This article contributes to the limited empirical literature on the impact of decentralization on psychological wellbeing by investigating the hypothesis which signifies that shifts toward more fiscal decentralization in health services would be accompanied by improvements in health outcomes. Formulating a conventional public finance model applied to health care, this hypothesis is tested on a panel data of the Pakistan's provinces during the period 1990 to 2015. The empirical underpinning of the article suggested that the economic reforms of 2001 in Pakistan's healthcare sector, through fiscal decentralization, have imposed a substantial and positive influence on the effectiveness of the public policy in improving the healthcare outcomes over the examined period.
The COVID-19 pandemic has provided an ultimate testing ground for evaluating the resilience and effectiveness of federal and decentralized systems. The article analyses how the Spanish asymmetrical system of decentralization has responded to the pandemic, focusing on the management developed by the sub-central governments (Autonomous Communities) during the first two waves of the pandemic in 2020. The research, which is both quantitative and qualitative, employs multidisciplinary tools and information sources, analyzing and linking fiscal and budgetary sources with the available statistics and information on health. Although the health, economic and social crisis caused by COVID-19 has highlighted appreciable shortcomings related to the decentralized model of territorial organization - in questions of both regional financing and health management - the research concludes that decentralization has not per se been a handicap when confronting the pandemic in Spain.
While the health grants to local governments recommended by Fifteenth Union Finance Commission in the wake of Covid 19 pandemic lays emphasis on the trust-based approach to local governments and decentralization of health, the danger of Mission Creep can undo the potential and effectiveness of the grants to strengthen the primary health care sector. Lack of sensitization towards local governments; the misconception that local governments and its stakeholders are illiterate, weak and corrupt entities; absence of an institutional monitoring mechanism to conduct a follow-up of the recommendations made by the respective Finance Commissions; lack of co-ordination between various Ministries of union and state governments; and the erosion of cooperative federalism can all contribute to health grants falling prey to the vicious cycle of Mission Creep Syndrome.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Decentralization reforms through Direct Health Facilities Financing (DHFF) have empowered Health Facility Governing Committees (HFGCs) to participate in different governance aspects to improve service delivery at the facility level. However, there is little research on how empowered HFGCs perform in the context of the DHFF. The purpose of this study was to evaluate the functionality of HFGCs under DHFF in Tanzanian primary health care facilities that had variation of performance in 2018. To collect both qualitative and quantitative data, the study used a cross-section design. The study had a sample size of 280 respondents, who were chosen using a multistage cluster sampling technique from 32 primary health care facilities that were practicing DHFF. Data was collected via a closed-ended structured questionnaire, in-depth interviews with chairpersons of HFGCs, and Focus Group Discussions. To examine the functionality of HFGCs, researchers used descriptive and theme analysis. In the 2018-star rating assessment, the study discovered that HFGCs functioned well in both high and low-performing health facilities. When HFGCs from high-performing health facilities were compared to HFGCs from low-performing health facilities, it was discovered that HFGCs from the high-performing health facilities had comparatively high functionality. The functionality of HFGCs in Tanzania has thus been impacted by the DHFF context.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Abstract Background In Lower and MiddleâIncome Countries (LMICs), decentralization has dominated the agenda for reforming the organization of service delivery (LMICs). The fiscal decentralization challenge is a hard one for decentralization. As they strive to make decisions and use health facility funding, primary healthcare facilities encounter the obstacles of fiscal decentralization. LMICs are currently implementing fiscal decentralization reforms to empower health facilities and their Health Facility Governing Committees (HFGCs) to improve service delivery. Given the scarcity of systematic evidence on the impact of fiscal decentralization, this study examined the functionality of HFGCs and their associated factors in primary healthcare facilities in Tanzania that were implementing fiscal decentralization through Direct Health Facility Financing (DHFF). Methods To collect both qualitative and quantitative data, a crossâsectional approach was used. The research was carried out in 32 primary healthcare facilities in Tanzania that were implementing the DHFF. A multistage sample approach was utilized to pick 280 respondents, using both probability and nonprobability sampling procedures. A structured questionnaire, inâdepth interviews, and focus group discussions were used to gather data. The functionality of HFGCs was determined using descriptive analysis, and associated factors for the functioning of HFGCs were determined using binary logistic regression. Thematic analysis was used to do qualitative research. Result HFGC functionality under DHFF has been found to be good by 78.57%. Specifically, HFGCs have been found to have good functionality in mobilizing communities to join Community Health Funds 87.14%, participating in the procurement process 85%, discussing community health challenges 81.43% and planning and budgeting 80%. The functionality of HFGCs has been found to be associated with the planning and budgeting aspects p value of 0.0011, procurement aspects p value 0.0331, availability of information reports p value 0.0007 and Contesting for HFGC position p value 0.0187. Conclusion The study found that fiscal decentralization via DHFF increases the functionality of HFGCs significantly. As a result, the report proposes that more effort be placed into making financial resources available to health facilities.
