Problems of `soft budget` constraints in intergovernmental relationships are currently at the frontier of research in local public economics. This paper reviews the Italian experience in the field, starting from the mid-1970s up to the present period, compares it with that of other countries, and uses it to comment upon the state of the literature. The paper argues that the soft budget constraint problem has been a rampant one in Italian local public finance, generating efficiency losses, lack of political accountability and undermining the soundness of public finances. The paper inquires into the causes and possible solutions to the problem, and in particular describes and comments upon the decentralization process of the 1990s. Finally, the Italian debate on fiscal federalism of the 1990s is also reviewed, arguing that some of the suggestions of this debate may be of interest more generally.
Private-ownership of roads in Nigeria is still at the deliberation stage. In other words roads (tarred and untarred) are owned by Federal, State and Local authorities in Nigeria. Most of these roads, however, share a common characteristic of being âunsafe at any speedâ, at any time of the day. This is as a result of the low quality of the road components, structures and patterns. For example, road surfaces are undulating and rough. Also, the poor standard of road infrastructure like guard railings/barriers; pavement marking and signs; illumination levels, traffic signals, horizontal/vertical alignment and sight lines contribute largely to the increasing carnage on Nigerian road network. This trend persists because authorities in Nigeria have practically relegated to the background regular road safety audit operations. This is an inevitable aspect of modern methods of road administration and management, which determines a number of traffic potentials concerning highway high collision locations; protection of errant vehicles from light poles, trees, ditches, replacement of damaged and missing signs, street lighting, capacity and level of service analysis. Finally, this paper suggests commissioning of a National Road Research Fund, with a view to developing an efficient road safety audit operational system. Also, the introduction of private initiatives and a Community-based Approach in road administration, as well as decentralization of road administration framework at all levels, will greatly help âengineer outâ potentially unsafe features across Nigerian roads, towards a better road traffic environment in the 21st century.
The paper has two main objectives. The first is to trace the progress in the process of decentralisation in the provision of public services in India. The second is to test the hypothesis that decentralisation in the system of public service delivery in primary health care and education led to improved outcomes for the rural Indian population. Before 1992, with few exceptions, there was little movement towards decentralisation. Rural local bodies functioned primarily as program executing agents for government line departments, with little control over finances, administration, or the pattern of expenditure. The only decentralisation that existed was in the importance of state governments vis-Ă -vis the centre. After the 1992 Constitutional Amendments, significant progress has taken place in the form of the passing of conformity legislation by state governments, the setting up of State Finance Commissions to examine the distribution of resources from states to local bodies, and accelerated moves towards transfer of planning and expenditure responsibilities to village bodies. The paper used data from the 1994 NCAER survey to test the hypothesis that increased decentralisation/democratisation positively influences enrolment rates and child mortality once the influence of socioeconomic circumstances, civil society organisations, the problem of capture of local bodies by elite groups, and so on are controlled for. Our main empirical findings are that indicators of democratisation and public participation, such as frequency of elections, presence of non-governmental organisations, parent-teacher associations and indicator variables for decentralised states generally have the expected positive effects, although these are not always statistically indistinguishable from zero.
