Public health care systems in countries all over the world are confronted with increasing difficulties. The problems are mainly economic, but they also reflect difficulties of adaptation to changes both in society as a whole and within the health care services.

The atmosphere of a crisis results from internal struggles within the health care system and with other welfare and social services that face economical difficulties, while confronting accelerated demographical, social, technological, and cultural changes.

The situation is more acute because of the inability of modern society to provide the public health care system with resources (human and financial) according to the expectations that have developed in the welfare state since the end of World War II.

New welfare policy, adjusted to the changes that occur within the society, is needed. In this struggle, the public health services find themselves in the center of the discussion as one of the whole of public social services and in competition with other public welfare systems.

Economical and organizational problems are the most acute and attract a great deal of interest, and they are amply discussed in many articles and conferences. I shall not deal with them in this article.

The growing attention paid to the evaluation of health care has focused on hospitalbased techniques. Meanwhile, a variety of diagnostic, therapeutic, and administrative technologies have become important, though inadequately understood, additions to diverse health care settings outside of the hospital – notably ambulatory care centers, physicians' offices, and the home. This special section is devoted to an analysis of the technology used in these settings, particularly in the context of primary care.

This article examines technology in primary care and its implications for technology assessment. Following an overview of the primary care setting and the importance of medical technology to primary care providers, the article identifies the new decisionmakers in medicine who both direct and respond to technological change in primary care, focusing, in particular, on their needs for information on primary care technologies. Furthermore, new methodologic issues for technology assessors are posed and examined. Finally, the authors offer conclusions about the need for changes in technology assessment and speculate about its future in primary care.

This article enumerates and describes the wide range of sites at which primary care is now offered; analyzes the impact of diagnostic testing procedures used in locations outside the doctor's office, such as imaging centers, hospices, and nursing homes; and looks at the effect of this decentralization on patients and medicine.

An inventory of the availability of medical devices and laboratory tests at primary health care centers in Sweden is reported. The availability is shown to depend on a number of medical, economic, societal, and organizational factors describing primary health care. Technical performance of devices, risk management, and training of users need special attention with regard to these applications.

This article examines the ends to which technology are employed in the office practice of medicine. It argues that the types of decisions technology supports are of greater impact on how medicine is practiced over the long view than the actual technologies themselves. The more relevant the technologies are to the effectiveness of diagnosis and treatment, the more they drive the practice of medicine toward a standard endeavor. Similarly, technologies that make existing tests and procedures more efficient often reduce the skill level that is needed to provide care. The results of these forces coupled with the increasing administrative, economic, and regulating pressures lead to a diminished role for physicians unless a conscious effort is made to introduce technologies that enhance their unique and discretionary work with patients.

This article studies the issues surrounding the assessment of several home diagnostic tests. First, the authors review the current data and proper use of fecal occult blood and pregnancy tests. Second, they evaluate the roles of blood and urine glucose monitoring in the management of diabetes mellitus and home pressure monitoring in the management of hypertension. The authors conclude that while home measurement of blood pressure or blood sugar can be recommended to improve compliance with medical programs, home fecal occult blood testing, while helpful, has not been fully investigated.

The North Slope Borough (NSB) Telehealth Project involves the use of slowscan (freeze-frame video) and telephone communications between 7 small villages, a central 14-bed hospital, and a large urban hospital over 700 air miles away. The project is intended to improve the quality of health care in this remote rural area in northernmost Alaska. This article describes the initial testing stages of the project and discusses applications for use of this technology. It focuses on the technological potentials for bridging cultural and linguistic differences between health care provider and client and from provider to provider for enhanced primary health care.

This article surveys the gradual diffusion of diagnostic technologies into homes in Sweden. The author speculates on the advantages and prospective problems of home care. In addition, the article proposes some general guides to assure that new technologies provide genuine benefits for the patient.

The use of computers in primary care in the United Kingdom has developed without coordination. The present situation is described. The proposal is that policies for improving primary care will be enhanced by appropriate application of information technology. Benefits and obstacles are identified; practical proposals for effective development are listed.

This article is concerned with principles that might help to ensure that procedures and tools used in primary care are appropriate to people's needs and expectations. It urges attention, not first to technology, but to the broad range of purposes served by primary care and to the relevance of procedures to them. Other criteria for ensuring appropriateness are also proposed.

This article examines the meaning of appropriate technology in the World Health Organization's comprehensive definition of primary care. The author concludes that broad-ranging aspects of health maintenance, such as public health, personal lifestyles, and scientific research, as well as traditional diagnostic and therapeutic practices, need to be subjected to clear and careful scrutiny. It is vital that the results of these technology assessment studies be disseminated as widely as possible to both health care professionals and the public.

This article highlights some of th issues ralsed by technology and primary health care (PHC) in the Western lndustrialized world. The author contends that while technology assessment has been focused mostly on hospital-based technology, the wider scope of PHC demands comprehensive assessment projects that would examine virtually every aspect of public health.

This article presents an overview of technology assessment in the United States. The authors argue that while there are numerous institutions carrying out assessments, the United States requires an overall plan that would provide a national system for technology assessment. If technology assessment were more organized and systematized, the authors argue, it would be more efficient and would reach the public and the medical world effectively.

In 1977, in the middle of a protracted debate on the costs and methods of paying for health care, the federal minister for health established a Committee on Applications and Costs of Modern Technology in Medical Practice. In 1978, the committee produced its report, which reviewed a number of cost containment strategies, including the reduction or regulation of fees paid to medical practitioners for specific procedures. It recommended that a national panel be established to collect information on medical technology and advise on its introduction in Australia.

In 1982, the National Health Technology Advisory Panel (NHTAP) was created to identify and examine existing and emerging medical technology, to determine methods and priorities for assessment, and to make recommendations to the minister for health with respect to assessment and funding of new technology.

The French health system is a complex organization that has developed since 1945 as the result of a subtle combination of two fundamental principles: liberal medicine — the freedom of both the consumers and the producers of care, and solidarity — universal access to health care — embodied in a quasi-generalized system of health insurance (4).

Today, this balance, to which the French are uncontestably dedicated, appears to be precarious. It has gradually become apparent that the financing system—80% of which is based on mandatory deductions and is intended to guarantee the balance between freedom of choice and universal access — is not consistent with the dynamic of health expenditures. The growing costs of care, as witnessed by the increase of health expenses as a percentage of total household expenses from 4.5% in 1950 to 13.3 in 1985, has led to increased state control over the health care system since 1975.

Twelve federal agencies and one cross agency program spent roughly $2.7 billion in fiscal year 1987 in support of research and development in biotechnology, according to a report by the Congressional Office of Technology Assessment (OTA) that was released today. Federal support of biotechnology has increased every year since 1984.

The National Institutes of Health contributed by far the largest share of federal support, approximately $2.3 billion, or 84%; the Department of Defense, $119 million, the National Science Foundation, $93.8 million; the U.S. Department of Agriculture, $84 million, and the Department of Energy $61.4 million, OTA reports.

The average lifetime cost of care for AIDS patients in the Kaiser Permanente Northern California (KPNCE) is $35,054, according to a study released today by the Congressional Office of Technology Assessment (OTA).

The study was prepared for OTA by KPNCR, part of the Kaiser Permanente Medical Care Program, the nation's largest prepaid group practice health plan. KPNCR provides medical and hospital services to more than 2 million people in northern California-25% of the area's population.