Introduction. For solving problems connected with slowing down of economic growth and declining of social welfare level, it is advisable to develop and implement state measures based on the concept of inclusive sustainable growth and forsee building an effective system of public financial management. This stipulates the necessity of improvement of budget policy, the principles of functioning of state and local budgets, inter-budgetary relations and requires detailed monitoring of the consequences of the transformation of the budget system as a result of administrative and territorial reforms and decentralization reforms.Methods. Such general and special methods as analysis and synthesis, comparison, generalization, associations, analogies and others have been used in the study. The purpose is to assess the impact of transformation processes on the functioning of state and local budgets, identifying problems and outlining prospects for improving the budget system in the context of continuation of reformation of the public financial management system.Conclusions. As a result of assessing the consequences of administrative and territorial reform and decentralization reform on functioning of the budget system, it has been found that most reform measures are aimed at improving the quality and accessibility of public services. Given the feasibility of raising the efficiency of the public financial management system, the need in the following has been proved: to develop a budget policy strategy that would take into account the key objectives of inclusive sustainable development; introduction of strategic and medium-term budget planning; improvement of program and target budgeting; increasing the financial capacity of territorial communities; development of gender-oriented and participatory budgeting; increasing the level of transparency of public finance management.Discussion lie in finding the ways of improving the functioning of the budget system in the context of continuation of reformation of the public financial management system.
At the time of its inception, in 1978, prevention and primary care were set as fundamental pillars of the Italian National Health Service (NHS), emphasizing the collective and social dimension of health. These principles were progressively neglected over the following four decades. Marketization, managed competition and managerialization privileged the individualized, highly specialized healthcare services mainly provided in hospitals, to the detriment of local outpatient and primary care services. After 2008â09, austerity policies exacerbated this situation determining under-financing as well as structural and staff shortages, while increasing tensions arose between the central government and Regions in the decentralized NHS. In 2020â21, the pandemic highlighted these critical issues. The need to develop a universal and strong outpatient, primary and community care system became evident in order to ensure the appropriateness and quality of foundational health services. This requires the State to play a more prominent role in the NHS governance.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Abstract Background: Decentralization has dominated the agenda for the reforms of the organization of service delivery in Lower and Middle-Income Countries (LMICs). Decentralization faces a formidable challenge of fiscal decentralization in primary healthcare facilities. Of now, LMICs are implementing fiscal decentralization reforms to empower health facilities and their Health Facility Governing Committees (HFGCs). Given the paucity of the impact of fiscal decentralization, this study was conducted to assess the functionality of HFGCs and their associative factors in primary health care facilities implementing fiscal decentralization through Direct Health Facility Financing (DHFF) in Tanzania. Methods: A cross-sectional design was employed to gather both qualitative and quantitative data. The study was conducted in 32 selected primary health facilities implementing DHFF in Tanzania. Probability and nonprobability sampling procedures were employed, in which a multistage sampling procedure was used to select 280 respondents. Data were collected through a structured questionnaire, in-depth interviews and focus group discussions. Descriptive analysis was employed to determine the functionality of HFGCs and binary logistic regression was employed to determine associated factors for the functionality of HFGC. Qualitative analysis was done through thematic analysis. Result: HFGC functionality under DHFF has been found to be good by 78.57%. Specifically, HFGCs have been found to have good functionality in mobilizing communities to join Community Health Funds 87.14%, participating in the procurement process 85%, discussing community health challenges 81.43% and planning and budgeting 80%. The functionality of HFGCs has been found to be associated with the planning and budgeting aspects p-value of 0.0011, procurement aspects p-value 0.0331, availability of information reports p-value 0.0007 and Contesting for HFGC position p-value 0.0187. Conclusion: The study has revealed that fiscal decentralization through DHFF significantly improves the functionality of HFGCs. Therefore, the study recommends more effort be put into facilitating the availability of finances to the health facilities.
