The purpose of this study is to explore what governance structures and leadership styles enhance community participation in school governance. The study specifically explored community participation and democratic leadership in improving school governance and management. Qualitative research approach was applied and twenty three (23) informants were interviewed for this study. The study sample comprises of Ministry of Education officials, School Management Committee (SMC) and Parent Teachers Association (PTA) members who represent the parents and the community, Head teachers, and teachers. Interviews, documents evidence, and general observation have been employed as a means of data collection methods. This use of interviews is to allow the informant express his or her views based on the subjective school of though. The data collected was analysed inductively. Educational decentralization is the common way through which community can participate in the governance and management of the schools in Sub-Saharan Africa. Governance and community participation, and organization theories which comprises of critical organization theory, bureaucratic theory, stakeholders theory, and Role theory form the bedrock of the study. The study reveals that the schools have formal structures (SMC and PTA) that promotes community participation in school governance, and that these formal structures are an expression of democratic governance that allow the community to participate in the governance and management of the school through democratic practices and democratic leadership that allows broader participation of the stakeholders in the governance and management of the school. The research findings reveal that community through the SMC and the PTA participate in the governance and management of the schools as the community is engaged in resources mobilization, planning, budgeting, school development, policy formulation, administration and financing of the school, but policies on the curriculum and exams is under the government and that the community is also limited with lacks training, and skills. As such the roles played by the community are underperformed and financed. The study concludes that community participation and democratic leadership enhance school governance and management, as educational providers are hold accountable by the community in this democratic school governance and management.
This article addresses several issues pertinent to health systems governance for health equity. It argues the importance of health systems using measures of positive health (well-being), discriminating in favour of historically less advantaged groups and weighing the costs of health care against investments in the social determinants of health. It cautions that the concept of governance could weaken the role of government, with disequalizing effects, while emphasizing the importance of two elements of good governance (transparency and participation) in health systems decision-making. It distinguishes between participation as volunteer labour and participation as exercising political rights, and questions the assumption that decentralization in health systems is necessarily empowering. It then identifies five health system roles to address issues of equity (educator/watchdog, resource broker, community developer, partnership developer and advocate/catalyst) and the implications of these roles for practice. Drawing on preliminary findings of a global research project on comprehensive primary health care, it discusses political aspects of progressive health system reform and the implications of equity-focused health system governance on health workers' roles, noting the importance of health workers claiming their identity as citizens. The article concludes with a commentary on the inherently political nature of health reforms based on equity; the necessary confrontation with power relations politics involves; and the health systems governance challenge of managing competing health discourses of efficiency and results-based financing, on the one hand, and equity and citizen empowerment, on the other.
In this paper we study the optimal monetary and fiscal policies of a general equilibrium model of unemployment and money with search frictions both in labor and goods markets\nas in Berentsen, Menzio and Wright (2010). We abstract from revenue-raising motives to focus on the welfare-enhancing properties of optimal policies. We show that some of the\ninefficiencies in the Berentsen, Menzio and Wright (2010) framework can be restored with appropriate fiscal policies. In particular, when lump sum monetary transfers are possible,\na production subsidy financed by money printing can increase output in the decentralized market and a vacancy subsidy financed by a dividend tax even when the Hosios’ rule does\nnot hold.
This study is intended to examine the influence of the current worldwide financial and economic crisis on financial decentralization process in Bulgaria and identify the answers of the central and lo-cal governments to the critical situation in the context of specific conditions of the national economy and the stage of financial decentralization reform. Analysis is focused on dynamics of the main mac-roeconomic indicators, based on fact figures for the period 1990–2009 and forecast for the period 2010-2011, and its impact on the public finance. The most important actions, taken by the national government to consolidate the crisis are described and evaluated on the base of their effects on the lo-cal finance. A comparison is made between the loss of Bulgarian economy in the beginning of transition (1991-1993), during the financial crisis in 1996-1997, caused by credit crunch and series of bank bankruptcies, and the current financial and economic crisis. Finally, some conclusions and pol-icy recommendations are outlined, intended to improve crisis management in Bulgaria both on the national and local level.
Government spending on health has grown as a percent of GDP over the last 40 years in industrialized countries. Widespread decentralization of healthcare systems has often accompanied this increase in spending. In this paper, we explore the effect of soft budget constraints on subnational health spending in a sample of OECD countries. We find countries where subnational governments rely primarily on central government financing and enjoy large borrowing autonomy have higher healthcare spending than those with more restrictions on subnational government borrowing.
