Zambia has been using output-based approaches for over two decades to finance whole or part of the public health system. Between 1996 and 2006, performance-based contracting (PBC) was implemented countrywide with the Central Board of Health (CBoH) as the provider of health services. This study reviews the association between PBC and equity of access to maternal health services in Zambia between 1996 and 2006. A comprehensive document review was undertaken to evaluate the implementation process, followed by a trend analysis of health expenditure at district level, and a segmented regression analysis of data on antenatal care (ANC) and deliveries at health facilities that was obtained from five demographic and health survey datasets (1992, 1996, 2002, 2007 and 2014). The results show that PBC was anchored by high-level political support, an overarching policy and legal framework, and collective planning and implementation with all key stakeholders. Decentralization of health service provision was also an enabling factor. ANC coverage increased in both the lower and upper wealth quintiles during the PBC era, followed by a declining trend after the PBC era in both quintiles. Further, the percentage of women delivering at health facilities increased during the PBC era, particularly in rural areas and among the poor. The positive trend continued after the PBC era with similar patterns in both lower and upper wealth quintiles. Despite these gains, per capita health expenditure at district level declined during the PBC era, with the situation worsening after the PBC era. The study concludes that a nationwide PBC approach can contribute to improved equity of access to maternal health services and that PBC is a cost-efficient and sustainable policy reform. The study calls for policymakers to comprehensively evaluate the impact of health system reforms before terminating them.
<ns4:p> <ns4:bold>Background:</ns4:bold> Health sector decentralization, defined as the transfer of decision making over health sector resources from a central to a peripheral entity; has been and continues to be a widely adopted health system reforms in many low and middle-income countries (LMICs). However, its reported effects have been varied. Nevertheless, decentralization reforms aimed at providing public hospital management autonomy are increasing in prevalence in many LMICs. The range and form of this autonomy because of these reforms has often produced mixed effects. We set out to understand the range of financial management autonomy that has been granted to public hospitals in decentralized health systems in LMICs, and what forms of accountability arrangements have been used to facilitate this autonomy. </ns4:p> <ns4:p> <ns4:bold>Methods:</ns4:bold> We systematically searched PubMed, Google Scholar, Web of Science and CINAHL databases for published articles on this subject. We only included articles that reported empirical findings on hospital level financing and financial management in the context of decentralization in LMICs and/or those that included findings on hospital level finance management accountability arrangements. After a systematic search we found four articles that met our inclusion criteria. We undertook a thematic synthesis of the data and narrative reporting of our findings. </ns4:p> <ns4:p> <ns4:bold>Results:</ns4:bold> From the review – we find that decentralization reforms did not result in improved funding flows, finance management autonomy or accountability mechanisms and for public hospitals. These outcomes were irrespective of the mode and form of decentralization reform adopted. </ns4:p> <ns4:p> <ns4:bold>Conclusion:</ns4:bold> From our review, it is evident that though health sector decentralization reforms have been widely promoted and adopted in the past few decades across LMICs, there is minimal evidence that these reforms have improved funding flows to public hospitals, improved financial management autonomy or accountability mechanisms; so as to enhance the performance of these hospitals at sub-national level. </ns4:p>
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.
A major challenge to achieve health coverage in Nigeria is expansion of health access to the poor, vulnerable and informal sectors, which constitute over 70% of the population of more than 186 million. Evidence from other countries suggests that it is difficult for contributory insurance schemes to achieve universal health coverage in such conditions, especially with such a large informal sector. In fact, Nigeria's national social health insurance program has provided coverage to less than 5% of the population since its implementation in 2005, private voluntary health insurance has shown poor potential to extend coverage, and community-based health insurance has failed to expand access to poor, vulnerable and informal sector populations as well. Decentralization of health insurance to the states has limited potential to expand health insurance coverage for the poor, vulnerable and those in the informal sector. Furthermore, social health insurance in many developed countries has taken many years to achieve universal health coverage. This paper suggests that policy makers should consider adopting a tax-based, noncontributory, universal health-financing system as the primary funding mechanism to accelerate progress toward universal health coverage. Social health insurance and its decentralization to states for formal sector workers should serve as a supplement, while private voluntary health insurance should cover better-off groups. Simultaneously, it is critical to tackle issues of poor governance structures, mismanagement of funds, corruption, and lack of transparency and accountability within regulatory and implementing agencies, to ensure that monies allocated for expanded health insurance coverage are well managed. Although the proposed universal health coverage reform may take some years to achieve, it is more feasible to collect taxes, improve tax administration and expand the tax base than to enforce payment of contributions from nonsalaried workers and those who cannot afford to pay for health insurance or for services out of pocket.
The Spanish National Health System (SNHS) was legally defined in 1986. There are many well documented studies on how its basic traits (universality, accessibility, decentralization, integrated public health networks, public and private provision, financed by taxes, social premiums and copayments, etc.) have evolved since then.
This paper explains how the SNHS facilities and functions are deeply decentralized and how the recent economic crisis has changed this picture, with central health planning basically located into the Ministry of Finance and mainly guided by deficit control considerations.