The paper analyzes the main aspects of the organization and support of territorial communities in the field of social security of the population of Ukraine. The main directions of development of the process of providing social services are outlined. The main instruments of budget financing of social protection and social security of the population of Ukraine are determined and the effects that affect the volume of expenditures of the State and Consolidated budgets on the social sphere are investigated. The existing problems in the field of social security are studied and the need to harmonize social standards with the standards of the European Union is emphasized. The thesis is put forward on the need to implement a number of measures for Ukraine's timely response to the sharp increase in socio-economic needs in the global crisis. Emphasis is placed on the problems and prospects for the development of social security in the decentralization process. The range of problems for the effective response of social policy to rapid changes in the development of the modern world economy is outlined. The necessity of the analysis of the EU experience in the field of social security and the need to adapt the best European practices in order to comply with the Western European models of social protection and / or social insurance is substantiated. The need to apply the tools of theoretical and methodological analysis of the conceptual foundations of sustainable development of social security to specific circumstances and realities in Ukraine. The study focuses on the relevance of strategic and operational objectives of the new Law of Ukraine "On Social Services" and the need for further harmonization of existing legislation with the basic standards of the Council of Europe and the European Union.
Ensuring the social welfare of societies is closely related to the type and manner in which governments use fiscal policies. In this regard, the main purpose of this study is to investigate the effects of fiscaldecentralization (income and expenditure) on social welfare. For this purpose, based on 30 provinces of Iran dataâs during the 2005-2017 period, first the variables affecting welfare have been identified and the social welfare index for the provinces has been calculated, then the effects of decentralization have been investigated using the generalized method of movements for Income and expenses on the welfare index. The results of the model estimations, indicate a direct relationship between income and expenditure decentralization with social welfare, but with further increase in decentralization, this relationship has become negative and this indicates the instability of the fiscal situation in improving social welfare and has led to further increase in decentralization, this relationship becomes negative. Therefore, increasing decentralization and delegating more development projects to the provinces does not increase welfare, but also, first the necessary infrastructure for delegating affairs to the provinces, the power of self-government of the provinces should be evaluated, then with independence in Finance, we should expect the realization and improvement of social welfare in the provinces.
expenses for hospitalized patients with chronic liver disease (CLD) poses an economic challenge on affected household in the form of catastrophic health expenditure (CHE), distress financing and impoverishment. OOP Expenses data for hospitalized CLD patients from Bangladesh is scarce. This study aimed to estimate the OOP expenses and resulting CHE, distress financing and impoverishment among hospitalized patients with CLD. This cross-sectional study was conducted among conveniently selected 107 diagnosed CLD patients admitted at Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) aged 18 years and above. Data were collected from the respondents using a semi-structured questionnaire through face to face interview during discharge from hospital. Out of pocket expenditure for chronic liver disease in selected hospitals was Bangladeshi Taka (BDT) 19,262. Direct medical, direct nonmedical and indirect cost was BDT 16,240; 2,165 and 1,510, respectively. Investigation cost and medicine cost contributed to 48.48% and 31.81% of the total OOP expenses, respectively. At 10% threshold level, 29% of the respondents were affected by CHE. 64.5% of the respondents were facing distress financing due to OOP expenses. Among the respondents, 1.9% slipped below the international poverty line of $1.90 (BDT 161.10, in 2019).There was statistically significant (p < 0.05) difference among the mean OOP expenses for different etiological types of chronic liver disease. The study concluded that it requires establishing a more accessible and affordable decentralized health care system for CLD treatment along with the implementation of financial risk protection.