Decentralization of decision-making on the availability of essential public goods for regional and local level raises questions regardless of ability to ensure or guarantee the supply by the small municipalities. It affects the delicate problem of fiscal decentralization and own limits of decentralization process. In this paper, we deal with problems concerning primarily the development of small municipalities as independent public corporations, their ability to play the self-government role and to ensure the availability of essential public goods and services. The main criteria for defining small rural communities are the population and the status of municipality in the settlement structure, which is a predetermined by range of services provided at territory of municipality (market services, public services) to its citizens and residents of surrounding villages. We deal with problems of financing small communities, their participation in the distribution of revenue from shared taxes, the availability of other resources. We monitor the factors that enter into models of reallocation of public resources. We base their findings mot only on information from literature, but also from terrain research, which not only confirmed some previously published facts, but allowed to reveal the factors that significantly affect the financial situation of small municipalities. This led to the determination of parameters, the key mechanism for setting the allocation of public resources. On the basis of the investigation, we analyze the parameters, the key mechanism for setting the allocation of public resources. In conclusion, the authors summarize the main issues and articulate the principles that should be respected in the formulation and adjustment of the budget determination.
Open access
Regional Development and Policy
Polish socio-economic development
Hungarian Social, Economic and Educational Studies
Improving quality and efficiency in providing public services by accelerating the decentralization process represents one of the fundamental premises of a democratic, rule of law state that is oriented towards achieving performance in public services for its citizens. Bringing public decision-making closer to the citizen, improving quality in providing public services to citizens, as well as reducing their costs, are but a small part of the advantages brought about by public services decentralization, with the major role in decentralization being played by both education institutions, and local public authorities. In this context, the study focuses firstly on approaching empirically and epistemologically the decentralization of Romanian public education system, which presupposes transfer of authority, responsibility and resources concerning decision-making, and of general and financial management towards education institutions and local community. What is also revealed in this study is the premises and stages of Romanian public education decentralization, the advantages but also disadvantages and limitations of decentralization, as well as the education public service prospects from the perspective of decentralization. Last, but not least the study approaches the subject from the viewpoint of related public policies and legislation; the research puts emphasis on the fact that in accordance with the present Romanian legislative framework, the entire patrimony of public schools- land and premises- is public property and belongs to communes, cities and municipalities, and it is managed by the respective local public authorities. Furthermore, it is local budges that finance schools, and school patrimony and funds are currently being handled by local councils. Insufficiency of financial resources on the part of local communities may represent a serious drawback in the way of achieving efficient and effective decentralization in Romania, thus indicating a need to identify feasible solutions for finding the resources necessary for the conclusion of this process.
Open access
Education, Management, Technology, Human Resources
Fiscal federalism has been an important topic among public finance theorists in the last four decades. There is a series of arguments that decentralization of governments enhances growth by improving allocation efficiency. However, the empirical studies have shown mixed results for industrialized and developing countries and some of them have demonstrated that there might be a threshold level of economic development below which decentralization is not effective. Developing and transition countries have developed a variety of forms of fiscal decentralization as a possible strategy to achieve effective and efficient governmental structures. A generalized principle of decentralization due to the country specific circumstances does not exist. Therefore, decentralization has taken place in different forms in various countries at different times, and even exactly the same extent of decentralization may have had different impacts under different conditions. The purpose of this study is to investigate the current state of the fiscal decentralization in Mongolia and to develop policy recommendations for the efficient and effective intergovernmental fiscal relations system for Mongolia. Within this perspective the analysis concentrates on the scope and structure of the public sector, the expenditure and revenue assignment as well as on the design of the intergovernmental transfer and sub-national borrowing. The study is based on data for twenty-one provinces and the capital city of Mongolia for the period from 2000 to 2009. As a former socialist country Mongolia has had a highly centralized governmental sector. The result of the analysis below revealed that the Mongolia has introduced a number of decentralization measures, which followed a top down approach and were slowly implemented without any integrated decentralization strategy in the last decade. As a result Mongolia became de-concentrated state with fiscal centralization. The revenue assignment is lacking a very important element, for instance significant revenue autonomy given to sub-national governments, which is vital for the efficient service delivery at the local level. According to the current assignments of the expenditure and revenue responsibilities most of the provinces are unable to provide a certain national standard of public goods supply. Hence, intergovernmental transfers from the central jurisdiction to the sub-national jurisdictions play an important role for the equalization of the vertical and horizontal imbalances in Mongolia. The critical problem associated with intergovernmental transfers is that there is not a stable, predictable and transparent system of transfer allocation. The amount of transfers to sub-national governments is determined largely by political decisions on ad hoc basis and disregards local differences in needs and fiscal capacity. Thus a fiscal equalization system based on the fiscal needs of the provinces should be implemented. The equalization transfers will at least partly offset the regional disparities in revenues and enable the sub-national governments to provide a national minimum standard of local public goods.
