Health care is widely considered to be an important determinant of health. The health care systems of Western Europe have recently experienced significant reforms, under pressure from economic globalization. Similarly, in Eastern Europe, health care reforms have been undertaken in response to the demands of the new market economy. Both of these changes may influence equality in health outcomes. This article aims to identify the mechanisms through which health care may affect inequalities. The authors conducted a literature review of the effects on health inequalities of European health care reforms. Particular reference was paid to interventions in the fields of financing and pooling, allocation, purchasing, and provision of services. The majority of studies were from Western Europe, and the outcomes most often examined were access to services or income distribution. Overall, the quality of research was poor, confirming the need to develop an appropriate impact assessment methodology. Few studies were related to pooling, allocation, or purchasing. For financing and purchasing, the studies showed that publicly funded universal health care reduces the impact of ill health on income distribution, while insurance systems can increase inequalities in access to care. Out-of-pocket payments increase inequalities in access to care and contribute to impoverishment. Decentralizing health services can lead to geographic inequalities in health care access. Nationalized, publicly funded health care systems are most effective at reducing inequalities in access and reducing the effects on health of income distribution.
[Excerpt] It is not surprising that most theories of human capital treat the firm as the key unit of analysis, given the deep imprint that Becker (1964 [1993]) left with his early efforts to distinguish between general and specific human capital. It is especially understandable for research that focuses on American institutions and practices. Ever since the passage of the New Deal employment policies of the 1930s, firms have been assigned central roles in the delivery and financing of a variety of labor-market services, including the provision of workforce training and development (Osterman et al, 2001). Most of the chapters in this volume reflect this emphasis by exploring how individuals and firms allocate the costs and share the benefits of human capital, incorporating human capital development into alternative theories of the firm (such as transaction cost, resource-based, agency, entrepreneurial, and knowledge-based perspectives), and how human capital plays into emerging research on social capital, organizational capabilities, learning, and human resource strategies and architectures. But, as Chapters 12, 22, and 23 each suggest, firm-centric theories, particularly those founded upon the neoclassical economics framework, need to more fully take into account how firm boundaries, strategies, and practices relate to other institutions in society. This is particularly important given the changes in employment relationships that are acting to reduce the labor-market functions served by individual employers. In short, the central argument of this chapter is that a more up-to-date theory of the changing nature of employment relationships is needed to understand whether and how human capital is to serve as a source of competitive advantage in a modern economyâeven one as decentralized as that of the US.
The purpose of this study was to assess the nature of Decentralization on Education Service Delivery in view of having the required institutions, manpower, availability of adequate finance and community participation in the provision of service delivery in the Woreda. The study was conducted Dubti Woreda of Afar National Regional State. To meet the above objective, Focus group discussion, In-depth interviews, and Observation were conducted with key informants, professionals, and community representatives. Data for the research was collected for primary sources of data with the help of interview guide, focus group discussion guide and observations. Secondary was also equally reviewed to assess the nature and performance of decentralization on education service delivery in Woreda.. According to the results of the study the student enrollment in the Woreda show that there is less parti cipation in student enrolment. According to the responses obtained from school directors, teachers a nd officials at Woreda Education Office level, the coordination and work relationship between Kebele Education Training Board on one side and Parent Teacher Associations' and Schools on the other is characterized as being very inadequate and minimal. The finding also indicated that the Education Office of Woreda and school are found to have manpower problem which appears to have negatively impacted the service of the office in the Woreda. According to the information obtained from officials through interviews indicated that, Woreda suffered from inadequate budget. Despite the block transfer increase from year to year for the Woreda, the revenue capacity of the Woreda was minimum because, of the Woreda lack of appropriate tax base identification.. Decentralized education service delivery requires available envir onment. However, since Woreda is characterized by Desert it is difficult to deliver education service delivery in the Woreda
This research tested the difference of financial performance between parent areas and new autonomy areas. The financial performances that meant in this research were degree of decentralization, level of independence, capital expenditure ratio, and level of financing capability. The aim of this research was to analyze the difference of financial performance between parent area and new autonomy area. The objects in this research were districts or cities that become parent areas and districts or cities that become new autonomy areas. The division period that used in this research was in the year of 1999â2004. Samples that used in this research were consists of 48 parent areas and 49 new autonomy areas. Data that used in this research is local government revenues and expenditures budget realization report in the period of 2005 â2007. Data analysis performed using independent sample t test from SPSS for window program. \nLevel of significance that used in this research was 5%. Result of this research showing that a) parent areas degree of decentralization significantly better than new autonomy areas, b) parent areas level of independence significantly better than new autonomy areas, c) no significantly difference of financing capability level both parent areas and new autonomy areas and d) new autonomy areas capital expenditure ratio significantly better than parent areas. \n \nKey words: \nparent areas, new autonomy areas, regional financial performance, degree of decentralization, level of independence, financing capability level, capital expenditure ratio.