The article deals with the impact of the COVID-19 pandemic on the financing of the health care system, and the main challenges to the stability of the financial mechanisms of post-pandemic health care development have been identified. The author substantiates the peculiarities of the crisis of health care financing in the conditions of the current pandemic, further economic recession and decreased fiscal sustainability. The global practice of fiscal response to the manifestations of the COVID-19 pandemic has been systematized and the volumes of the corresponding financing in the countries with insurance and budgetary systems of health care financing have been estimated. The article identifies mechanisms for the transformation and expansion of the fiscal space in the context of expanded financing of the growing need for medical care in the face of new epidemic risks in different countries. Most often, the expansion of a country's fiscal space is carried out by: redistributing the existing amount of government expenditure for health care and redirecting funding flows from financing certain types of medical care to financing programs to overcome and combat COVID-19; changes in the priority of government health expenditure to combat COVID-19 compared to other budget expenditures on the social sphere and economic development; and using national reserve funds and emergency funds. It has been found that in the field of health care, the vast majority of countries have reduced the economic and territorial deprivation of all population groups in access to the diagnosis and treatment of COVID-19. The author emphasizes the weaknesses of insurance based and decentralized health financing mechanisms to respond to the growing need for health care and financial stability during the pandemic. Substantiated the necessity to expand the fiscal space needed to cover the fiscal gap in Ukraine caused by the requirement to increase health care financing in response
This empirical study addresses the role of economic and institutional determinants on population health, estimated by life expectancy and accessibility to good quality medical services. Several national health systems are described descriptively and analytically. The practical application considers 30 European countries for which data on all necessary variables are available. The data are provided by international institutions such as the World Bank, Insurance Europe, Global Health Security and national institutions from the sampled countries. The results of the OLS cross-country regressions clearly demonstrate the positive role of health financing and the decentralization of the national health system. Instead, the role of private health insurance remains debatable, as does its complementarity or substitutability in relation to public funding. Based on the main results, recommendations are formulated regarding possible adjustments for an increased efficiency of the medical system and possible future research directions, especially regarding the role of the financing structure and the type of decentralization of the medical services.
In the implementation of decentralization, the Special Allocation Fund (DAK) for health is given to certain areas of Indonesia to support health financing. The performance of this financing, along with national health development prioritiesâ achievements, is illustrated through the indicators of coverage of deliveries in health care facilities (PF) and coverage of first neonatal visits (KN1). Yearly increases in the health DAK budget have not been accompanied by increases in these coverages, and there are still significant disparities between regions. Using secondary data at the district/city level for 2014â2017, this study aims to investigate the impact of health DAK on coverage of PF and KN1. The analytical method deployed is linear regression of panel data using a fixed-effects model. The results show that in the short term, health DAK has a positive but insignificant effect on PF and KN1 coverage. However, health DAK has a positive and significant impact on PF coverage in the second year. Impact on KN1 coverage is unfeasible, even over a period of two years. These results indicate that the processes of planning, budgeting, and administering of health DAK require improvement so that benefits can be felt in the short term through better innovations in health programs. Nevertheless, given that our findings are based on a short period of study, the results from such analyses should consequently be treated with the utmost caution Therefore, future research should target a longer period of data collection to detect more trusty lagged effects and structural breaks of a policy intervention.