Rwanda is a good example of how a country can overcome challenges and obstacles to improve the socioeconomic well-being of citizens. With no reliable healthcare system in 1994, after the genocide against the Tutsi, the country has come a long way in building a decent healthcare system for its people. The purpose of this research is to analyze the changing PPP mixed in health care sector in Rwanda. The study was carried out to reflect/reveal or bring to light the perennial problems of the healthcare mixes within a period of six months. This work looked at the public-private sector mixes in healthcare system using Rwanda as a case study. In Rwanda, the ministry of health began health sector reforms in accordance with the Lusaka declaration in 1995. These reforms included decentralization of the health system, development of the primary healthcare system, and community participation in managing health service financing. Rwanda is one of the few African countries with 90% coverage in all Districts for immunization and access to critical health services including TB treatment and access to ARVs for HIV patients. Within a very short period of 23 years, Rwanda has built a working health system in which even the poor and disadvantaged have access to quality medical care through the Community Based Health Insurance.
Like many countries, the health care industries of England 1 and the United States consume large amounts of resources and struggle to achieve equity and efficiency. They attempt to reach these goals in quite different ways, exhibiting common challenges familiar to reformers throughout the world. Recent activities in England and the United States suggest that significant changes being discussed in the United States or implemented in the United Kingdom could upset previously accepted policies and threaten some or many of the gains made to provide more equal and timely accessible care to all individuals. Policy makers in both countries wrestle with similar problems of redistribution and system design. Although in the United States, the issues of equity and expenditure controls do not have the same importance as in England, both countries seek the “Holy Grail” of limiting spending both by government and the private sector by redesigning institutions that manifest inefficiency and contribute to inflationary pressures. Yet competing value systems permeate the political debate about how to accomplish these aims. These value systems underlie political preferences for regulation and markets. Although a minority in the United States advocates for universal care funded by a single payer, private employer-based insurance remains the bedrock mechanism. Unlike the United Kingdom and most Organisation for Economic Cooperation and Development (OECD) countries, the United States has never shown a political willingness to have government responsible for financial protection for all inhabitants against the cost of medical care. The United States has, however, accepted this responsibility for major components of society, namely, the aged, disabled, and low-income families and children (e.g., via Medicare, Medicaid, and the State Children's Health Insurance Program). This commitment was expanded with the Affordable Care Act (ACA) in 2010, commonly known as Obamacare. The outcomes of the two health care systems reflect a preference for collectivism in funding and access in the United Kingdom and for pluralism in funding (less third-party coverage) and a greater role for privately delivered care in the United States. But the battle continues in both countries as important groups advocate for the reversal of these preferences. Policy makers continually try to change their health care systems. Some of these changes seek to develop greater efficiency in how care is delivered as a means of controlling the burdens imposed on society by ever-increasing public and private expenditure. Both countries face common problems that have been well identified for decades but have proven difficult to resolve. Reformers face three common problems. First, unwarranted variations in clinical practice (Wennberg, 2008, Wennberg, 2012) are produced by price variations in insurance systems and volume variations elsewhere (Institute of Medicine, 2013). Second, both systems have been slow to develop measures of the value of health care outcomes, that is, improvements in the length and quality of life. Third, both health care systems have perverse incentives that inhibit efficiency-inducing change; for example, they use hospital pricing or tariff systems that incentivise activity with little regard to patient value. Inadequate evaluation and political resistance to change continue to produce inefficiency. The end result is unnecessary spending and unethical deprivation of beneficial care for some populations. The English single payer system is characterised by frugality and cycles of famine and plenty, with attendant bouts of supply side reform (Street & Maynard, 2007). Constrained funding in the 1980s led to the Thatcher reforms and the creation of the “quasimarket” of purchaser and providers contracting for public and private care. These structural reforms received increased funding in the early 1990s. By the end of the 1990s, financial parsimony was creating renewed performance problems, for example, increased waiting times for elective surgery. As a consequence, the Blair government financed a large increase in funding. Since 2010, the Coalition and now Conservative government has exerted extreme expenditure controls, and current plans will result in real per capita funding falling by 2018. Since the Thatcher era, the often violent fluctuations in NHS funding have been accompanied by the “redisorganisation” of structures and processes of care whilst maintaining universal cover age free at the point of use. The purchaser side of the National Health Service (NHS) market has evolved from health authorities to primary care trusts and now to clinical commissioning groups, all with similar functions and uncertain impact. The provider side of the market remains dominated by public institutions as private providers have made only marginal inroads to public funding. The current chronic underfunding of the NHS and social care, manifested currently by increased waiting times for elective procedures, has produced inevitable pursuit of the “Holy Grail” of increased productivity. The Five Year Forward View (NHS, 2014) involved the acceptance of government parsimony and for the 2015–2020 period. Its authors argued that the NHS would require £30 billion to meet demographic and technological demands, of which only £8 billion was to be provided from tax revenues. The additional £22 billion was to be funded from productivity increases. Current NHS spending is £110 billion. Currently, a frenzy of structural reform proposals range from integration of currently fragmented hospital, primary and social care systems to hospital mergers to the abolition of the purchaser-provider “market” with the creation of accountable care organisations. These proposals involve unevidenced merger plans and deskilling of nursing and other workforce changes. The Sustainability and