This article is based on the research project 'The functioning of sector level wage bargaining systems and wage setting mechanisms in adverse labour market conditions', commissioned and financed by the European Foundation for the improvement of Working and Living conditions, whose support is
There is an avalanche of interest in health systems with countries, donors, international experts and academic institutions all rushing to promote, fund or build capacity to address this wave of interest. As Anne Mills documents in an article in this volume, there is also a growing literature on how to think about health systems, how to use research on health systems to improve their performance, and pleas for greater investment in knowledge about health systems. We are probably riding on the crest of this new wave and it will be important to make use of it to further our knowledge about how to achieve health system effectiveness. With continuing global economic uncertainty, this wave may pass if we do not take advantage of it now. It is useful to reflect on why there is such interest in this theme now. There are probably many converging causes but the most important, to my mind, is a replay of an old debate between vertical programmes and horizontal, integrated approaches that has experienced swings of interest at least since the Alma Ata Conference in 1978 emphasized the integrated primary health care approach. During the last decade or more, there has been a major focus on vertical disease-specific programmes supported by greatly increased funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Alliance for Vaccines and Immunisation (GAVI), US Presidentâs Emergency Plan for AIDS Relief (PEPFAR), Bill and Melinda Gates Foundation, among other donors. The major claim of these programmes was that by focusing on clear disease-specific objectives they would be more effective in shorter time periods and they could be held more accountable to donors (since the results could be more measurable) than the difficult and diverse efforts to improve the many elements of a health system through the horizontal integrated approach. While there were evident successes in these programmes, there was also a growing recognition that health system constraintsâespecially in human resources and logistics systemsâwere becoming major obstacles to achieving even their limited objectives of increased coverage of HIV/AIDS, tuberculosis, malaria and immunizations. With the added emphasis on the Millennium Development Goals (MDGs) and the slow progress toward their achievement in many countries, the international community and national governments have turned increasingly toward attempting to reduce the health system constraintsâan approach that is closer to the integrated horizontal approach. Both GAVI and the Global Fund have added a separate fund for health systems interventions. In 2008, the G8 called for greater attention to health system strengthening as compatible with the prior focus on vertical programmes (Reich et al. 2008). In 2009, the World Bank convened a seminar on health system strengthening attended by representatives from the World Health Organization (WHO), GAVI and Global Fund. A task force on Healthy Women and Healthy Children calling for a health system funding platform was initiated at the UN General Assembly. In 2010, the WHO and others sponsored the First Global Symposium on Health Systems Research in Montreux, Switzerland. While many observers are trying to argue that the two approaches are now more compatible, at least in rhetorical terms it seems that the pendulum is shifting toward greater attention to health system strengthening. So how do we, the readers of Health Policy and Planning, take advantage of this interest? Health Policy and Planning is dedicated to the publication of high quality research that, as the name implies, improves decisions on policy and planning. This poses for us a central question: how can we do research that will improve health systems? The answer is complex for it requires attention to the kind of knowledge that is both researchable and leads to practical, implementable recommendations. The place to start is with a framework of analysis that is both analytical, in that it provides empirically based categories about health systems, and purposive, in that it is oriented toward how to improve the system. Many of the frameworks that are available provide a recognizable set of functional issues whose boundaries help focus attention on specific interactions that can be studied, such as financing, service delivery, human resources, governance (Mills et al. 2001). The WHO Building Blocks framework is a very popular approach that is guiding much of the discussion and research in health systems (WHO 2007). Another approach developed by Harvard School of Public Health faculty is oriented toward using analytical categories in a purposive manner that starts with an ethically derived vision of what we would like to achieve, and works back toward finding the reasons why we have not achieved those objectives. It then focuses our attention on what we can change using evidence on the effectiveness of changing different âcontrol knobsâ or policy levers, including financing, payments, organization, regulation and persuasion (Roberts et al. 2004). There is a great deal of overlap in these models and they are compatible in many ways that can guide research toward practical recommendations for policy. A second question is about levels of analysis. Should