This article discusses the model of oral health care implemented in the Unified Health System of Brazil in the last decade. This model was conceived as a sub-sector policy that, over the years, has sought to improve the quality of life of the Brazilian population. Through a chronological line, the study presents the National Policy on Oral Health as a counter-hegemonic patient care model for the dentistry practices existing in the country before this policy was implemented. The reorganization of the levels of oral health care, the creation of reference facilities for secondary and tertiary care, through Centers of Dental Specialties and Regional Dental Prosthesis Laboratories, and the differential funding and decentralized management of financial resources were able to expand the actions of oral health for more than 90 million inhabitants. The evolution shown after the deployment of the National Oral Health Policy, as of 2004, demonstrates the greater integration of oral health care under the Unified Health System and provides feedback information to help this policy to continue to be prioritized by the Federal Government and receive more support from the state and local levels in the coming years.
Tax increment financing (TIF) is the most widely used local government program for financing economic development in the United States, but the proliferation of TIF is puzzling. TIF was originally created to support urban renewal programs and was narrowly focused on addressing urban blight, yet now it is used in areas that are plainly unblighted. TIF brings in no outside money and provides no new revenue-raising authority. There is little clear evidence that TIF has done much to help the municipalities that use it, and it is also a source of intergovernmental tension and a site of conflict over the scope of public aid to the private sector. Yet, the expansion of TIF makes sense in light of the basic structure of American local government law. Studying TIF can illuminate central features of our local government system. TIF succeeds -- in the sense of its widespread adoption and use -- because it, like local government more generally, is highly decentralized; reflects and reinforces the fiscalization of development policy; plays off the fragmentation of local governments and the resulting interlocal struggle for investment; and fits well with the entrepreneurial spirit characteristic of contemporary local economic development policy. A better understanding of TIF contributes to a better understanding of the political economy of American local government.
THE IDEA THAT WE ARE—or should be—moving from an “industrial age government” to an “information age government” is a staple of political rhetoric. But has the information age significantly altered government in the liberal democracies? And if it has not yet done so, should we expect the liberal state to change in any fundamental way, or be entirely replaced, because of the chain of consequences set in motion by new technology? Since the early development of computers, there have been, broadly speaking, three phases in thinking about the potential of new technology to improve government. Beginning in the 1950s, the application of digital technology to the public sector was conceived of as automation and the hope was mainly for greater efficiency and control in governmental operations. A second phase, dating from the 1980s and rising to a climax in the following decade, pitted two alternative visions against each other—privatization and reinvention—each premised on the idea that the information age made traditional forms of public administration obsolete. Finally, in the most recent phase, digital democracy has become a central theme of visions of new forms of governance based on the diffusion of cheap computing and online communication. Each of these phases has brought some notable but far from revolutionary achievements, and that is what we should continue to expect. Digital technology does enhance some features of democratic government, but the fundamental problems of democracy are not susceptible to technological solutions, and the same developments that strengthen some democratic capacities degrade others. In this new environment, it will be a struggle just to maintain some of the minimal conditions of political accountability that democracy requires. The U.S. federal government, particularly the military, was initially a leader in the development of computers, and from World War II to the 1960s, the state stood on the frontier of information technology. The application of computers to the public sector raised expectations not of radical change but of doing what government agencies already did, only faster and more cheaply—that is, automating the bureaucratic status quo. Top-down control and economy of administration were the primary purposes of computerization. Computers were supposed to cut paperwork and costs, reduce crime, and give managers and policymakers better information. The pursuit of control is at the core of bureaucratic administration. Bureaucracy is ideally supposed to ensure adherence to rules through such means as hierarchical command, specialization of functions, uniformity of procedure, and formal documentation. By limiting individual discretion, these elements of bureaucracy are supposed to increase the capacity of the state to carry out whatever purposes animate it. Democracy, far from being antithetical to bureaucracy, has often stimulated its growth. Scandals regularly prompt demand for new rules. The progressives who brought America the popular referendum and direct election of senators also introduced unified budgetary control and stricter rules about the award of government jobs and contracts. They sought as well to professionalize administration and make it more scientific. Computerization fit the progressive bureaucratic paradigm perfectly. The introduction of computers in the 1950s and 1960s coincided with budgetary reform efforts that were intended to give chief executives and their finance officers greater control over how money was spent. Computerization offered the promise of achieving the elusive fiscal goals of unified control and accurate cost accounting for public services. The very nature of early mainframe