Transformation Plans (https://www.england.nhs.uk/stps/) are radical but unlikely to yield £22 billion of productivity gains in 5 years. There is little available funding to finance the change process, and its duration is likely to take many years to free up resources. Both options assume that healthcare is much more expensive in the United States than in any OECD country because American patients use too much medical care. Yet the evidence does not support this assumption. Americans are less likely to be admitted to a hospital and have a lower length of stay once in a hospital than many OECD countries. Americans also are less likely to see a doctor or use fewer pharmaceuticals than patients in OECD countries. U.S. patients do use more very expensive medical devices such as MRIs or new and expensive drugs, but on net, the pluses and minus may cancel out. What separates United States spending from that in OECD countries are the prices charged for all medical activities. The reasons for the higher prices are complicated and due to a myriad of factors including the higher wages paid to most participants in the healthcare system (not only physicians); the much higher prices Americans pay for drugs and medical devices; and the fact that the complexity of the U.S. system has evolved in a way that requires the use of many more lawyers, consultants, and administrators, all of whom are well paid. The latter consideration is possibly more central because some key providers such as primary care physicians receive relatively low compensation relative to education costs and work conditions. Additional efforts within the United States that are sometimes related to the ACA include a broad interest in insurance redesign, emphasis on value from services provided, and a focus on patient-centred outcomes. Value-based cost-sharing approaches are being implemented in the United States as well as other OECD countries (Thomson, Schang, & Chernew, 2013), though these approaches are more easily implemented for certain services such as pharmaceuticals. The Medicare program is testing a number of value-based payment innovations and incentive payments. The Patient-Centered Outcomes Research Institute is a nongovernmental institute created under ACA that was charged with assessing the effectiveness and appropriateness of medical treatments. However, the Patient-Centered Outcomes Research Institute is not able to mandate coverage or reimbursement for any treatments and infamously is prohibited from considering cost per quality-adjusted life years in its recommendations despite widespread interest in this measure in many other countries. The American and the English health and social care systems differ greatly, but they are surprisingly similar in some dimensions. Key differences pertain to who pays for care and how it is delivered, with the United States having a more decentralized and fragmented system leading to inequalities in the provision of care and its funding. The English system is universal and largely free at the point of consumption system but constrained by limited funding (which also generates inequalities in access to timely care). The supply side problems are more similar for both countries. Increasingly, U.S. reform in terms of payment mechanisms is being emulated by the English. Both systems seek better measurement and management of “value,” that is, the effects of health care on the length and quality of patients' lives. The hospital systems of both countries are attempting to integrate care function and move away from “fee for service” to bundled or incentive payments. The American system is the product of producer incentives producing grossly inflated costs. Concomitantly, a growing proportion of the U.S. population has a limited view about who should be eligible for government-supported health care services and the types of services that should be supported. Despite greater underlying consensus in favour of universal coverage, the English system's crisis is a product of parsimony and fragmentation of funding and provision. Both systems are permeated by organisational inertia and the defence of political values and self-interest. The United States is grappling with more than a sea change given political restructuring and the very uncertain future of most expansions of insurance or medical cost coverage under the ACA. England faces potentially revolutionary structural changes in supply and a real political challenge in its single payment system. Although current trends are not positive, the authors maintain hope that both countries will prevent further deterioration in health care coverage and return towards more progressive policies to protect their inhabitants' access to care when subjected to the misfortunes of medical illness.
This analysis of the Romanian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Romanian health care system is a social health insurance system that has remained highly centralized despite recent efforts to decentralize some regulatory functions. It provides a comprehensive benefits package to the 85% of the population that is covered, with the remaining population having access to a minimum package of benefits. While every insured person has access to the same health care benefits regardless of their socioeconomic situation, there are inequities in access to health care across many dimensions, such as rural versus urban, and health outcomes also differ across these dimensions. The Romanian population has seen increasing life expectancy and declining mortality rates but both remain among the worst in the European Union. Some unfavourable trends have been observed, including increasing numbers of new HIV/AIDS diagnoses and falling immunization rates. Public sources account for over 80% of total health financing. However, that leaves considerable out-of-pocket payments covering almost a fifth of total expenditure. The share of informal payments also seems to be substantial, but precise figures are unknown. In 2014, Romania had the lowest health expenditure as a share of gross domestic product (GDP) among the EU Member States. In line with the government's objective of strengthening the role of primary care, the total number of hospital beds has been decreasing. However, health care provision remains characterized by underprovision of primary and community care and inappropriate use of inpatient and specialized outpatient care, including care in hospital emergency departments. The numbers of physicians and nurses are relatively low in Romania compared to EU averages. This has mainly been attributed to the high rates of workers emigrating abroad over the past decade, exacerbated by Romania's EU accession and the reduction of public sector salaries due to the economic crisis. Reform in the Romanian health system has been both constant and yet frequently ineffective, due in part to the high degree of political instability. Recent reforms have focused mainly on introducing cost-saving measures, for example, by attempting to shift some of the health care costs to drug manufacturers by claw-back and to the population through co-payments, and on improving the monitoring of health care expenditure.
