis and somatoform disorders which were suffered by many soldiers during their wartime service and on their return home after fighting in war.

Non-motorized public transport : a global review and analysis of trends and issues

Over recent decades there has been growing interest in the role of non-motorized modes in the overall transport system (especially walking and cycling for private purposes) and many government initiatives have been taken to encourage these active modes. However there has been relatively little research attention given to the paid form of non-motorized travel which can be called non-motorized public transport (NMPT). This involves cycle-powered vehicles which can carry several passengers (plus the driver) and a small amount of goods; and which provide flexible hail-and-ride services. Effectively they are non-motorized taxis. Common forms include cycle-rickshaw (Bangladesh, India), becak (Indonesia), cyclos (Vietnam, Cambodia), bicitaxi (Columbia, Cuba), velo-taxi (Germany, Netherland), and pedicabs (UK, Japan, USA). --------- The popularity of NMPT is widespread in developing countries, where it caters for a wide range of mobility needs. For instance in Dhaka, Bangladesh, rickshaws are the preferred mode for non-walk trips and have a higher mode share than cars or buses. Factors that underlie the continued existence and popularity of NMPT in many developing countries include positive contribution to social equity, micro-macro economic significance, employment creation, and suitability for narrow and crowded streets. Although top speeds are lower than motorized modes, NMPT is competitive and cost-effective for short distance door-to-door trips that make up the bulk of travel in many developing cities. In addition, NMPT is often the preferred mode for vulnerable groups such as females, children and elderly people. NMPT is more prominent in developing countries but its popularity and significance is also gradually increasing in several developed countries of Asia, Europe and parts of North America, where there is a trend for the NMPT usage pattern to broaden from tourism to public transport. This shift is due to a number of factors including the eco-sustainable nature of NMPT; its operating flexibility (such as in areas where motorized vehicle access is restricted or discouraged through pricing); and the dynamics that it adds to the urban fabric. Whereas NMPT may have been seen as a “dying” mode, in many cities it is maintaining or increasing its significance and with potential for further growth. --------- This paper will examine and analyze global trends in NMPT incorporating both developing and developed country contexts and issues such as usage patterns; NMPT policy and management practices; technological development; and operational integration of NMPT into the overall transport system. It will look at how NMPT policies, practices and usage have changed over time and the differing trends in developing and developed countries. In particular, it will use Dhaka, Bangladesh as a case study in recognition of its standing as the major NMPT city in the world. The aim is to highlight NMPT issues and trends and their significance for shaping future policy towards NMPT in developing and developed countries. The paper will be of interest to transport planners, traffic engineers, urban and regional planners, environmentalists, economists and policy makers.

The researcher’s perspective on procuring public works projects

Purpose: As part of a comprehensive research study looking at implementing PPPs, interviews with experienced researchers were conducted to realize their views on private sector involvement in public works projects. Design / methodology / approach: Amongst these interviews, five were launched with academics from Hong Kong and Australia, and two were conducted with Legislative Councillors of the Hong Kong Special Administration Region (HKSAR) government. Findings: The interview findings show that both Hong Kong and Australian interviewees had previously conducted some kind of research in the field of PPP. The interviewees highlighted that “Different risk profiles” and “Private sector more innovative / efficient” were the main differences between projects that were procured by PPP and traditionally. Other differences include risk transfer. In a PPP arrangement the public sector passes on a substantial amount of the project risks to the private sector, whereas in a traditional case the public sector would take the largest responsibility in bearing these risks. Another common feature of the private sector is that they tend to be more efficient and innovative when compared to the public sector hence their expertise is often reflected in PPP projects. The interviewees agreed that the key performance indicators for PPP projects were unique depending on the individual project. The critical success factors mentioned by both groups of interviewees included “Transparent process”, “Project dependent” and “Market need”. Due to the fact that PPP projects tend to be large scaled costly projects, adequate transparency in the process is necessary in order to demonstrate that a fair selection and tendering process is conducted. A market need for the project is also important to ensure that the project will be financially secure and that the private sector can make a reasonable profit to cover their project expenditure. Originality / value: The findings from this study have enabled a comparative analysis between the views of researchers in two completely different jurisdictions. With the growing popularity to implement PPP projects, it is believed that the results presented in this paper would be of interest to the industry at large.