D. Drache and T. Sullivan (eds) Routledge, London, 1999 Quality, Evidence and Effectiveness in Health Promotion: Striving for Certainties J. K. Davies and G. Macdonald (eds) Routledge, London, 1998 Managing for Health: Implementing the New Health Agenda D. J. Hunter Institute for Public Policy Research, London, 1999 Health sector reform has been high on the international agenda for more than a decade, driven by rising costs, globalization and a political resurgence of interest in market solutions to what were previously seen as the responsibility of the welfare state. For many it is hard to remember that less than 20 years ago, ideas now taken as part of conventional wisdom were to some extent unimaginable. The first of the three books reviewed here, Drache and Sullivan's Health Reform: Public Success, Private Failure provides a useful reminder of the relationship of current health care reform discourse to its wider political origins. Health Reform: Public Success, Private Failure began as a seminar on reforming Canada's health care system, held in 1996. The book contains papers presented at that meeting, and many commissioned expressly for publication. Contributors include leading international commentators on health and social policy, e.g. Yale University's Ted Marmor, Columbia's Mary Ruggie and Canadian economist, Robert Evans. Throughout, the major theme is that of the tensions between publicly funded health care and the increasing enthusiasm of decision-makers for health systems driven by market dynamics. While consideration of the Canadian system forms the core of the content, papers from US and Australian authors, and the way the topics are approached, ensure that the book has an international perspective and relevance. The 18 chapters are organized into five parts. Their titles give something of a sense of the flavour and organization of the book. They are as follows. Publicâprivate conflicts in health policy. Restructuring Anglo-Saxon health systems: shifting state/market boundaries. Decentralization and devolution: new state forms and practices. The political economy of health care reform in Canada. On the frontier of reform. In their introductory chapter, Drache and Sullivan identify three major objectives for health reform, which provide the conceptual organizing framework for much of the book's content. The first, and they argue, most important consideration, is âhow to sustain a public commitment to a comprehensive range of health services for all citizensâ. The second is how to improve the efficiency of health care services in times of fiscal constraint. The focus on these objectives, particularly the first, reflects the fact that this publication is clearly more sympathetic to a Beverage-style model of publicly financed health service provision than much of the literature on health care reform. In fact, the views of many of the contributors appear well encapsulated in a comment (attributed to Robert Evans in Ted Marmor's chapter), which refers to the influence of market-oriented US ideas on health system reform as âintellectual acid rainâ, which falls on their Canadian neighbour. Many in the health promotion field may see the book's title and think that this is a publication purely concerned with health âcareâ, and hence perhaps focused too âdownstreamâ to be of great interest. If so, they would be mistaken on two counts. Firstly, the third objective proposed by the editors indicates why this is one of the more relevant publications on health reform for a health promotion audience. According to Drache and Sullivan, the third objective of health reform should be how to âdevise social arrangements which engender healthy populationsâ. This perspective is canvassed most fully in the book's final chapters, which deal with the social determinants of health. For example, in their chapter âGoverning Healthâ, Lavis and Sullivan examine the important contribution of working life and labour market arrangements to health as well as considering the type of governmental structures required to take a broader, more holistic view of health determinants. The book's final chapter, titled âHealth, Health Care and Social Cohesionâ by Canadian J. Fraser Mustard, sets out a persuasive argument for social investment in the early years of life, and for the significance of trust and social capital as the basis for a healthy society. There is a second reason why this book should be of more than passing interest for readers of Health Promotion International. This is that the book's contributors make a persuasive case that how a health care system is organized and funded can itself be health promoting, in ways perhaps not widely recognized. This capacity of a publicly funded health system to foster a sense of a caring society, in which people see themselves as citizens rather than consumers, is a theme running throughout the book. As the editors comment in their introduction âmarkets may be back with a vengeance but health care remains a stabilizing instrument of citizenship at a time of global instabilityâ. Publicly financed health care systems which provide universal coverage and access to care do appear to offer equity benefits