For more than three decades healthcare decentralization has been promoted in developing countries as a way of improving the financing and delivery of public healthcare. Decision autonomy under healthcare decentralization would determine the role and scope of responsibility of local authorities. Jalal Mohammed, Nicola North, and Toni Ashton analyze decision autonomy within decentralized services in Fiji. They conclude that the narrow decision space allowed to local entities might have limited the benefits of decentralization on users and providers. To discuss the costs and benefits of healthcare decentralization this paper uses the U-form and M-form typology to further illustrate the role of decision autonomy under healthcare decentralization. This paper argues that when evaluating healthcare decentralization, it is important to determine whether the benefits from decentralization are greater than its costs. The U-form and M-form framework is proposed as a useful typology to evaluate different types of institutional arrangements under healthcare decentralization. Under this model, the more decentralized organizational form (M-form) is superior if the benefits from flexibility exceed the costs of duplication and the more centralized organizational form (U-form) is superior if the savings from economies of scale outweigh the costly decision-making process from the center to the regions. Budgetary and financial autonomy and effective mechanisms to maintain local governments accountable for their spending behavior are key decision autonomy variables that could sway the cost-benefit analysis of healthcare decentralization.
Devolution, as other types of decentralization, profoundly changes governance relations in the health system. Devolution is meant to affect performance of the health system by transferring responsibilities and authority to locally elected governments. This study aimed to establish the effect of devolved governance on the performance of the health sector in Kenya. The guiding objectives included: To establish the influence of devolved procurement on the performance of the health sector; to determine the effect of devolved leadership on the performance of the health sector; to evaluate the effect of devolved resources on the performance of the health sector; and to establish the effect of devolved policy and regulatory framework on the performance of the health sector in Kenya. The study adopted the descriptive survey research design. The target population was 572 patients and health care providers from Nairobi and Mombasa County. Stratified sampling method was adopted at the rate of 10% to come up with a sample size of 57 respondents. Primary data was collected using questionnaires from all the respondents. Secondary data was sourced from health sector reports in Kenya from the year 2010 to 2014. The collected data was then analyzed through frequencies and percentages to enable the research come up with conclusions and recommendations for the study. The researcher employed the assistance of some computer tools, including the Statistical Programmes for Social Sciences (SPSS) and excel version 16 to analyze the data quantitatively. The analyzed data was presented in the form of graphs tables and charts. The Study established that devolution process has not been fully implemented and its effect has not been fully experienced in the health sector. The sector performance was averagely rated in the study and its contribution to GDP reduced by 0.5 percent by the end of the year 2013. The devolved procurement process, organizational leadership, resources allocation and availability as well as policy and regulatory framework had a significant influence on the performance of the level four hospitals and the overall health sector. It was recommended that the health sector players should improve in financing of critical health investment areas, particularly those relating to improving quality of care.
Evelyn Waweru, Catherine Goodman, Sarah Kedenge, Benjamin Tsofa · 5 authors
In many African countries, user fees have failed to achieve intended access and quality of care improvements. Subsequent user fee reduction or elimination policies have often been poorly planned, without alternative sources of income for facilities. We describe early implementation of an innovative national health financing intervention in Kenya; the health sector services fund (HSSF). In HSSF, central funds are credited directly into a facility's bank account quarterly, and facility funds are managed by health facility management committees (HFMCs) including community representatives. HSSF is therefore a finance mechanism with potential to increase access to funds for peripheral facilities, support user fee reduction and improve equity in access. We conducted a process evaluation of HSSF implementation based on a theory of change underpinning the intervention. Methods included interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. We found impressive achievements: HSSF funds were reaching facilities; funds were being overseen and used in a way that strengthened transparency and community involvement; and health workers' motivation and patient satisfaction improved. Challenges or unintended outcomes included: complex and centralized accounting requirements undermining efficiency; interactions between HSSF and user fees leading to difficulties in accessing crucial user fee funds; and some relationship problems between key players. Although user fees charged had not increased, national reduction policies were still not being adhered to. Finance mechanisms can have a strong positive impact on peripheral facilities, and HFMCs can play a valuable role in managing facilities. Although fiduciary oversight is essential, mechanisms should allow for local decision-making and ensure that unmanageable paperwork is avoided. There are also limits to what can be achieved with relatively small funds in contexts of enormous need. Process evaluations tracking (un)intended consequences of interventions can contribute to regional financing and decentralization debates.
The Government of Lao PDR has formulated a National Growth and Poverty Eradication Strategy (NGPES) that links sustainable economic growth, human development, reduced vulnerability and poverty alleviation; and addresses the key issues of public sector governance and public sector management. Implementation of the overall strategy focuses on rural Districts and relies on decentralized authority and beneficiary participation. Health services are a vital component of the NGPES, which reiterates the Government’s commitment to achieving the Millennium Development Goals (MDGs) and identifies improved access, equity, quality and strengthening the health workforce as key goals. Ministry of Health (MOH) supported by the World Bank (WB) is implementing the Health Services Improvement Project-Additional Financing (HSIP-AF) with the objective to increase utilization and quality of health services, particularly for the poor women and children in rural areas. The consultations with ethnic groups during project implementation is necessary in order to assess whether the design of the HSIP-AF is succeeding in responding to the needs for MNCH services of ethnic groups in project provinces, understand the extent to which free delivery, and outreach activities impact health seeking behaviour of pregnant women and new-born children from ethnic groups and ascertain based on the result of such consultations, broad community support to project activities. The principle of SWOT Analysis was adapted in the consultation methodology. The Consultations however, indicated that ethnic communities were not fully informed of and understood project benefits available to them and requirements for participation. Communication is often particular problematic in areas with language barriers. A higher degree of inclusion in terms of community participation in the identification of problems and ways of solving them would demand bottomup implementation mechanisms and more flexibility to adapt project activities and supplied resources to local needs. The health service providers should preferably be female and members of local communities in order to overcome cultural and language barriers.