Relevance of the research topic. The implementation of medical reform in Ukraine, which provides radical structural changes in the health care system, the transformation of financing mechanisms for services, and at the same time the implementation of budgetary reform, an integral part of which is budget decentralization, makes the issue of assessing the role of local budget spending on health care. Formulation of the problem. In conditions of limited budgetary funds, growing debt and budgetary decentralization, successful implementation of health care reform is impossible without increasing the role of local budgets in financing the industry of development priority areas. Analysis of recent research and publications. The works of I. Chygynova, V. Makogon, M. Pasichnogo, Ju. Markuts, I. Kogut, Y. Pasichnik, V. Tropina [1-6] and others are devoted to the study of issues related to the problems of the article. The results of their own research of some of the indicated problems are presented in [6-8]. Segregation of unexplored parts of a common problem. In the context of deepening budget decentralization, strengthening the financial base of local budgets, expanding the functional powers of local governments, it is necessary to further search for ways to increase the role of local budgets in health care financing. The purpose of the article is to assess the role of expenditures of local budgets of Ukraine on the health care sector in the context of deepening budget decentralization and to develop proposals for improving its financing. Duringresearch, general scientific and special methods were used: analysis and synthesis, the method of generalization, statistical, etc. The article analyzes and evaluates the total expenditures of local budgets for health care, as well as for the regional program "Health of the population of the Dnipropetrovsk region for 2020-2024". The attention is focused on increasing the role of local budget expenditures in the process of changing the health financing model. The basis for expanding the capacity of local governments to finance health care was the deepening of budgetary decentralization, changes in the distribution of taxes to local budgets, etc. Conclusions. In conditions of acute limited financial resources, success in the formation and effective use of funds from local budgets of Ukraine for the development of an appropriate health care system is associated, first of all, with the consistent implementation of the financial and budgetary policy of the state, the coherence of medical and budgetary reforms, priorities, increasing the efficiency of the use of budgetary funds in format of target program budgeting. The results of this study can be applied in the process of forming and implementing social and budgetary policies for the development of the health care system in the country.
The Nigeria State Health Investment Project (NSHIP) was implemented in three Nigerian states between 2013 and 2018. Under the NSHIP, some local government areas were randomly assigned to Performance-Based Financing (PBF) intervention while others received decentralized facility financing (DFF) for comparison. This article evaluates the effect of PBF compared with DFF on health service delivery indicators in Adamawa state, under this quasi-experimental design, using the difference-in-differences technique. The analysis used health facility monthly data collected by the Health Management Information System through the District Health Information Software 2 (DHIS2). The PBF intervention group significantly increased the quantity of most of its service delivery indicators, such as antenatal care visits and deliveries by skilled personnel compared with the comparison group (DFF) after the introduction of NSHIP, although the baseline level of service delivery between PBF and DFF health facilities was statistically identical prior to the introduction of the intervention. We also conducted robustness check analysis to confirm the effect of PBF. Overall, we found a significant positive effect of PBF on most service delivery outcomes, except full vaccinations and post-natal care. One important policy implication is that we should carefully use PBF for targeted indicators.
ABSTRACT For the last three decades, healthcare systems have been under pressure to adapt to a neoliberal world and incorporate market principles. The introduction of market-based instruments, increasing competition among health care providers, introducing publicly -funded private sector provisioning of healthcare through health insurance financing systems to replace public provisioning of health care, promoting individual responsibility for health and finally, the introduction of market relations through privatization, deregulation and decentralization of health care have been some common elements seen globally. These reforms, undertaken under the guise of increasing efficiency and quality through competition and choice, have in fact harmed the physical, emotional and mental health of communities around the world and also contributed to a significant rise in inequities in health and healthcare access. They have weakened the public healthcare systems of countries and led to commercialization of healthcare. This article presents three case studies of resistance, to the commercialization of health care, by the Peopleâs Health Movement (PHM) and associated networks. It aims to contribute to the understanding of the way neoliberal reforms, including those imposed under structural adjustment programmes and some promoted under the Universal Health Coverage (UHC) paradigm, have impacted country-level health systems and access of people to health care, and bring out lessons from the resistance against these reforms.