and better health outcomes than alternative models. However, even in these circumstances there remain non-financial barriers to health care usage, and disparities still exist, e.g. in uptake of preventive care by lower income groups. Nevertheless, there appear to be broader, if diffuse, benefits to health from a publicly financed system. As Mustard states: A society that decides to make health care available to all of its citizens through a universal insurance system, makes provision of health care a potential institutional structure to help sustain social cohesion and trust (p. 334). While much of the book therefore is concerned with social and health care arrangements that are âhealth promotingâ in the broadest sense, health promotion tends to be treated as a strategy targeted at individual lifestyle. For example, Gail Donner's challenging chapter on the âfallacy of demand reductionâ, i.e. demand reduction as increasingly embraced as part of managed care in the US, equates health promotion with health education efforts to, e.g. stop people smoking. Donner argues that demand reduction strategies in isolation from broader system reforms and âupstreamâ public policy change, can themselves become both victim blaming and ineffective. In their chapter, âThe Virus of Consumerismâ, Feldberg and Vipond argue that health promotion itself represents one of the instances in which market-oriented health care systems treat people as âconsumersâ rather than citizens. The answer to why health promotion is viewed in this way, in a book explicitly concerned with the social determinants of health, may perhaps in part be explained by the relationship of several contributors to the Canadian Institute for Advanced Research (CIAR), an organization closely associated with the development of the âpopulation healthâ perspective on health improvement in Canada. For example, Fraser Mustard was the founder of CIAR, and another contributor, economist Robert Evans, is a CIAR fellow. Perhaps not surprisingly then, to the extent that Health Reform deals with the health care system's role in the broad domain of prevention, the perspective is strongly âpopulation healthâ rather than âhealth promotionâ.1 For those who have not been engaged with this peculiary Canadian debate see Frank, J. W. (1995) why âpopulation health?â and Labonate, R. (1995) Population health and health promotion: what do they have to say to each other? both in the Canadian Journal of Public Health.86, 162-168. In contrast to the âwhole of systemâ policy perspective of Health Reform: Public Success, Private Failure, the focus of John Davies and Gordon Macdonald's book is on the more specific elements of health promotion research and practice. The contributors are drawn from the UK, Australia, the USA, Canada and a number of European countries, and most are well known in international health promotion circles. As with the Canadian book, Quality, Evidence and Effectiveness in Health Promotion has its origins in a conference, in this case the Third European Conference on Effectiveness: Quality Assessment in Health Promotion and Health Education, held in Turin in 1996. However, while many of the contributors participated in that event, the book's 11 chapters were developed after the conference, and many include references as recent as 1998. The book is divided into three parts, broadly reflecting the themes in the title. Part 1, âMethods for Assessing Evidence and Effectivenessâ, contains three chapters, one an overview of health promotion in the United States, and two which are concerned with measuring effectiveness and evaluating health promotion in various community settings. Part 2, âMethods for Assessing Qualityâ consists of three chapters which each provide practical guidance on different aspects of quality assurance and assessment in health promotion. The four chapters of Part 3, âApproaches to Synergismâ are more of a mixed bag, with the first two chapters providing case studies intended to illustrate the synergy of linking effectiveness measures with quality assurance. Of the final two chapters, one provides an international overview from the perspective of a World Health Organization working group on quality assurance and effectiveness, and one, by the book's editors, provides a summary of the âstate of the artâ, and suggests a number of steps and principles for improving effectiveness and quality assessment in health promotion. The real strength of this book is the range of practical models, tools and techniques presented. For example, the chapter by Baum contains a useful tool for monitoring the changing expectations of key players in a community-based health promotion initiative. An approach of this type, as Baum notes, could potentially be of great value in helping make explicit changing and conflicting objectives, and in analysing progress of an initiative. What results is the construction of a âstakeholder-focusedâ approach to outcome assessment, which recognizes that interventions in human systems are likely to have multiple impacts, and that assessments of the value of these effects are likely to differ according to where one stands. Similarly, Speller and colleagues