This thesis asks whether the increased autonomy and decentralization associated with the New Public Management (NPM) have impacted on the coordination of organizations within the public sector. Ideas and practices once typical of the private sector have become increasingly common in public sectors around the world. Often times they have been promoted under the umbrella of fashionable terms such as rdquo;, “modernization” or New Public Management (NPM). Although not entirely new, these ideas gained momentum, starting in the early 1980s, in some Western democracies and then increasingly became promoted as a solution – and sometimes the solution nbsp;to public administration problems across the world. Great variation exists, however, in their spread and implementation across countries and sectors. Two of these proposals for change are the disaggregation of bureaucratic forms of organization and decentralization. The expectation has been that these reforms would improve operational flexibility, responsiveness to the needs of service users and ultimately quality and performance. Following these reform proposals, administrators are supposed to make use of greater discretion in the application of managerial principles and techniques. Managers and the entities they lead are expected to exercise initiative, to be proactive, and to act rather than just to react to imperatives from politicians, as it was traditionally common in public administration. A second major reform that has been widely experimented with in the public sector is decentralization. Decisions, it is argued, ought to be made as close to the citizen as possible. In this way it is assumed that information and understanding of local needs improve, which can further translate into better decision making. There is also an ambition to reduce the overload and delay associated with highly centralized decisions. However, the trend towards decentralization is neither new nor uniform across public sectors. Some governments have taken steps to recentralize certain functions after earlier efforts to decentralize while others have been initially reluctant to decentralize, but recently have taken more confident steps in this direction. The specific setting of this doctoral dissertation comprises public hospital systems in selected European countries: 1)nbsp; a Nordic country – Norway 2)nbsp; nbsp;Baltic, EU member state since 2003, formerly part of the Soviet Union – Estonia 3) a nation in Central and Eastern Europe (CEE), a former communist state and an EU member state since 2007 – Romania. The thesis comprises eight chapters. Chapter 1 introduces the subject matter and motivates its academic and social relevance. Chapter 2 reviews the literature and shows how the subject matter of the thesis is embedded in the broad academic discourse. This consists of the public administration and management literature – particularly New Public Management, governance and coordination – on the one hand, and healthcare and hospital management and governance, on the other hand. It provides a theoretical review of the concept of coordination, and shows how different theories have dealt with coordination in a public sector context. The chapter also reviews existing analytical and empirical approaches to coordination. In chapter 3 we propose an analytical framework geared to the central coordination of publicly-owned hospitals. The framework builds on two theories – principal-agent theory and sociological institutionalism – and seeks to explain why coordination problems occur across the three cases. Chapter 4 includes the research design: the case selection and methods. The thesis uses an explanatory comparative case study approach to understand how reform affects coordination in hospital systems in the three country cases: Estonia, Norway and Romania. We use congruence analysis as a specific type of case study research. Congruence analysis connects empirical observations to expectations derived from theory. The main source of empirical material comprises of a program of semi-structured interviews conducted in all three countries with various stakeholders – both in central institutions and public hospitals. This evidence is supplemented with relevant documentary data and statistical information. Chapters 5 through 7 constitute the core of the thesis and they describe, evaluate and explain the relationship between organizational reform in public hospitals and coordination problems. Each of these three country chapters ends by discussing the compatibility between empirical findings and the theoretical propositions derived from the two theories. In each country chapter we seek to explain the relationship between organizational reform in public hospitals and central coordination by means of the theoretical framework introduced in Chapter 3. Chapter 8 concludes by comparing the empirical and theoretical findings across the three cases and discusses the implications of the results for theory and practice. The research has reached the following conclusions: nbsp; Organizational reform in public hospitals has constituted an important component of healthcare policy in all three countries in the past 10 to 15 years. All three countries have experimented with structural reform (including decentralization or centralization) and have grappled with granting management autonomy to public hospitals while seeking to solidify policy-making and coordination capacity at the center of government nbsp; This administrative change across the three hospital systems has not been marginal only – it has involved major resources and has received considerable attention from different stakeholders •nbsp; Although hospital decentralization and autonomy reform constitute on-going processes that may constantly undergo some degree of change, we have observed that in two of our three cases, Estonia and Norway, the reform model proposed more than 10 years ago has essentially endured to the present. While ideas for change to the model have been put forward, in Norway for example, it is unlikely that this change would radically reshape the type of reform model adopted years ago. Romania, while clearly experimenting with the same types of international ideas, has thus far only implemented decentralization. Granting greater autonomy to hospital management is still an idea that is being considered by central policy makers in Romania, but it is uncertain if, when and how it will be implemented nbsp; In the face of organizational reform the state capacity to coordinate the decentralized and autonomous hospitals has been put to the test nbsp; We have observed a reconsideration of the role of central institutions, most notably the ministries of health, but also health insurance funds in social insurance systems or other central bodies in tax-based systems nbsp; Hospital autonomy has overall posed serious challenges to the central coordination of autonomous hospitals in Estonia, much more so than in the case of Norway and Romania nbsp; However, the autonomy of hospitals is not the only factor that affects the effectiveness of coordination. Hospitals that enjoy a lower degree of autonomy, as in Romania for example, are not necessarily more effectively coordinated than hospitals that enjoy a high degree of decision-making discretion nbsp; nbsp;Norway, a high-trust society that is compliant with government regulation, coordination problems exist in more specific areas of ICT and in the case of elite medical specialties in the Oslo University Hospital. Overall, coordination in Norway has significantly improved following