Innovative and entrepreneurial activity in the public sector : the changing face of public sector institutions

This paper investigates the elements which support innovative and entrepreneurial activity in New Zealand’s state owned enterprises (SOEs). An inductive case study design, involving interview data, textual analysis, and observation, was applied to three SOEs. Findings reveal that those aspects typically associated with entrepreneurship, such as innovation, risk acceptance, pro-activeness and growth, are often supported by a number of unexpected elements within the public sector. These elements include culture, branding, operational excellence, cost efficiency, and knowledge transfer. The implications are twofold. First, that innovative and entrepreneurial activity in the public sector can go beyond policy-making, with SOEs representing an important policy decision and sector of the New Zealand Government. And second, that the impact of several SOEs on international markets suggests competition on the global stage will increasingly come from both public and private sector organizations.

The impact of managers' characteristics on the use of public relations strategy : an exploratory study in Queensland schools

While previous positive and normative studies have focused on the role public relations should play in organisations and the need for management in all organisations to attend to public relations (Cutlip et al., 2006), there has been little discussion in the public relations literature on why or how managers choose to enact public relations strategies for their organisations. If the discipline of public relations is to cement itself as a management function, then researchers must gain a better understanding of managers themselves given that they are the ones who decide if and how public relations strategies should be employed in the organisation. This study has sought to explore evidence of a relationship between management characteristics and their impact on decisions managers make when choosing which public relations strategies to adopt in response to changes in the organisation’s operating environment. This exploratory research study has been conducted within a specific context of schools in Queensland, Australia. Queensland schools have been facing a number of changes within their operating environment due to changes in Federal funding models in Australia’s education system. This study used an exploratory, qualitative approach to understand the management characteristics demonstrated by managers in schools and how these have impacted on the selection of public relations strategies for responding to their changing and increasingly competitive environment. The unit of analysis for this research study was principals in State (government) schools and in non-government schools. Ten principals were interviewed from four different types of schools in Queensland – the more traditional, elite, private schools (GPS Schools); other Independent Schools; Catholic Schools; and State (or public) schools. These interviews were analysed for quantitative comparisons of the managers’ characteristics across the different schools (in terms of the number of principals in each age bracket, those holding postgraduate qualifications, years of experience etc.); and for qualitative data to provide a greater sense of their understanding of public relations. The 10 schools were selected within a geographic area from Brisbane’s inner city to its outer western suburbs to include an element of competition amongst those managers being interviewed. A detailed review of government, school and other public documents was also conducted to gain an insight into the environment in which principals made decisions about public relations strategy to respond to increasing competition. This study found support for the literature on the relationship between management characteristics and strategy. However, there was also variation in findings warranting further investigation of the literature on the relationship between management characteristics and strategy in a school setting. Key relationships found in this study were between: management characteristics themselves; age and the use of public relations strategies; and gender and the use of public relations strategies. There was also evidence of support for the literature linking the impact that the combination of managers’ age, education and experience had on the use of public relations strategies. While this study was exploratory in nature, it did reveal a number of areas that require further investigation to gain a deeper understanding of how and why managers choose public relations strategies as a response to changes in their operating environment. It also provided a different framework to gain a better understanding of managers’ understanding and support of public relations in schools, which, in conjunction with an analysis of their management characteristics, will hopefully allow public relations scholars and practitioners alike gain an understanding of how and why managers use public relations strategies.

The formation of, and change in, the psychological contracts of graduates entering the Queensland public sector

The workplace is evolving and the predicted impact of demographic changes (Salt, 2009; Taylor, 2005) has seen organisations focus on strategic workforce planning. As part of this, many organisations have established or expanded formalised graduate programs to attract graduates and transition them effectively into organisations (McDermott, Mangan, & O'Connor, 2005; Terjesen, Freeman, & Vinnicombe, 2007). The workplace context is also argued to be changing because of the divergence in preferences and priorities across the different generations in the workplace - a topic which is prolific in the popular culture media but is yet to be fully developed in the academic literature (Jorgenson, 2003). The public sector recruits large numbers of graduates and maintains well established graduate programs. Like the workplace context, the public sector is seen to be undergoing a transition to more closely align its practices and processes with that of the private sector (Haynes & Melville Jones, 1999; N. Preston, 1995). Consequently, questions have been raised as to how new workforce entrants see the public sector and its associated attractiveness as an employment option. This research draws together these issues and reviews the formation of, and change in, the psychological contracts of graduates across ten Queensland public sector graduate programs. To understand the employment relationship, the theories of psychological contract and public service motivation are utilised. Specifically, this research focuses on graduates' and managers' expectations over time, the organisational perspective of the employment relationship and how ideology influences graduates' psychological contract. A longitudinal mixed method design, involving individual interviews and surveys, is employed along with significant researcher-practitioner collaboration throughout the research process. A number of important qualitative and quantitative findings arose from this study and there was strong triangulation between results from the two methods. Prior to starting with the organisation, graduates found it difficult to articulate their expectations; however, organisational experience rapidly brought these to the fore. Of the expectations that became salient, most centred on their relationship with their supervisor. Without experience and quality information on which to base their expectations, graduates tended to over-rely on sectoral stereotypes which negatively impacted their psychological contracts. Socialisation only limited affected graduates' psychological contracts and public service motivation. The graduate survey, measured thrice throughout the first 12 months of the graduate program, revealed that the psychological contract and public service motivation results followed a similar trajectory of beginning at mediocre levels, declining between times one and two and increasing between times two and three (although this is not back to original levels). Graduates attributed these to a number of sectoral, organisational, team, supervisory and individual factors. On a theoretical level, this research provides support for the notion of ideology within the psychological contract although it raises some important questions about how it is conceptualised. Additionally, support is given for the manager to be seen as the primary organisational counterpart to the employee in future theoretical and practical work. The research also argues to extend current notions of time within the psychological contract as this seems to be the most divergent and combustible issue across the generations in terms of how the workplace is perceived. A number of practical implications also transpire from the study and the collaborative foundation was highly successful. It is anticipated that this research will make a meaningful contribution to both the theory and practice of the employment relationship with particular regard to graduates entering the public sector.