computers seemed to dictate centralized control, although line agencies fought to get their own computers. Thus, the most widely anticipated effect of computers on government was the centralization of power. Greater executive control over the bureaucracy was an explicit reform objective, but many critics feared that computerization would augment the state's dominion over the individual, and this concern focused the attention on privacy protection. These anxieties were hardly unreasonable. At all levels, government was oriented not to the computerization of service but to the computerization of constraint—that is, to computerizing functions such as police, revenue collection, and motor vehicle licensing. Within the service agencies, computerization chiefly involved functions in back offices such as record keeping. The “backstage” locus of automation concerned both supporters, who thought the public might not appreciate the value of computers, and critics, who thought the public might fail to appreciate the threat to privacy. The early decades of computerization did bear positive fruit. The mid-twentieth century saw enormous growth in government, and after 1955, computers helped public agencies cope with the sheer increase in transactions. Despite the rise in federal expenditures in the United States, the number of federal civilian employees fell; productivity gains from computerization helped to make that possible. But by the 1980s, new developments in both politics and information technology led to a dramatic turn in thinking. Instead of improving bureaucracy, the goal became overthrowing it. The rise of conservative antigovernment sentiment in the Reagan era coincided with a shift in the relationship of government to technological change. The private sector had now moved into the forefront in the use of information technology. In 1983, a Reagan administration commission was stating the obvious when it declared that although the federal government in the 1960s had been “the acknowledged leader in using state-of-the-art computer hardware and software,” the government had fallen “farther and farther behind.” The technological lag of the public sector was particularly evident at government's front end—that is, where the public had direct contact with government. By this time, businesses were using telecommunications and information technology to improve customer service and produce a wider array of products tailored to different tastes; consumers had become used to the convenience of automated teller machines (ATMs), credit cards, and free, round-the-clock calls to 800 numbers. By comparison, public agencies were far slower to take up the new possibilities. The shift from mainframes to minicomputers and the rise of personal computers also turned earlier assumptions upside down; instead of favoring centralized control, the new technology could be a means of decentralization. Conservatives and liberals responded to this situation in different ways. To conservatives, the failure of government to keep up with information technology confirmed the need for privatization. As many corporations were outsourcing specialized functions, so government should do the same—indeed, the state should generally cut back its size and role. The information revolution thereby provided a legitimizing rhetoric for policies that conservatives had long favored for other reasons. To liberals, the logical response to public sector lag was not to privatize government but to “reinvent” it by making public agencies more flexible in organization, more focused on results rather than procedures, and more responsive to “customers.” The Clinton administration's National Performance Review, led by Al Gore, embodied this approach and linked it to the information revolution. In the same period as this debate was playing out, the Internet was becoming a popular medium, and the vision of a reinvented state increasingly emphasized the use of online communication in making government more customer friendly. The focus on improving government at the point of contact with the public involved more than a pretty new interface; electronic access offered the promise of better integrated and more consistently delivered services. But besides improving government's output, the Internet also awakened an interest in giving citizens more input. And with the development of the Web and tools built on it, that interest has gained traction. Digital media have unquestionably expanded the democratic repertoire. Political campaigns and social movements now have cheap, instant means of communication that circumvent the established mass media, and they can use those resources to mobilize followers, coordinate their activity, and aggregate contributions of money, labor, and knowledge. The successful use of new media in politics has raised expectations about its use in government, particularly for three purposes—increased transparency, collaboration, and participation. Transparency is the most readily achievable of these goals. Just as some early advocates of “teledemocracy” envisioned, the Internet now provides instant access to government documents and data, and allows the public to track legislation and regulatory decisions. The idea of transparency has grown, moreover, into the notion of government as a “platform” that routinely makes granular data available in a form that enables others to build applications on top of it. Here, the goal of open government moves from transparency to collaboration and participation, which raise more difficult questions. Other ideas along these lines call for crowdsourcing proposals for government action and putting such proposals up for electronic voting. The further one moves along the spectrum of actions from transparency to participation, the more vexed the idea of digital democracy becomes. Even though the digital divide has narrowed, any reliance of government on digital technology will put people with less income and education at an inequitable disadvantage because of persistent differences in digital skill as well as access. Moreover, where online participation is opened up, highly committed minorities and special interests are likely to dominate. In a crowdsourcing initiative after the election, the Obama transition effort