provide useful guidance in tracking and evaluating the progress of alliances for health; Springett provides a framework for indicator development to track the effects of policy change on health and social well-being in a healthy cities initiative (and highlights the difficulties involved); Haglund and colleagues present a quality assurance instrument based on the SESAME health promotion planning model. The book contains many more examples than this brief selection can do justice to. While issues of effectiveness and quality assurance are well covered, the book is less helpful on the question of evidence in health promotion. Accepting that this is intended as a publication to improve and inform practice, nevertheless one might have expected from the title a more organized and comprehensive discussion of the challenges associated with âevidence-basedâ health promotion, e.g. those associated with theories of knowledge, power and the nature of social systems. Some of these issues have been raised in recent issues of Health Promotion International. Another issue which the authors might have considered for inclusion, and one which often figures strongly in discussions of quality assurance elsewhere, is the role of management and leadership. This topic is well covered in David Hunter's short publication Managing for Health, prepared for the London-based Institute for Public Policy Research. Hunter is Professor of Health Policy and Management at the Nuffield Institute. This report is primarily concerned with the contribution of management to achievement of the Labour Government's objectives for Britain's National Health Service (NHS), and its main theme is the importance of effective management in moving from a focus on health care to a focus on health. Hunter argues that a new type of management is needed to move beyond the market-oriented approach of the so-called ânew public managementâ which has dominated the health system since the early 1980s. This does not mean, however, a return to the inflexible bureaucratic models of the past, but needs to consider a management approach consistent with the âthird wayâ in British politics championed by intellectuals, such as Anthony Giddens. Hunter suggests a way of thinking about âmanaging for healthâ, where the goal of management is health gain and health outcomes, rather than the management of inputs for health care. Hunter identifies a number of key health policy themes that managers will need to deliver on in the policy context created by the government's NHS reforms. These include: a commitment to narrowing the health gap; a commitment to quality; a greater emphasis on primary health care. The first theme Hunter suggests will require nothing less than a paradigm shift in the way health services are managed, requiring managers to develop a âwhole systemsâ way of thinking and to actively promote âjoined up solutions to joined up problemsâ. For Hunter, good management is critical to closing the gap between policy and effective implementation, and this is particularly true in terms of addressing health inequalities. Hunter identifies a number of key skills health managers will need to develop. These include the following. Building alliances and networks with non-health organizations, and the capacity to work within alliances. Talking and listening to users of services. Developing information and intelligence databases to support the new public health. Having a strategic framework based on health improvement. Paying attention to the organizational forms needed to fulfil these functions; including development of vision, culture, people and skills. While Hunter's report is very much focused on the UK, the principles it espouses have international relevance, and its public health perspective makes it highly relevant to a health promotion audience. It is useful to see these three publications as a âpackageâ. Together they provide a policy overview of health care reform; some specific guidance, on how, within that context, health promotion can move to more effective practice; and a consideration of the role of management as the key linkage between policy and practice. A comment contained in the editors' introduction to Quality, Evidence and Effectiveness in Health Promotion provides an example of the lessons for health promotion in the health care reform literature. Davies and Macdonald note that a key theme at the conference which inspired their book was that the development of an evidence-based approach to health promotion would help ensure that health promotion remains âat the forefront of local, national and international health policy development and investment ...â However, a reading of Drache and Sullivan's book perhaps provides a more realistic perspective on where health promotion sits in the eyes of both policy commentators and health system decision-makers. While health promotion as yet is not at the top of the health reform policy agenda, the insights contained in these three publications help point the way to how health promotion might achieve this position in the future. The author would like to thank Jenny Jefferson for her assistance in the preparation of this review.