we attempt to research whole national systems, with typologies of systems and comparisons of the achievements of the different models? We often hear this orientation used in policy arguments such as the recent arguments over whether the USA should adopt the Canadian single payer model. However, this approach suffers from methodological challenges such as the âsmall numberâ problem (which limits the ability to use sophisticated quantitative analysis due to the few comparable national systems) and the many different characteristics and historical trajectories that confound the analysis. Few countriesâChile, China, Colombia, Ghana, Taiwan, Turkey and Eastern European countriesâhave even attempted broad multifaceted health system reforms and they have tended to develop their own reform models rather than copying others. Nevertheless, there are many country studies of health reforms that provide evidence and much can be gained by detailed evaluation of the effectiveness of these models that can inform policy choice in different contexts. An alternative means of assessing health systems is to focus on sub-systems or analysis of specific policy changes, focusing on different social health insurance approaches, pay for performance, contracting, decentralization or other reforms, and assessing their performance in terms of achieving health system objectives like the MDGs, reduction in catastrophic expenditures caused by paying for illness, or broader responsiveness and accountability to citizens. The advantage of this approach is that, if the research is well designed, the causality of the impact of the changes on health system objectives can be more clearly demonstrated, and it allows a more focused attention to policy changes that different countries can adopt in an incremental way. This approach can address both systems issues and vertical programme needs. For instance, the work that I am involved in on decentralizationâlooking at the relationship between choice, capacity and accountability at different levels of a health systemâcan be used to make policy recommendations on general health system reform as well as specific reforms of logistic systems, vertical immunization or family planning programme effectiveness (Bossert et al. 2007). The challenge in this approach is to account for the general national context factorsâpolitical, economic, social and culturalâwhich may influence the performance of these initiatives. What works in Chile may not work in China due to many different characteristics of the country contexts. This is a major lacuna in the current research in health systems often covered over by focusing only on the differences in average income levels, assuming for instance that health system changes in low-income countries are all relatively similar. However, governance issues, cultural and ethical differences, past histories with different health systems, all play a role in constraining the lessons learned from one country to another. The recent concern with political economy and political institutionalism may inform future work in this area (Fox and Reich, forthcoming). In addition, focus on one subsystem or one policy lever is likely to miss the interactions among different subsystems changes that synergistically influence outcomes. For instance, changes in decentralization may be enhanced by changes in social insurance programmes, or the creation of a new cadre of health workers. Focusing on one in order to evaluate its separate impact will miss the role of the combined changes on achieving objectives. However, if we are aware of these limitations, it might be possible to move collectively toward setting a research agenda in which multidisciplinary researchers assess the different subsystems in ways that inform each other. Those of us who focus on organizational issues like decentralization and human resources need to be aware of and incorporate in our studies, the work of experts in economics, ethics, politics and other behavioural sciences, as well as epidemiologists and biostatisticians who help us understand the underlying population and social processes underpinning those systems. There is also an imbalance of research on functional areas of analysis with a much greater body of knowledge on financing and payment issues than on organizational issues and governance and regulation. In recent years, there has been greater interest in governance, politics and human resources issues, but these areas are so complex that they require much greater attention and more funded research than is currently in the pipeline. This poses an additional requirement for multidisciplinary studies that address these under-researched areas to bring the level of knowledge up to that of the more economic themes. This is a huge task of course and current funders have little patience for large research projects in health systems. Indeed there is considerable pressure for evaluating the performance of programmes and projects that have been funded in a very short and unrealistic time frame. It suggests that we need to be nimble and develop cadres of multidisciplinary experts to be able to quickly do the solid research necessary but within limited funds and short time horizons to provide well-documented policy recommendations. If we do not, we are likely to have missed the opportunities of this wave of interest as funding for health systems declines due to alternative priorities, donor fatigue or general global economic restrictions. None declared.