Health indicators have been gradually improving in India, but health for all is yet to be achieved. The life expectancy is 68.7 years, infant mortality rate is 33/1000 live births, maternal mortality ratio is 130/100,000 live births, and total fertility rate is 2.3 children/woman; however, large inequities by geography, gender, class, caste, religion, and region are seen.[1] Health of the Nation's States Report[2] indicates that despite rising income, poverty and hidden hunger still exist; environmental pollution has increased, more so, in urban areas; sanitation services and clean fuel use have not yet improved to the desired level, especially in the villages. In urban areas, slums have mushroomed, built area has increased, and open spaces have shrunk. Moreover, dietary patterns have changed in favor of more sugar, salt, fat, and alcohol, whereas consumption of vegetables and fruits has declined. Mechanization, especially motorized transport, has encouraged sedentary life styles and a rise in road traffic injuries is noticed. The gap between aspirations and real-life situations has pushed many into addictions and mental health problems. To address these issues, multisectoral public health actions are needed, in addition to the reorientation of health sector. In the last decade, the implementation of the National Health Mission (NHM) did bring back some focus on social determinants of health and encouraged development of a health system based on primary health care.[3] Investments in health system led to improvement in health services. It had an impact on health indicators, but the full potential of NHM is yet to be realized.[4] The recently announced Ayushman Bharat Mission (ABM) has started insurance coverage for selected package of medical and surgical procedures for hospitalized patients belonging to socioeconomically vulnerable families on the lines of Rashtriya Swasthya Bima Yojna though the insurance amount is larger.[5] The development of subcenters into health and wellness centers continues to be under the NHM. These two missions, i.e., NHM and ABM, deal with primary and secondary care, respectively. In the absence of a linkage between these two missions, it may not be possible to maintain a balance. Therefore, the funds earmarked for ABM should flow through the primary health-care system on per capita basis. The primary health-care providers should be empowered to decide which patient to refer, to which hospital (public or private), and at what cost to pay, so that ultimately health services are cashless for the patient. Coordinated actions are required not only within the health and family welfare ministry, but across multiple sectors. Hence, to operationalize multisectoral public health action in a decentralized manner, every village or urban ward should have Arogya Kendra (health center) financed by the state through a village or ward fund, but managed by local volunteers under the guidance of the community it serves, and it should have a decentralized Integrated Health Information System for Universal Health Care supported by Information Communication Technology (ICT), if possible. Devolution of funds to district health societies and decentralization of planning, implementation, and monitoring would build a sustainable system rooted in local sociocultural contexts, which will be able to harness the locally available resources. However, broad policy framework, guidelines, and oversight can remain at the central and state level. Primary health-care teams should be incentivized to invest in prevention and health promotion, so that health literacy improves and spending on illness care can be reduced. Therefore, NHM and ABM should advocate for a comprehensive public health-oriented âwhole-of-governmentâ intersectoral health promotion initiative keeping in view âinclusive growthâ and âhealth developmentâ as a social goal of the society. Health impact assessment of all public policies should be mandated by legislation. âPrevention of diseasesâ is a more cost-effective strategy than the popular approach of âTreatment.â Therefore, several countries have reengineered their health systems in a variety of ways to protect and improve peoples' health. For example, in England, the Health and Social Care Act 2012 reorganized the health services to create National Health Service England and Public Health England,[6] and in Thailand, the National Health Security Act 2002 granted everyone the right to a standard and efficient health service and established National Health Security Office to improve universal health coverage.[7] The World Health Organization has also recently planned a call to countries to set up leadership at all levels to protect the people from public health emergencies, to improve universal health coverage, and to ensure that people enjoy better health and well-being.