invited the public to submit and vote on ideas, but the results were embarrassing. As the New York Times reported, “In the middle of two wars and an economic meltdown, the highest-ranking idea was to legalize marijuana, an idea nearly twice as popular as repealing the Bush tax cuts on the wealthy. Legalizing online poker topped the technology ideas.” Conceived this way, digital democracy recapitulates the classic problems of direct democracy—skewed participation and lack of deliberation. Other difficulties with the idea of revitalizing democracy through online communication arise from the indirect effects of new media on traditional mechanisms of political accountability. By providing an alternative platform for advertising as well as news, the Internet has undercut the sources of newspaper revenue, plunging journalism into a deep crisis and weakening the ability of the press to keep watch on government, particularly at the state and local levels. Resources for journalism are now disappearing from the old media faster than the new media can create them. Furthermore, newspapers have assembled a broad public, including many people who have bought a paper for the sports or crossword puzzle but nonetheless scanned the front page and learned something about the news of their community and the world. Online, however, they can go to a sports or puzzle site without any exposure to the news. In the early years of television, when the evening news was on all three available channels, the national news had a similarly broad public. But beginning with cable television, the advent of new media has brought a profusion of choices of different kinds of entertainment. The share of the public who regularly follows the news and public affairs has declined, though those with the most interest in politics (usually people with strong partisan commitments) have access to more news and a wider range of opinions than before. Despite the cornucopia of information, the politically attentive public has diminished and become more sharply divided along ideological lines. The gains for democracy from new technology are real, but unfortunately, so are the losses. It may be a long time before we can add them up and determine the net impact. In each phase, early enthusiasms have run up against stubborn and uncomfortable limits, even as new democratic possibilities have opened up. We are still in the midst of tremendous ferment in technology, media, and politics, and the creativity now being unleashed is our best hope that when the digital revolution finally runs its course, free societies and popular self-government will be left standing.
This paper examines the financial crisis in light of the local economic development and sets out some policy recommendations. Local economic development is a process in which the local authorities cooperate with the public sector, business community, and NGOs, in order to create more appropriate environment for economic development and for unemployment decreasing. The last months saw the world economy facing to the worst financial crisis in history, causing unprecedented drop in demand and sales and record‐breaking unemployment levels worldwide. No country can escape certain economic and social consequences from the global financial crisis. The main research question is the following: How does the gobal crisis affect local governments? The local governements are facing several problems such as: higher unemployment and social needs at the community level, pressure for increased spending, difficulties of investment financing, need of deferring maintenance. Then, the paper sets some policy recommendations adressed to the following aspect‐ what should and can local governments do? The crisis offers some chances for change in the context of strengthening the role of local governments.The central government will rely on local governments to bring policies rapidly to bear on the economy. This could and should intensify the intergovernmentaldialogue and it could also lead to strengthening fiscal autonomy of municipalities. Improving the competitiveness at the local level and developing a strong local economy can help the country cope with the effects of the global economic slowdown. Local government units should improve their competitiveness to attract more investments and to develop their local economy. Given that the responsibility of assisting the national government in mitigating the impact of the crisis through stimulation of the local economy are given to local governments, this paper aims to discuss issues related to enhancing local economic development and fiscal decentralization as a means of improving overall service delivery in the country, in the context of global economic and financial crisis. Local governments may also be succesful in the promoting productivity locally in order to enhance the country’s competitiveness in anticipation of a greater role in global trade during the recovery in the next few years. The special focus of this paper has been given to the case of local economic development in the Republic of Macedonia.
Open access
Regional Development and Management Studies
Regional Development and Policy
Hungarian Social, Economic and Educational Studies
The essay provides support to the hypothesis that financing of provincial public spending through national transferences leads to overspending. We rest on persuasive economic and politicoinstitutional arguments. Fiscal illusion and the Leviathan model help to explain the overspending. And cartelization of tax collection helps to explain why governors are so reluctant to decentralize this task. We conclude that a fiscal organization closer to that of a confederation would be desirable. Two ways of organizing fiscal relations between the Nation and the provinces are considered. One way consists of paying for national spending by means of periodic provincial transferences; control of public spending by tax-payers would be the greatest possible in this scenario, though leaving national financing in provincial hands could be a risky affair. Another way consists of allowing the Nation some taxing power and incorporating constitutional restrictions as regards the kinds of public goods the national government is permitted to provide.