In mid 1997, Indonesia was seriously affected by the Asian economic crisis. This quickly spread into monetary, political, and social crises. Following a new presidential appointment, pressures and demands from the grass-roots to reform government systems become stronger and more persistent. Several provinces, particularly those having rich natural resources, pressed for greater autonomy. They felt that their natural resources were being taken by the central government but only a small part came back to them. If the central government did not respond to their pressures and demands, they threatened to proclaim independence from Indonesia. <br><br>Education in Indonesia has been a decentralized system since the issuance of Law Number 22/1999 on Local Government. This law was reviewed in 2004 and became Law Number 32/2004 on Local Government. The essence of Law Number 22/1999 was that education was devolved mostly to local government which in Indonesia is at the district level. As a consequence, education was no longer dominated by the central government; local government had voices in policy, planning, management, finance and delivery of education. Law Number 32/2004 revised some earlier decisions and provided more authority to Provinces. <br><br>Despite an initial impression that the Ministry of National Education (MONE) has real power, its reach is limited and constrained by political and bureaucratic structures and the capacity of those working in the system at all levels. It is worth noting that the MONEâs role is rendered even more complex by the fact that education in Indonesia falls under three ministries: MONE, Ministry of Home Affairs (MOHA) and Ministry of Religious Affairs (MORA). While MONE has the responsibility for coordinating education, each ministry has its own political and administrative agenda and processes, complicating the already complex and demanding tasks associated with decentralization. <br><br>Implementation of education decentralization in Indonesia is not easy because of its political dynamics and geographic and administrative complexity. The dynamics and complexity of Indonesia can be seen in its demography â population size and variations in density and ethnicity, and its geography â the 13,000 islands causing serious communication problems. From the political perspective, issues such as bureaucratic complexity, complex processes of decentralization due to it being driven by political and donor forces, and implementation complexity involving a range of actors and arenas have also contributed to the challenges. From the administrative view point, the challenges included rapid implementation (big bang), simultaneous political, administrative, and fiscal decentralization, and delays in establishing legal frameworks stipulating the divisions of obligatory functions between central, provincial, and district levels. In addition, the lack of capacity amongst local managers to do their jobs created real problems at the district level. <br><br>Decentralization of education in Indonesia has brought a lot of changes and one of the most important of them is community participation in education. The community must now take part in the quality improvement of educational services, which includes planning, monitoring, and evaluation of educational programs through Boards of Education.<br>
Decentralization policy in Indonesia has given an increase of authority to local government in managing their own local finance. One of the characteristics of the decentralization policy is to increase local taxing power, with the objective to optimize local own revenue in supporting local spending. Given the current data observation, it is obvious that many local governments do not have significant local own revenue to support their local spending. This paper-adopting tax elasticity method-attempts to evaluate the present local own revenue optimization. Furthermore, by adopting a decomposition of tax elasticity, this paper also attempts to elaborate factors affecting local own revenue collection. The estimated local own revenue elasticity show that most taxes and user charges, which are the main sources of local own revenue, are considered not a buoyant tax. More analysis using a decomposition of tax elasticity shows that tax to base elasticity is weak, suggesting that local governments need to improve discreationary tax changes at local level, such as local base changes, collection changes, and enforcement changes. The analysis also shows that some local tax bases are not responsive to the economic growth, which leads to the recommendation to improve local business environment, such as streamlining local regulations and reducing harmfull local taxes and user charges. Keywords: local finance, local government owned revenue, fiscal decentralization, local tax elasticity, local tax base, nuisance local taxes, local economic growth
Financial decentralization, along with financial globalization, are currently two of the phenomena that concern professionals involved in reforming the local government finance and accounting systems, that are trying hard to become a language of communication for those interested in knowing the position and financial performance of local communities in Romania, as well as internationally. To meet the need of informing the taxpayers interested in knowing the methods of incorporation and usage of resources, of training financial creditors in administering their capacity for repaying any loans, as well as all the interest parties (including central government), local communities have turned to instruments they have at hand: budget and accounting.