In this short but complex monograph Heyman uses his expertise as an ethnographer of both borderlands and border enforcers to devise moral and practical improvements in U.S. immigration policy. Heyman argues persuasively that current U.S. immigration policies are both unjust and unworkable. They are unjust, he contends, because they are fueled by antiimmigrationism, a sentiment that fails to recognize the common humanity of others. They are unworkable, he notes, because numerical controls have not prevented the influx of immigrants who are not authorized to live and work in the United States. Heyman reasons that as a member of a profession that is dedicated to analyzing the human condition, he is ethically obligated to promote policies that are both realistic and moral. Finding a moral heart for U.S. immigration policy is devoted to this endeavor. Heyman proposes that immigration to the United States be governed by compacts between the local communities where immigrants reside and employers or relatives who want to bring an immigrant into the country. Local communities would assess the improvements in housing, education, and public services that would be needed to accommodate new residents. Immigrant sponsors would then contribute to the costs of these improvements. According to this plan, immigration would be decentralized, the U.S. Immigration and Naturalization Service would become a clearinghouse, illegality and law enforcement activities along U.S. borders would be reduced, immigrants could travel more freely, and all immigrants would be legal permanent residents entitled to live, work, receive public services, and even vote in local elections within the United States. There is much to commend about this proposal. Shifting the focus of the INS from enforcement to regulation would make crossings less hazardous, thus reducing death tolls along the U.S.-Mexico border. The current artificiality of the categories of kin who can sponsor immigrants would be replaced by a system that more realistically reflects individuals' actual relationships. Immigrants would be able to come and go legally, instead of being trapped within U.S. borders by a pending legalization case or by a fear of being apprehended upon reentry. According immigrants greater (indeed almost all) legal rights would reduce discrimination. I do, however, have some doubts about the proposal. For instance, migration from one part of the United States to another also adds new residents to local communities, and could potentially burden local services. Why then should employers only have to contribute to local infrastructure if they hire individuals from outside of the country? Also, if employers face extra costs for hiring immigrant workers, immigrant workers may face job discrimination. It seems more equitable to hold the federal government responsible for allocating resources to local communities based on their population sizes and demographics. Financing such allocations through across-the-board taxes instead of through compact costs charged to immigrant sponsors would further reduce distinctions between permanent residents and citizens. Heyman grounds his policy critique and proposal in what he characterizes as core anthropological values and the common characteristics of moral systems. âŚ
Fiscal Decentralization is a popular economic development strategy among transition and developing countries. This article reviews the advantages of fiscal decentralization in a theoretical context, but critiques the relevance of the standard theory of federalism as it applies to emerging economies. It is argued that the macroeconomic benefits of fiscal centralization, the absence of good instruments of local government finance, and the centralist politics that characterize most low income countries have been strong enough to hold back increased emphasis on local government finance.
The purpose of the paper is to revaluate the roles of the reformed local autonomy for promoting decentralization and local autonomy against new centralization. I consider the local autonomy and finance in Japan after World War II, focussing on the roles of so called 'Kakushin Jichitai', reformed local autonomy in the 1960's and 1970's. Firstly I review the developing and declining processes of 'reformed local autonomy' in the period of high economic growth in Japan. Then I discuss the roles of these reformed local government bodies through rising citizen movements. The local governments like Minobe-Tosei or Asukata-Yokohama-Shisei contributed to the tax reforms and some other financial reforms and promoting decentralization. The 1960's and 1970's in Japan are called 'The Period of New Centralization' in intergovernmental relations. However, the roles of these reformed local autonomy for promoting decentralization against new centralization should be revaluated.