In OLG economies with life-cycle saving and exogenous growth, competitive equilibria in general
fail to achieve optimality because individuals accumulate amounts of physical capital that differ from the one that maximizes welfare along a balanced growth path (the Golden Rule). With human capital, a second potential source of departure from optimality arises, related to education decisions. We propose to recover the Golden Rule of physical and also human capital accumu-
lation. We characterize the optimal policy to decentralize the Golden Rule balanced growth path
when there are no constraints for individuals to finance their education investments, and show that
it involves education taxes. Also, when the government subsidizes the repayment of education
loans, optimal pensions are positive
BACKGROUND: In recent years there have been innovations in immunization financing and new technologies, and the scaling up of investment by the Global Alliance for Vaccines and Immunization (GAVI) in the Asia region. The main mechanism for coordination of this global health initiative (GHI) investment is country-level 'Inter-Agency Coordination Committees' (ICCs). AIM: The aim of the evaluation was to determine the utility and future perspectives of stakeholders regarding the role of ICCs in improving immunization services in the Asian Region. METHODS: A literature review, documentary analysis and semi-structured interviews (n = 65) were undertaken in five countries (India, Bangladesh, Nepal, Sri Lanka and Indonesia), with senior level members of Ministries of Health and the GAVI partnership. RESULTS: The evaluation has identified that there have been significant changes recently in the strategic environment for immunization, including developments in new vaccines, increasing GAVI investment, trends towards health system integration and decentralization, and institutional development of the non-government sector. This evaluation found that ICCs are functioning well in relation to information sharing and GAVI application processes. However, they are performing less well in the areas of evaluation, strategic gap analysis and coordination of immunization technical co-operation. CONCLUSIONS: There are high levels of institutional and contextual complexity at country level that require a more focused global response by GAVI to the governance challenges of institutions and partners implementing GHIs at the country level. ICCs should be maintained and strengthened in the more pluralistic context of an 'immunization coordination system' that is represented by the wider health sector, regulatory authorities, and civil society and private sector interests. Managing through systems, rather than being over-reliant on committees, will broaden participation in implementation and, in doing so, expand the reach of immunization and maternal and child health care services in developing countries.
This paper analyses health reforms in Tanzania since 1924 to 1993 to determine how each paradigm influenced the next by using the recent World Health Organization (WHO) framework of health system. Published and gray documents were reviewed and analyzed for the four discrete attempts at reforming the health sector, focusing on the district health system decentralization. The findings revealed that for each wave, there was a review of the health system, making information from preceding efforts to be available to the subsequent reforms. After independence the political party in power played a major role in ensuring availability of information and its utilization. Predominant information in each wave showed that the health system was underfinanced, there was poor performance of PHC strategies, non-integration of DMO and poor health workers income. Health reforms should focus on health system finance, integrated district health system, health workers welfare and community participation.
Regional form of Organization of the health care that are called today DyPE, have as a main \ngoal to promote more rational resource allocation through decentralization in the decision \nmaking process. The concern for more effective and efficient use of resources devoted into \nthe health care sector renders hospitals a critical vehicle of the quest for superior economic \nperformance, especially if we take into our consideration their mounting over time deficits. \nEconomic performance is primarily traced through a set of specific financial ratios, which \nembrace important elements that constitute the substance of the financial well-being of \nhospitals as economic units. An array of financial ratios is critically reviewed and a \ncombination of them is proposed as a means of effective financial management. The later is \nnecessary to ameliorate the funding strain imposed on the health care system and especially \non hospitals. The financial performance is determined by the return on capital (profitability) \nin connection with the risk involved. Both factors determine the value created, which in turn \naffects the amount of financing attracted in the sector. The financial information available \nto the supervising regional bodies (DyPE), don’t considered sufficient for their management \nto assess financial management of hospitals effectively. The lack of the appropriate economic \ndata is due to the fact that double entry accounting has not yet fully adopted by the economic \nunits that report to the corresponding DyPE. So, double entry accounting is prerequisite for \nreporting and monitoring acceptable financial performance. The later is vital in securing \nthat the financial needs of the health sector that are growing at an ever accelerating pace, \nare met.