This contribution is aimed at comparing fiscal autonomy of self-governing units after fiscal decentralization in the Slovak republic. Evaluated and compared are budgets of selected Slovakian towns with the accent on the budget incomes creation. The contribution evaluates the level of self-financing as the share of own incomes to current expenditure, and also the level of self-sufficiency as the share of own incomes (including local taxes and fees) to total incomes.
The dissertation examines the political challenges of public utility reform through the analysis of urban water and sanitation services in Mexico. Decentralization of services to municipal governments was coupled with promotion of "market-based" policies in the 1980s and 1990s. However, the unpopularity of these policies provided political obstacles for mayors now charged with reforming the sector because many consumers were not accustomed to paying for water services. These policies--increased water prices, rigorous fee collection practices, and service suspension for non-payment--were political costs felt in the short-term, whereas the benefits of reform were long-term service improvements in water quality and quantity, reduced environmental pollution, and increased economic and social development. This problem of time inconsistency is a challenge even for pro-reform mayors because mayors in Mexico have a narrow window of time within which to enact policy. Mayoral administrations are three years long with no immediate re-election, and bureaucratic administrators follow the electoral cycle, which further exacerbates the challenge of long-term policymaking.Based on a comparative analysis of nine Mexican municipalities, I argue that mayors whose constituent base is primarily composed of middle and upper income consumers and business are more likely to reform because these groups are more able to pay short-term costs for long-term service improvements than the urban poor. With the support of a pro-reform mayor, reform is likely under two conditions: a) the presence of a water intensive industry and b) institutional support from the state government. Water intensive industry prioritizes improvement in service delivery, calculates costs based on the long run, and, further, has long-term financial and professional ties in the community. Water intensive industry is well positioned to support the policy process over time by participating in the leadership of the water utility board of directors. Also, water intensive industry can help offset the costs of reform because it pays more per cubic meter through a block tariff pricing scheme, a policy that subsidizes domestic consumers and helps to finance the reform agenda. Therefore, water intensive industry can lengthen the political problems of imposing costs in the short-term for mayors, lowering the costs to consumers before the long-term benefits of service improvements appear. Finally, state governments can provide legal, fiscal and technical resources that can help shorten the learning curve of incoming mayoral administrations. As such, state government can shorten the long-term planning of the reform process to make it more consistent with the shorter electoral cycle found at the municipal level. This research advances debates on policy adoption and implementation, highlighting the importance of political-business coalitional support as well as the role of inter-tier relations in maintaining policies over time.