[8] Indian should also reorganize its health system. Parliament should promulgate Indian Public Health Act with a mandate to protect and promote health of people as a fundamental right to health and health care. An autonomous âPublic Health Commissionâ should be established to implement the provisions of the Act. It should have a public health commissioner with three deputy commissioners to head (a) epidemiology, (b) public policy, and (c) health promotion and education divisions. At state level, an additional public health commissioner should chair the State Public Health Commission which should have three deputy commissioners representing the above-mentioned three divisions, and at district level, a public health officer should head the District Public Health Commission who should be assisted by three additional public health officers. Each municipality should have a deputy public health officer and three public health supervisors. The Panchayat Raj Institutions, at district and community development block level, should have a deputy public health officer and an assistant public health officer. At Panchayat level, a public health supervisor should be appointed. Public Health Commission should have sufficient infrastructure (secretarial support staff, technical staff, equipment, office space, and budget) so that, in coordination with all sectors, a Public Health Action Plan can be prepared, funded, implemented, and monitored periodically. In summary, to achieve the universal health coverage, major challenge in India is promotion of health, prevention of diseases, and provision of health care in a balanced manner, which will require innovative public policies, strategies, and programs in many sectors. Development and implementation of a multisectoral approach to achieve sustainable development goals is the need of the hour. Establishment of a Public Health Commission will go a long way in achieving coordination of various initiatives not only in the Ministry of Health and Family Welfare but also in many other relevant ministries/sectors. At least 5% of the gross domestic product should be earmarked for public health and a responsive governance mechanism as outlined above should be set up, to achieve universal health coverage by 2030 as envisaged in the United Nations sustainable development goals which are also endorsed by the Government of India.[9]
INTRODUCTION: Fiscal federalism and fiscal decentralization are distinct policy options in public services in general and healthcare in particular, with possibly opposed effects on equity, effectiveness, and efficiency. However, the pertinent discourse often reflects confusion between the concepts or conflation thereof. METHODS: This paper performs a narrative review of theoretical literature on decentralization. The study offers clear definitions of the concepts of fiscal federalism and fiscal decentralization and provides an overview of the potential implications of each policy for healthcare systems. RESULTS: The interpretation of the literature identified three different dimensions of decentralization: political, administrative, economic. Economic decentralization can be further implemented through two different policy options: fiscal federalism and fiscal decentralization. Fiscal federalism is the transfer of spending authority of a centrally pooled public health budget to local governments or authorities. Countries like the UK, Cuba, Denmark, and Brazil mostly rely on fiscal federalism mechanisms for healthcare financing. Fiscal decentralization consists of transferring both pooling and spending responsibilities from the central government to local authorities. Contrarily to fiscal federalism, the implementation of fiscal decentralization requires as a precondition the fragmentation of the national pool into many local pools. The restructuring of the pooling system may limit the cross-subsidization effect between high- and low-income groups and areas that a central pool guarantees; thus, severely affecting local equality and equity. With the limited availability of local public resources in poorer regions, the quality of services drops, increasing the disparity gap between areas. Evidence from Italy, Spain, China, and Ivory Coast -countries with a strong fiscal decentralization element in their healthcare services- suggests that fiscal decentralization has positive effects on the infant mortality rate. However, it decreases healthcare resources as well as access to services, fostering spatial inequities. CONCLUSION: If public resources are and remain adequate, allocation follows equitable criteria, and local communities are involved in the decision-making debate, fiscal federalism -rather than fiscal decentralization- appear to be an adequate policy option to improve the healthcare services and population's health nationwide and achieve health sector economic decentralization. HIPPOKRATIA 2020, 24(3): 107-113.
A mainstream motivation for decentralized government is to enable public service investments to better align with political preferences that may differ by geographical region. This paper examines how political preferences determine local government provision of hospital services. We find that local governments in areas more supportive of public insurance expansion responded to such state action by increasing expenditures on hospitals, whereas those in areas that voted against such expansions used the savings to reduce property taxes. This finding suggests that local government financial responses indeed align with political preferences.