The European Union (EU) is built on the federalist principle of subsidiarity, which we consider in the policy field of financial reporting. We attempt to answer the question, whether the current accounting regulation in Europe is sensibly balanced between centralized and decentralized decision making. Drawing on comparative accounting research to identify criteria for “local preferences,” we conclude that local solutions currently remain preferable for small and medium-sized companies. For them, a centralized solution would result in additional costs for at least some member states and their residents. Large international firms, in contrast, face an increasingly integrated capital market and rather need a central solution as currently implemented by the EU. However, recent developments in corporate finance may align local preferences on accountancy in the future.
Intergovernmental fiscal transfers are critical elements of public finance in decentralized countries. In the context of Indonesia’s decentralization reforms, their design and implementation have significant impacts on the potential revenue and fiscal capacity of basic public service provision. The case of Indonesia’s 2001 Big Bang decentralization illustrates the challenges associated with implementing significant reforms in the intergovernmental fiscal system. The practice of decentralization policy in Indonesia since the time has not generally improved local development performance yet. This study evaluates fiscal decentralization, focusing on fiscal capacity as the impacts of the intergovernmental fiscal equalization transfers, in the case of Gunung Kidul, Yogyakarta. The study shows a low percentage of its own revenue compared to its total budget. It indicates the failure of fiscal decentralization policy in improving local government fiscal capacity.
A persistent headache is a symptom, but the underlying cause can be anything from a migraine to a brain tumor. Good medicine means identifying and treating the cause as well as the symptom. The same is true in health care reform.
Though most Americans are satisfied with their own health care, they also see the need for substantial reform. Unfortunately, the well-meaning plans currently presented to Congress are the wrong therapy because they mistake the symptoms for the underlying disease. Nearly everyone agrees on the symptoms: rapidly growing health expenditures, diminished access to affordable insurance causing many to be uninsured, and inadequate quality and outcomes for the dollars spent. But what are the root causes? While there are many contributing factors, three merit special attention.
First, there is our inefficient and inequitable system of tax-advantaged, employer-based health insurance. While the federal tax code promotes overspending by making the majority unaware of the true cost of their insurance and care, the code is grossly unfair to the self-employed, small businesses, workers who stick with a bad job because they need the coverage, and workers who lose their jobs after getting sick.
This employer-based system arose not by thoughtful design but as an unforeseen result of price controls during World War II and subsequent tax policy. How this developed and persisted despite its unfairness and maladaptive consequences is a powerful illustration of the law of unintended consequences and the fact that government can take six decades or more to fix its obvious mistakes.
Second, in health care as in other markets, real progress depends on innovation. Yet health care markets rarely conduct successful experiments with new ways of paying for and organizing health care delivery. Why? Although health care markets have some unique attributes, these are not the explanation for lack of successful innovation. Rather, health insurance markets suffer from overregulation, which limits innovation in both insurance and new ways of delivering medical care.
Third, we have Medicaid and Medicare. These enormous federal programs address critical needs by delivering health care to the poor, the disabled, and the elderly. These programs pay providers by administrative pricing formulas that are well documented to promote both overuse and underuse of appropriate care, have led to rising expenditures decoupled from better health, and obligate massive future deficits that everyone agrees are unsustainable. They are also rife with fraud and abuse.
And yet the current political debate and the several and incomplete versions of “reform” proposals do little to address these core problems. Proposals such as those that would create a new public insurance program, for example, would likely magnify them and create a new generation of problems that will be as difficult to fix as Medicare has proven to be.
Why does the current set of reforms fall short? One reason is that all changes must pass through the political process. For example, any effort at Medicare reform rapidly morphs into a struggle for influence between insurers and pharmaceutical companies, big-city academic health centers and hospitals in rural areas, specialists and primary care providers, federal and state governments, and on down the line. Sadly, innovators — and all too often patients — get lost in these power struggles. Any reform effort that fails to correct the acknowledged fiscal and organizational flaws of Medicare and Medicaid while extending the political gridlock that attends it to a broader segment of the health care system is doomed to failure.
Some have offered novel approaches to “payment reform,” but none of these can realistically claim to both increase quality and reduce costs, while being acceptable to Congress. One proposal would create a new executive branch commission to propose changes to Medicare benefits and price controls that Congress could only override with a supermajority vote. While such an experiment might have the potential to reduce political gridlock, it would centralize power in a manner that seems exceptionally risky for a field that accounts for one-sixth of our economy and affects the lives of hundreds of millions of people. I anticipate many new advances in diagnostics, therapeutics, and devices over the coming decades. Optimal development and application of these will flow from a decentralized and innovative health care market and will be suppressed by a system that relies on politics and an all-powerful commission.