The determinants of multinational contractors' willingness to bid for Australian public sector major infrastructure projects : towards deploying the eclectic paradigm of internationalisation

Against a background of already thin markets in some sectors of major public sector infrastructure in Australia and the desire of Australian federal government to leverage private finance, concerns about ensuring sufficient levels of competition are prompting federal government to seek new sources of in-bound Foreign Direct Income. The aim of this paper is to justify and develop a means to deploying the eclectic paradigm of internationalisation that forms part of an Australian federally funded research project designed to explain the determinants of multinational contractors' willingness to bid for Australian public sector major infrastructure projects. Despite the dominance of the eclectic paradigm as a theory of internationalisation for over two decades, it has seen limited application in terms of multinational construction. It is expected that the research project will be the first empirical study to deploy the eclectic paradigm to inbound FDI to Australia whilst using the dominant economic theories advocated for use within the eclectic paradigm. Furthermore, the research project is anticipated to yield a number of practical benefits. These include estimates of the potential scope to attract more multinational contractors to bid for Australian public sector infrastructure, including the nature and extent to which this scope can be influenced by Australian governments responsible for the delivery of infrastructure. On the other hand, the research is also expected to indicate the extent to which indigenous and other multinational contractors domiciled in Australia are investing in special purpose technology and achieving productivity gains relative to foreign multinational contractors.

Thrown in the deep end : newcomers and public sector reform

Triggered by the continuing global financial crisis, most public administration systems internationally are reviewing their ability to meet public expectations in more challenging strategic environments, while satisfying the pressure from their political masters to drive down the costs of public administration. Consequently public sector organizations are under constant pressure to reform to meet not only the global economic challenges, but the need for more responsive government (Brown et al 2003). Doyle et al (2000) propose that organizational change is seldom well managed, but that the public sector faces greater difficulty in implementing corporate change than the private sector because of its unique environment, e.g. the need to deliver bureaucratically impartial outcomes. The scale of the changes required, and the constraints imposed by the context within which these changes need to occur, have intensified the need for capable public sector leadership and management. The types of capability required now extend beyond those typically required in public organizations through the efficiency drive of new public management. Acquiring these capabilities remains a key issue for public organizations. One challenge for public management, then, is leadership and management quality, including the need to recruit externally to refresh, re-energize and change the sector and its individual organizations as well as develop advanced skills among existing senior executives.

Legislating for sustainability: a framework for managing statutory rights obligations and restrictions affecting private land

The ad hoc growth of administrative controls on land use has produced an information management problem. Land registries face growing demands to record on the Torrens register particulars of rights, obligations and restrictions created under public law statutes, in order to reduce information costs, promote compliance and inform planning. As sustainable management of land and natural resources will require more legislative regulation, this paper proposes a framework of principles for the more coherent and consistent management of public law controls on private land use.

Efficient and secure self-escrowed public-key infrastructures

A self-escrowed public key infrastructure (SE-PKI) combines the usual functionality of a public-key infrastructure with the ability to recover private keys given some trap-door information. We present an additively homomorphic variant of an existing SE-PKI for ElGamal encryption. We also propose a new efficient SE-PKI based on the ElGamal and Okamoto-Uchiyama cryptosystems that is more efficient than the previous SE-PKI. This is the first SE-PKI that does not suffer from a key doubling problem of previous SE-PKI proposals. Additionally, we present the first self-escrowed encryption schemes secure against chosen-ciphertext attack in the standard model. These schemes are also quite efficient and are based on the Cramer-Shoup cryptosystem, and the Kurosawa-Desmedt hybrid variant in different groups.