Cinzia Di Novi, Massimiliano Piacenza, Silvana Robone, Gilberto Turati
Recent theories on fiscal decentralization support the view that sub-national governments who finance a larger share of their spending with taxes raised locally by themselves are more accountable towards their citizens. Whilst evidence on improvements in spending efficiency is relatively common, little is known about the effects on inequalities amongst the population. In this paper we exploit a reform aimed at increasing regional tax autonomy in Italy to provide quasi-experimental evidence on the impact of fiscal decentralization on health disparities between- and within-regions. Our findings, robust to a number of robustness checks, support the view that fiscal decentralization does not impact on between-regional inequalities but can help to reduce inequalities within regions. However, this last effect depends on the degree of economic development: richer regions are better than poorer ones in containing inequalities.
Abstract Primary health care (PHC) represents one of the most important parts of any health system, and consists of first-contact medical services (preventive, curative and rehabilitation) for the patients. Our study analyses the family physicians' opinions related to a series of measures that could improve Romania's healthcare system through an online survey. We identified three components, first one related to control over spendings, increase of medicine market efficiency and transparency in using public funds, second one related to standardization of care processes, accreditation, implementation of guidelines and control over utilization of specialty services and component number three related to type of insurance houses, with competition among them, better decentralization and integrated provision of medical services. The conclusions of the survey emphasize the fac that primary care health is affected by sub optimal financing, with a need of better support for its development through investments in health promotion, services integragion and human resources as means of increasing general health status of the population.
Trisya Rakmawati, Reece Hinchcliff, Jerico Franciscus Pardosi
The local-level impacts of decentralizing national health systems are significant yet infrequently examined. This review aims to assess whether localized health services delivery in Indonesia, which commenced a health system decentralization process in 2001, achieved its objectives or could be enhanced. A systematic review was undertaken to collate published evidence regarding this topic and synthesize key findings holistically using the six building blocks framework of the World Health Organization (WHO) to categorize health system performance. Four research databases were searched in 2016 for relevant evidence published between 2001 and 2015. The inclusion criteria were relevance to the topic of decentralization impacts at the district level, original research, and published in English. Included articles were appraised for quality using a standardized tool, with key findings synthesized using the WHO building blocks. Twenty-nine articles met the inclusion criteria and categorized under the WHO building blocks categories. The findings highlight problematic impacts of decentralization related to three building blocks: service delivery, health financing, and workforce. In the 15 years of post-decentralization in Indonesia, the service delivery, health workforce, and health financing blocks should be prioritized for further research and policy evaluation to improve the overall health system performance at the district level.
BACKGROUND: Universal health coverage (UHC) assures all types of health service and protects all citizens financially in any conditions due to illness. Globally, the UN sustainable development goal (SDG) provides high priority for UHC as a health related goal. The National health system of Nepal has prioritized in similar way. The aim of this study is to explore the challenges and opportunities on the road to UHC in Nepal. METHOD: We used varieties of search terminologies with popular search engines like PubMed, Google, Google Scholar, etc. to identify studies regarding Nepal's progress towards UHC. Reports of original studies, policies, guidelines and government manuals were taken from the web pages of Ministry of Health and its department/division. Searches were designed to identify the status of service coverage on UHC, financial protection on health particularly, health insurance coverage with its legal status. Other associated factors related to UHC were also explored and presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. RESULTS: We found 14 studies that were related to legal assurance, risk pulling and financing of health service, 11 studies associated to UHC service coverage status and, 7 articles linked to government stewardship, health system and governance on health care. Constitutional provision, global support, progress on the health insurance act, decentralization of health service to the grass root level, positive trends of increasing service coverage are seen as opportunities. However, existing volunteer types of health insurance, misleading role of trade unions and high proportion of population outside the country are main challenges. The political commitment under the changing political context, a sense of national priority and international support were identified as the facilitating factors towards UHC. CONCLUSION: To achieve UHC, service and population coverage of health services has to be expanded along with financial protection for marginalized communities. Government stewardship, support of stakeholders and fair contribution and distribution of resources by appropriate health financing modality can speed up the path of UHC in Nepal.