the 2002 hospital reform, but this does not necessarily mean that coordination in the public hospital sector is problem-free nbsp; Hospital system culture and principal-agent theory offer complementary insights into the dynamics of public hospital coordination. Conflicting interests and goals and cultural factors are particularly relevant in understanding the effectiveness of central coordination of public hospitals nbsp; There is more evidence for some propositions of principal-agent theory than for othersnbsp;more evidence was found in favour of conflicting interests and goals than in the case of imperfect information. Positive and negative incentives are situated in the middle with more evidence in some cases than in others. The thesis contributes to the existing literature in the following ways: nbsp; Directly compares two eastern and one western European system and shows that such comparison, although it does not follow a most similar research design, is both feasible and productive. This research finds that problems of coordination can occur in different systems and therefore to study public sector coordination comparatively one can choose to select cases that display differences between them and look for factors that can explain a similar outcome nbsp; Covers one country where only very limited research on hospital reforms has previously been published (Romania) •nbsp; Sets out new primary evidence in the form of original interviews and documentary evidence which has not previously been cited in academic research nbsp; Employs two theoretical approaches in a comparative and complementary way, and argues that conflicting interests and goals and hospital system culture help explain coordination in European public hospital systems nbsp; Proposes an analytical framework for analyzing coordination in public hospital systems and finds the framework to be useful in that it encourages researchers and practitioners to think specifically about the implications of coordination; that is, the problems and effects of coordination problems.
Open access
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
Carlo De Pietro, Paul Camenzind, Isabelle Sturny, Luca Crivelli · 8 authors
This analysis of the Swiss health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Swiss health system is highly complex, combining aspects of managed competition and corporatism (the integration of interest groups in the policy process) in a decentralized regulatory framework shaped by the influences of direct democracy. The health system performs very well with regard to a broad range of indicators. Life expectancy in Switzerland (82.8 years) is the highest in Europe after Iceland, and healthy life expectancy is several years above the European Union (EU) average. Coverage is ensured through mandatory health insurance (MHI), with subsidies for people on low incomes. The system offers a high degree of choice and direct access to all levels of care with virtually no waiting times, though managed care type insurance plans that include gatekeeping restrictions are becoming increasingly important. Public satisfaction with the system is high and quality is generally viewed to be good or very good. Reforms since the year 2000 have improved the MHI system, changed the financing of hospitals, strengthened regulations in the area of pharmaceuticals and the control of epidemics, and harmonized regulation of human resources across the country. In addition, there has been a slow (and not always linear) process towards more centralization of national health policy-making. Nevertheless, a number of challenges remain. The costs of the health care system are well above the EU average, in particular in absolute terms but also as a percentage of gross domestic product (GDP) (11.5%). MHI premiums have increased more quickly than incomes since 2003. By European standards, the share of out-of-pocket payments is exceptionally high at 26% of total health expenditure (compared to the EU average of 16%). Low and middle-income households contribute a greater share of their income to the financing of the health system than higher-income households. Flawed financial incentives exist at different levels of the health system, potentially distorting the allocation of resources to different providers. Furthermore, the system remains highly fragmented as regards both organization and planning as well as health care provision.
Background: In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy \nof teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in \neach hospital and significant modifications in hospitals’ financing. Since the reform aimed to improve its predecessor \npolicy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as \nenhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were \nnever realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of \ntrustees’ policy did not achieve its perceived objectives. \nMethods:We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 \nand 10 participants, respectively) with experts at high, middle, and low levels of Iran’s health system, using purposive \nand snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed \nverbatim and analyzed thematically, following a mixed inductive-deductive approach. \nResults: Three main themes emerged from the analysis. The implementation approach (including the processes, views \nabout the policy and the links between the policy components), using research evidence about the policy (local and \nglobal), and policy context (health system structure, health insurers capacity, hospitals’ organization and capacity \nand actors’ interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization \npolicies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration \nof the above factors in policy implementation into account. \nConclusion:The implementation of the board of trustees’ policy did not achieve its desired goals in teaching hospitals \nin Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not \nprepared appropriately and key stakeholders, particularly the government, did not support the decentralization of \nIran’s health system.
Claudio Ronco, G. Mason, A. Nayak Karopadi, Ashlea Bennett Milburn · 5 authors
Today, health policy seems to be on the top of governments' agendas around the world. Healthcare systems are challenged by a number of phenomena happening on a global scale; these trends include demographic change in terms of an ageing population, an increase in chronic disease, patients having higher expectations on healthcare delivery and above all a major pressure on public finances to slow increasing healthcare expenditures. Such developments are forcing policy-makers to reform healthcare systems. First, there is a tendency towards decentralization of responsibilities. Second, governments are moving towards reimbursement schemes rewarding good outcomes and performance. Third, great importance is being attributed to transparency and accountability, and to introduce competition in healthcare. Fourth, attention is being shifted from simple treatment of a disease towards preventive initiatives, in a more holistic approach to health. Finally, healthcare policy-makers are recognizing the importance of empowering patients to give them control over decisions regarding their own health. These dynamics can be observed in chronic kidney disease, the management of which is a huge economic burden to healthcare systems globally, and which represents a good example of a field where important changes can be witnessed in therapy, technology, delivery and financing.