In continental Europe, the unemployment rate has risen continuously from a low level of below 3 percent in the early 1970s to more than 10 percent in the late 1990s. If those who are in governmental employment schemes and in early retirement are included, the unemployment rate runs as high as 20 percent in quite a few European countries, including France and Spain. The basic rule for a stable employment situation in an economy is: nominal wages should stay in line with labor productivity growth plus the increase in producer prices. In a situation of high unemployment, however, when the unemployed are to be integrated into the labor market, the productivity rule has to be modified: the increase in real wages should stay below the productivity growth rate until a satisfactory level of employment has been obtained. The most elegant approach to creating more employment is to improve labor productivity. If an economy succeeds in raising labor productivity, there is more scope for real wage increases or for more employment. We should, however, not overestimate the potential of an economy to increase labor productivity. If we want to integrate the unemployed, average labor productivity in the economy is likely to decrease. We should be realistic enough as to expect trends in Europe to be similar to those in the United States, where labor productivity per hour has increased by less than 1 percent per year since 1980. The task for Europe is to change the institutional setup of labor relations, to move wage formation closer to the market process, and to allow greater wage differentiation. It is unlikely that the "social partners", i.e., the trade unions and employers' associations, will be able to change the rule system sufficiently. Therefore, it is necessary to change the legal rules, especially those in favor of the unemployed, for instance, by introducing a legal right for each individual to enter the labor market at a wage of his or her choice. If continental Europe wants to reduce unemployment, it will have to change the impact of the welfare state. With respect to the level of benefits provided by unemployment and health insurance, a distinction should be made between large risks and small risks for the individual. Such a distinction between large and small risks would allow the costs of the social security system to be reduced, thus lowering the tax on labor. Insurance against large risks would be mandatory, small risk coverage would be optional. With respect to financing the welfare state, more choice should be given to the individual as concerns the insurance coverage that he/she desires. One serious issue concerning social welfare payments is determining the extent to which the level of social welfare benefits should be scaled down for those who are able to work in order to increase the incentive to work and the intensity of the search for work. A related issue is whether unemployment benefits should be reduced in their level or in the length of time they are paid in order to intensify the job search and reduce the reservation wage. ⢠Shifting the employment issue to the EL) level would take attention away from the need to decentralize wage formation, i.e., to negotiate wages at the level of firms. It would be an incentive not to undertake the necessary steps to solve national unemployment problems and it would shift the financial burden to those countries that are successful in reducing unemployment. It would elevate the national labor market cartels to the EU level and it would blur the lines of responsibility. National governments would shift their responsibility to the EU level. This would be an extremely dangerous development for European integration because the European cause would become the scapegoat of failed national policies.
The note highlights the importance of \n sound intergovernmental fiscal relations, and proper \n regulation for successful sub-national borrowing, and \n illustrates the potential macroeconomic hazards of \n decentralizing borrowing powers, arguing that the impact of \n a possible moral hazard problem, namely, the access to \n financial markets by sub-national governments, may generate \n unplanned liabilities for central governments. Yet academia, \n and country experiences do not suggest adverse links between \n decentralized borrowing powers, and the central \n government's ability to maintain fiscal discipline, and \n macroeconomic stability. Rather the key seems to lie in the \n design of fiscal decentralization, particularly the \n regulatory framework under which borrowing powers are \n decentralized. The note outlines the reasons why \n sub-national governments require access to financial \n markets: to finance capital spending, and foster political \n accountability, which can be achieved through direct \n borrowing by central government, through a public financial \n intermediary, or, through direct borrowing. As per designing \n the regulatory framework, the note suggests better \n information systems, bankruptcy laws, and access to tax \n bases, in addition to separate fiscal/financial systems, and \n sound legislation to impose budget discipline, enabling \n access to capital markets to complement fiscal powers \n devolution to regional authorities.
This paper explains the evolution of the metropolitan organizations that have been established to oversee the development of Metro Manila, provides a survey of their responsibilities, authorities, organizational structure, financing, institutional relationships as well as briefly assess their strengths and weaknesses. It then discusses the major management challenges in Metro Manila at present and how they are being addressed under the current set-up. Under the present decentralized framework, governance of Metro Manila becomes more challenging as cities and municipalities that compose it have political legitimacy and significant powers and authorities relative to the Metropolitan organization. However, the paper has emphasized that with proper allocation of powers, authorities and financing, the metropolitan body can take on a more important role in terms of actual delivery of metro-wide services. While the present metropolitan body appears to have taken on more responsibilities in the delivery of services transcending local boundaries, still a large part of these metro-wide services still remain with the national government agencies. This is primarily explained by the fact that while the national government has continuously provided subsidies to the metropolitan body, it still allocates a sizeable portion of the budget for metro-wide services to the national government agencies. These agencies, being line departments, are inherently concerned with their own sectoral priorites rather than serving the needs of the metropolis per se. Consequently, the metropolitan body is left with very difficult task of having to orchestrate the sectoral programs of various national government agencies, including metro-wide services. This situation not only makes government effort almost intractable but also increases costs in terms of both manpower and financial costs. The advantage of metropolitan governance under a decentralized framework is that it allows the local government units within the metropolis to respond directly to the priority needs of their respective constituents by seeking creative means to deliver urban services. This is attested to by the innovative programs and projects some cities in Metro Manila have implemented which have been included in this paper under the discussion of models of good city governance.