Some have proposed that comprehensive reform must be achieved quickly, capitalizing on a sense of crisis. I see unacceptable risks to this approach. Instead of achieving a far-reaching and necessary solution for our economy and the nation’s health, the necessity of pleasing enough special interests to get a bill passed will exacerbate our long-term crisis of cost and access. Who can tell what deals within a thousand-page bill that few, apart from lobbyists, have read will influence the state of health care for decades to come?
Now that a vote on health care reform will not occur until at least the fall, we should seize this opportunity by stepping back, making the right diagnosis, and then applying therapies that address the underlying disease. Here are a few ideas, based on the diagnoses discussed above, that may work. As with any therapy, these should be introduced as pilot programs, to be extended only if data reveal the desired outcomes. While such an approach will not fulfill the wish to produce a dramatic cure through a single stroke of legislation, it may avoid the pitfalls of the latter approach and have a greater likelihood of reducing the number of uninsured while controlling costs and enhancing outcomes. I propose this without any relationship to the partisan politics of the day that substitutes slogans and misinformation on both sides for meaningful analysis.
First, make the tax shelter for health insurance, currently limited to employers, independent of employment. This single, and morally imperative, step would enable the uninsured to use tax-sheltered money to buy health insurance for themselves while permitting insured employees, who are currently limited to a few employer-selected health insurance choices, to become more central in decision making.
Second, identify and eliminate the many barriers to entry and innovation in the health care and insurance marketplace. Eliminating what are often hidden barriers to competition will encourage entrepreneurs to offer lower-cost ways of financing and delivering health care, approaches that will deliver greater health care value for the dollars spent.
Third, make a serious effort, despite the context of widespread political demagoguery, toward deeply reforming Medicare and Medicaid. As one of many possible examples, try giving some Medicare and Medicaid enrollees earned income credits so they can make cost-conscious decisions among competing health plans. The sicker and less affluent should receive larger transfers, so they can buy adequate coverage. Among other benefits, such an experiment could break the logjam in payment reform and reliance on fee for service and centralized price controls.
Reducing rather than increasing the role of politics in health care decisions, while providing assistance for those in need, these pilot therapies would have the salutary effect of placing patients and innovators in a more central role as we determine the future of health care in America. And we would then, at last, be able to align the treatment with the disease, a fundamental principle of responsible medicine.
Addendum. I coauthored an article on health care reform and its underlying issues in 1994, and although it was written fifteen years ago, some of the concepts within this article may be relevant today (1). In addition, a recent article in the Atlantic magazine addresses key issues underlying this discussion that I find quite compelling but could not address due to considerations of length (2).
A gestão democrática, a autonomia e a participação popular nos processos decisórios são elementos que sintetizam as características das relações sociais que fundamentam um tipo de sociedade pautada em relações transparentes e solidárias. Nesse sentido, a escola pública é local privilegiado para o estabelecimento de relações sociais dessa natureza. A instituição de canais de participação e a oferta de condições institucionais, materiais e humanas para as escolas públicas são elementos indispensáveis para que isso se realize. A implementação de políticas públicas comprometidas com as classes trabalhadoras sugere que o Estado, por intermédio de suas instituições, se aproxime dos usuários dos bens e serviços públicos, provendo-lhes os meios necessários que garantam condições dignas para o exercício da cidadania. No caso das escolas públicas municipais de São Carlos, a regularidade na disponibilização de recursos financeiros para os gestores escolares foi uma forma de descentralização adotada pela Administração Municipal de São Carlos, no período 2001-2004 para garantir as condições materiais de funcionamento das escolas, com a participação popular. A análise dos dados demonstrou que essa política pública é um instrumento importante para atender as necessidades materiais e de serviços mais imediatos das escolas públicas. O desenvolvimento do trabalho mostrou que a prioridade dos gastos foi com a manutenção predial e aquisição de materiais pedagógicos, contudo as características históricosociais da cidade de São Carlos são elementos dificultadores para que as intenções democratizantes da gestão estudada, com a instituição de canais de participação popular e outros mecanismos de aproximação do Estado dos usuários dos bens e serviços públicos fossem apropriados. Como instrumento indutor da gestão democrática, a análise reafirmou o tecido social da cidade e mostrou que a organização interna, na maioria das escolas públicas, não tem favorecido a participação popular. Como proposta, o estudo sugeriu o aprimoramento dos critérios utilizados para a descentralização de recursos financeiros para as escolas municipais e o fomento às ações que possam contribuir para que haja a ruptura com práticas tutelantes.