Open access
Chronic Disease Management Strategies
Health Systems, Economic Evaluations, Quality of Life
OBJECTIVE: China's ongoing new health reform aims to reduce individual out-of-pocket (OOP) payments for healthcare services. The aim of this article is to analyse the impact of this reform and to draw policy implications. METHODS: Data are retrieved from the relevant government publications. Polynomial regression models are used to predict future health expenditures. An extensive sensitivity analysis is conducted to investigate the ratios of OOP payments to the total health expenditures (THEs) and to the disposable personal income (DPI) for 2009-11 under different scenarios of cost projections and personal income distributions. Both quantitative and qualitative analyses are carried out to draw conclusions. RESULTS: The ratios of OOP payments to THE and DPI vary significantly across scenarios tested. Only if all committed government investments and social health expenditure are realized can China's new health reform reduce both ratios and achieve its target goals. In particular, the ratio of OOP payments to DPI can also be significantly reduced by improving income distribution. Due to the complicated interplay among different cost components in health expenditures, these two ratios may not change in the same direction, indicating that both need to be examined when evaluating the reform. CONCLUSION: The new health reform in China aims to alleviate the high OOP payments for healthcare services, but it has not yet been able to reduce both OOP-to-THE and OOP-to-DPI ratios simultaneously. Major reasons include (1) inability of local governments to fulfil their responsible investments due to health finance decentralization and uneven economic development in China and (2) a serious cost inflation in health expenditures coupled with a low level of income distribution. It is suggested that the central government should bear more financial responsibility and assist local governments to fully invest, and should improve individual incomes, in particular for the poor.
Ingrid Sperre Saunes, Anna Sagan, Ingrid Sperre Saunes
Norways five million inhabitants are spread over nearly four hundred thousand square kilometres, making it one of the most sparsely populated countries in Europe. It has enjoyed several decades of high growth, following the start of oil production in early 1970s, and is now one of the richest countries per head in the world. Overall, Norways population enjoys good health status; life expectancy of 81.53 years is above the EU average of 80.14, and the gap between overall life expectancy and healthy life years is around half the of EU average. The health care system is semi decentralized. The responsibility for specialist care lies with the state (administered by four Regional Health Authorities) and the municipalities are responsible for primary care. Although health care expenditure is only 9.4% of Norways GDP (placing it on the 16th place in the WHO European region), given Norways very high value of GDP per capita, its health expenditure per head is higher than in most countries. Public sources account for over 85% of total health expenditure; the majority of private health financing comes from households out-of-pocket payments.The number of practitioners in most health personnel groups, including physicians and nurses, has been increasing in the last few decades and the number of health care personnel per 100 000 inhabitants is high compared to other EU countries. However, long waiting times for elective care continue to be a problem and are cause of dissatisfaction among the patients. The focus of health care reforms has seen shifts over the past four decades. During the 1970s the focus was on equality and increasing geographical access to health care services; during the 1980s reforms aimed at achieving cost containment and decentralizing health care services; during the 1990s the focus was on efficiency. Since the beginning of the millennium the emphasis has been given to structural changes in the delivery and organization of health care and to policies intended to empower patients and users. The past few years have seen efforts to improve coordination between health care providers, as well as an increased attention towards quality of care and patient safety issues. Overall, comparing mortality rates amenable to medical intervention suggests that Norway is among the better performing European countries. Despite having one of the highest densities of physicians in Europe, though, Norway still struggles to ensure geographical and social equity in access to health care.
Open access
Healthcare Policy and Management
Primary Care and Health Outcomes
Health Systems, Economic Evaluations, Quality of Life
Víctor B. Penchaszadeh, Francisco A. Leone, Mario Rovere
The modern health system of Argentina was developed in 1945-1955, a period of economic bonanzacharacterized by industrialization, rapid urbanization and activist labor organizations. During the ensuingyears it evolved in three sectors: public, social security and private, with separate services, populationcoverage and funding. While the national Ministry of Health is nominally responsible for general healthpolicies and regulations, overseeing the general operation of health services, designing preventive medicineprograms and negotiating the coverage and fees of health insurance plans, it has in fact very low leverage toenforce decisions in the provinces, which are autonomous, as well as in the social security and private sectors,which are weakly regulated if at all. While the health workforce, medical facilities and level of spending areacceptable, the fragmentation and segmentation of the system render it highly inequitable and inefficient.During the 1980s and 1990s, the health system has experienced further transformations, as neoliberalpolicies took hold in the country and dictated a reduction of state involvement in social services in favor ofprivatization and decentralization of health care. The result has been increased fragmentation, inequity andinefficacy, as health care is increasingly prey to the economic interests of private corporations (insuranceand pharmaceutical industries), trade union bureaucracies and the medical professional and technologyestablishments. The expectation of popular sectors of society are that progressive polices recently enactedby Congress, and being implemented in the fields of education, retirement pensions and the media, will befollowed with much needed public health policies based on equity and efficiency.