This thesis will take issue with Citibank's purchase of Banamex and its art collection in 2001 as a point of departure to discuss how legislation on national patrimony is changing as Mexico opens up the cultural sector to foreign and private ownership. I will contextualize this change through a review of Banamex and Televisa involvement in the cultural field since the late 1960s. I will also examine how the adoption of neoliberal economic measures has encouraged the participation of the private sector and the shift from a state funding system towards a model of transnational corporate philanthropy. In this context, I will argue that the emergence of corporate philanthropy in Mexico is a direct result of the re-distribution of finance capital that accompanied Mexico's neoliberal turn. For most part of the twentieth century, the Mexican state was the sole sponsor and manager of cultural matters. This funding system began to change in the late 1960s when private citizens and corporations began to invest more openly in the arts as the one-party-rule of the Institutional Revolutionary Party (PRI) began to decline. In the late 1990s as Mexico integrated to the global economy, a need to update this form of management became urgent. Encouraged by the possibility to democratize and decentralize the state's funding system, new state cultural apparatuses that promoted private intervention were established. However, within the framework of the North American Free Trade Agreement (NAFTA), these newly formed state institutions did not legislate in favor of protectionist measures in the cultural field and rather opted to continue espousing a nationalist rhetoric (without a legal backing) while opening up the sponsoring and ownership of culture and national patrimony to an increasingly transnational private sector. This situation gave rise to debates about the privatization of culture, the inefficient legislation in cultural patrimony, and most importantly, the new role that the state should adopt in handling cultural matters as Mexico's political environment moved towards a democracy aligned to neoliberal economics. I will address how Banamex and Televisa, two of the first corporations to invest in culture and develop cultural foundations, became protagonists in these debates.
In the last years we witnessed the continuous growth of local public resources, while public authorities from territorial-administrative units diversified their structures in order to achieve all the tasks that have been transferred. As a result, the position of subordinated public institutions was strengthened by increasing their number and volume of resources developed by them. In this paper we propose to highlight the features of the financial management of public funds by public institutions of local subordination in the context of decentralization in Romania.
Carmen Maria LÄcÄtuĆ, Ioana Duca, Florin VÄduva
This paper is studying the degree of financial independence and decision of local authorities, in a number of transition countries in South-Eastern Europe. Our research identified the strengths and weaknesses of public finance reform, for each country, followed by a classification of decentralization in the analyzed area.
Published as: Jorge Martinez and Paul Smoke. Conclusion in <em>Local Government Finance: The Challenges of the 21st Century. </em>United Cities and Local Governments' Second Global Report on Decentralization and Local Democracy, Barcelona 2010.Edward Elgar, 2011. (c) United Cities and Local Governments. Published by <a href="http://www.e-elgar.co.uk/">Edward Elgar</a>. Posted with the permission of the publisher for personal use only.
Tatiana MoÈteanu, Carmen Maria LÄcÄtuĆ, Mirela Anca Postole
This paper work aims to identify the issues of Romanian local public decentralization, recommending measures to streamline the public finance circuit. The reorganization of the public government in three levels, the growth of the financial independence of local authorities and public administrationâs decisionsâ transparency next to a better information of citizens, coupled with their empowerment and involvement in public affairs, all these represents key points for the discharge of decentralization of public finances: to increase social welfare.
This chapter is intended to examine the influence of the current worldwide financial and economic crisis on local government finance in Bulgaria and identify the answers from central and local governments to the critical situation in the context of specific conditions of the national economy and the stage of financial decentralization reform. It contains three sections. Section one describes the level of fiscal decentralization at the beginning of the crisis and the general effects of the crisis in the country. Analysis is focused on the dynamics of the main macro economic indicators, such as GDP growth, inflation rate, unemployment rate, consolidated budget balance (deficit / surplus), consolidated public debt, and its impact on public finance. The assessment is based on factual figures for the period 1990â2009 and forecast for the period 2010â2011. A comparison is made between the loss of the Bulgarian economy at the beginning of transition (1991â1993), during the financial crisis in 1996â1997, caused by a credit crunch and a series of bank bankruptcies, and the current financial and economic crisis. Section two outlines the most important actions taken by the national government to consolidate the crisis and the respective effects on local finance. Section three concludes.