Incentivising private health insurance through the income tax regime : Capitalising on behavioural models

The Australian income tax regime is generally regarded as a mechanism by which the Federal Government raises revenue, with much of the revenue raised used to support public spending programs. A prime example of this type of spending program is health care. However, a government may also decide that the private sector should provide a greater share of the nation's health care. To achieve such a policy it can bring about change through positive regulation, or it can use the taxation regime, via tax expenditures, not to raise revenue but to steer or influence individuals in its desired direction. When used for this purpose, tax expenditures steer taxpayers towards or away from certain behaviour by either imposing costs on, or providing benefits to them. Within the context of the health sector, the Australian Federal Government deploys social steering via the tax system, with the Medicare Levy Surcharge and the 30 percent Private Health Insurance Rebate intended to steer taxpayer behaviour towards the Government’s policy goal of increasing the amount of health provision through the private sector. These steering mechanisms are complemented by the ‘Lifetime Health Cover Initiative’. This article, through the lens of behavioural economics, considers the ways in which these assorted mechanisms might have been expected to operate and whether they encourage individuals to purchase private health insurance.

Effort-release public-key encryption from cryptographic puzzles

Timed-release cryptography addresses the problem of “sending messages into the future”: information is encrypted so that it can only be decrypted after a certain amount of time, either (a) with the help of a trusted third party time server, or (b) after a party performs the required number of sequential operations. We generalise the latter case to what we call effort-release public key encryption (ER-PKE), where only the party holding the private key corresponding to the public key can decrypt, and only after performing a certain amount of computation which may or may not be parallelisable. Effort-release PKE generalises both the sequential-operation-based timed-release encryption of Rivest, Shamir, and Wagner, and also the encapsulated key escrow techniques of Bellare and Goldwasser. We give a generic construction for ER-PKE based on the use of moderately hard computational problems called puzzles. Our approach extends the KEM/DEM framework for public key encryption by introducing a difficulty notion for KEMs which results in effort-release PKE. When the puzzle used in our generic construction is non-parallelisable, we recover timed-release cryptography, with the addition that only the designated receiver (in the public key setting) can decrypt.

The emerging role of private health care provision in China : a critical analysis of the current health system

China continues to face great challenges in meeting the health needs of its large population. The challenges are not just lack of resources, but also how to use existing resources more efficiently, more effectively, and more equitably. Now a major unaddressed challenge facing China is how to reform an inefficient, poorly organized health care delivery system. The objective of this study is to analyze the role of private health care provision in China and discuss the implications of increasing private-sector development for improving health system performance. This study is based on an extensive literature review, the purpose of which was to identify, summarize, and evaluate ideas and information on private health care provision in China. In addition, the study uses secondary data analysis and the results of previous study by the authors to highlight the current situation of private health care provision in one province of China. This study found that government-owned hospitals form the backbone of the health care system and also account for most health care service provision. However, even though the public health care system is constantly trying to adapt to population needs and improve its performance, there are many problems in the system, such as limited access, low efficiency, poor quality, cost inflation, and low patient satisfaction. Currently, private hospitals are relatively rare, and private health care as an important component of the health care system in China has received little policy attention. It is argued that policymakers in China should recognize the role of private health care provision for health system performance, and then define and achieve an appropriate role for private health care provision in helping to respond to the many challenges facing the health system in present-day China.

Early users of fertility treatment with hormones and IVF : women who live in major cities and have private health insurance

Objective: To identify early users (women aged <34 years) of fertility treatment with hormones and in vitro fertilisation (IVF). Methods: A cross-sectional survey of infertile women from fertility clinics (n=59) and from the community (Australian Longitudinal Study on Women's Health participants) who had (n=121) or had not (n=110) used hormones/IVF as treatment for infertility. Associations between socio-demographic, reproductive and lifestyle factors, medical conditions and recurrent symptoms and using treatment (or not) were analysed using multivariable logistic regression. Results: Among infertile women who had used treatment (community vs clinic), women from clinics had lower odds of living outside major cities, using hormones only, i.e., not IVF, or recurrent headaches/migraines, severe tiredness, or stiff/painful joints; and higher odds of recent diagnoses of urinary tract infection or anxiety disorder. Compared to infertile women who had not used treatment, women from clinics had lower odds of living outside major cities, recurrent allergies or severe tiredness; and higher odds of having private health insurance for hospital or ancillary services, recent diagnosis of polycystic ovary syndrome or recurrent constipation. Conclusions: Compared to infertile women in the community, living in major cities and having private health insurance are associated with early use of treatment for infertility at specialist clinics by women aged <34 years. Implications: These results provided evidence of inequity of services for infertile women.