Open access
Public Health in Brazil
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
Western countries with strong primary care systems organize their health services around this healthcare modality, which serves as a gateway to the system and is characterized by multidisciplinary teamwork, management transferred to the teams and a broad services portfolio. The contractual relationship between professionals and the public health system is a useful tool to modulate the efficiency of services and their ability to meet the expectations of citizens and professionals. Some countries choose to contract professionals directly, either individually or through a professional organization, an option known as a self-management system. Others opt to contract public or private entities, which in turn recruit health professionals as employees. In the latter countries, the concept of management decentralization and managerial autonomy has arisen. In Spain, only Catalonia has enabled professional entities to be hired to provide public health services, through commercial formulas, i.e. in a competitive market relationship. This relationship allows the use of corporate governance mechanisms that are not subject to public control through state intervention. The other forms of management promoted in Spain to avoid the controls of state intervention - foundations or associations - have been unsuccessful, except in the autonomous region of Valencia and some models in the autonomous region of Madrid.
Open access
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
Under traditional health insurance arrangements, citizens were covered by some insurance scheme.When sick, insurance arrangements allowed citizens to go to a health care provider, pay the price of the care received and be reimbursed later.Alternatively, the care provider would be owned by the insurer (like in integrated national health systems) and the patient paid nothing at the moment of consumption.In such arrangements, providers would freely set their prices or have no price to set at all (in an NHS-like system).Recent developments in health care financing include independent institutions that negotiate the prices with the financing institution.This is true with respect to health maintenance organizations (HMOs), managed care in general, but also in national health systems where decentralization and the split between provision and financing is implemented.In this scenario, negotiation over contractual terms, including prices as one major element, becomes a relevant issue in the analysis of performance of health care systems.Both empirical and theoretical analyses have been produced, and are reviewed below.This chapter reflects our views and preferences.It does not aim to be an encyclopaedic view of the existing literature on bargaining in health care.Instead, we try to highlight the new developments associated with explicit bargaining between third-party payers and providers of health care (a relation which is, in itself, only one of many that exist in the health care sector).Bargaining theory has a long tradition in the economics literature.However, it is only recently that this approach has found space in the analysis of the health care sector.The recognition of the strategic interaction among agents in the health care sector (patients, providers and third-party payers) came with the application of models borrowed from the industrial organization tradition dating from the 1970s.It was in the early 1990s when a step forward was taken with the eruption of the models of bargaining (see for example, Osborne and Rubinstein, 1990, for a nice presentation) In many situations the health care sector has the structure of a bilateral monopoly/oligopoly.In this context, bargaining becomes the natural way to approach the interactions among agents.Most economic analyses of contract design in health care in fact assume that the party that moves first, typically the payer, proposes a take-it-or-leave-it offer to the provider.We take here a broader view, looking at other types of negotiation procedures.We do not discuss issues related to contract design, which are taken up in chapter 22 by Chalkley in this Companion.We focus here on models of explicit bargaining between two parties, which we call the payer and the provider.On theoretical grounds, simple bargaining models can have their results transposed in a straightforward way: higher bargaining power and higher M2835-JONES9781849802673PRINT.
In a wide-ranging look at many aspects of health care financing and delivery, the concepts of glasnost and perestroika are used as a framework for presenting ideas from the American system that may have value for European health care planners. These include more uniform approaches to data collection and cost reporting, patient outcome studies, evaluation of service and access standards, publication of information, quality assurance review, decentralization and independent institutions, prepaid group practice, demonstrations and experiments, and managed competition. Suggestions are offered for making health care systems on both sides of the Atlantic more manageable, efficient, and responsive.
Open access
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
Both national equity in healthcare and the county councils’ local autonomy are important values supported by Swedish law. Politically it is a balancing act; how much freedom should the county councils have and to what extent should healthcare be equal throughout the country? The general aim of this dissertation, concerning political governance in Swedish healthcare, is to investigate the tensional values of national equity and local autonomy in the light of current trends in healthcare governance in Sweden. How is this tension manifested? Four studies are included in the dissertation. These studies show that the Swedish state is becoming more active in governing and regulating healthcare, for example by the use of informative governance and legislation, which increasingly rely on monitoring and evaluation of results that are made public. The findings show that the tension between national equity and local autonomy is manifested in increasing emphasis on national equity – or rather national equivalence – which is interpreted in terms of Swedish healthcare being recentralized. Delivery and financing of healthcare are still the responsibilities of the county councils. Planning and arranging – the setting of the regulatory framework – is increasingly taken over by the central state. Although power seems to be transferred from local level to central level, the county councils’ autonomy is only partially restricted, which means Swedish healthcare is still decentralized. However, if the recentralization process proceeds further, the county councils´ autonomy may be seriously challenged. Another challenge is to maintain or strengthen the procedures for democratic legitimacy through citizen participation at the local level. When local autonomy looses ground, it becomes more difficult to tailor healthcare according to local needs and conditions in the county councils, and decisions are taken at greater distance from the citizens.
Open access
Health Systems, Economic Evaluations, Quality of Life