The current economic problems in Southeast Asia can be attributed not to too much reliance on financial markets, but to too little . Like the U.S. economy a century ago, the emerging Asian economies do not have welldeveloped capital markets and so remain heavily dependent on their banking systems to finance growth. For all its benefits, banking is ânot only basically 19thâcentury technology, but disasterâprone technology.â The extreme maturity (and, in some cases, currency) mismatch on banks' balance sheets plus the firstâcome, firstâserved nature of the deposit obligations mean that banks are inherently vulnerable to massive runs by depositorsâand that their economies are subjected to periodic credit crunches. And, as the author says, âin the summer of 1997 a bankingâdriven disaster struck in East Asia, just as it had struck so many times before in U.S. history.â In this century, In this century, the U.S. economy has steadily reduced its dependence on banks by developing âdispersed and decentralizedâ financial markets. In so doing, it has increased the efficiency of the U.S. capital allocation process and reduced its susceptibility to the credit crunches that have occurred throughout U.S. history. By contrast, Japan has not reduced its economy's dependence on banks, and its efforts to deal with its banking problems have served only to destabilize itself as well as its neighbors. Developing countries in Southeast Asia and elsewhere are urged not to follow the Japanese example, but to take measures aimed at developing financial markets and institutions that will either substitute for or complement bank products and services.
This dissertation starts from the presupposition that Mental Health, Primary Care and their articulations are propositions originated specific historical contexts and social conditions, implying necessarily in a translation when their assimilation occurs in Brazil and the state of São Paulo.The investigation developed along two lines: the building of the Mental Health field and its links with health and Primary Care in general and the articulation of Mental Health and Primary Care in the state of São Paulo.The study concludes that Mental Health emerges in historical conditions which favor public policies of social inclusion, through the extension of care, In this way it integrates hygiene and therapeutic propositions, and continues to exert a normative social hygiene.The integration of preventive and medical practices, taken as part of specific levels of prevention, makes possible the articulation of Mental Health to Primary Care and public health services.In the state of São Paulo, Mental Health in Primary Care emerges in the context of political redemocratization in 1982, as part of the implementation of specific forms of financing health care ("Açþes Integradas de Saúde -AIS"), the decentralization of the governmental programs and the importance of Primary Care as a political banner.This implementation occurs in specific conditions in the state of São Paulo, with the inclusion of multiprofessional mental health teams in public primary health care services, as an experience of psychiatric reform.
Local governments (LGs) are seen as producers of the local public good ('the good'). An authoritarian country is one in which the government decides if the good should be produced and how much to tax to finance it, as versus a democracy in which voters decide. This paper identifies conditions under which it is more efficient for a non-democratic government to delegate to the LGs the authority to 1) decide whether or not to produce the good and2) Collect tax to finance it if the good is produced. Two conditions are identified First, when the net benefit of producing the good is sufficiently small so that, compared with the benefit, inducing LGs effort under the centralized system is too costly (a moral hazard problem). Second, when the net benefit of the is higher in a locale with a higher production cost parameters, making it difficult for the center to induce the LGs to truthfully reveal the cost parameter (an adverse selection problem). These results are consistent with the experience of China in the past several decades, where "too small to be worth bothering" and "too diversified and complicated local conditions for the center to know" have been the two most prominent official arguments made by the communist government itself for decentralization
This dissertation examines why and how jurisdictions choose to finance their roads. The systematic causes of revenue choice are explored qualitatively by examining the history of turnpikes. The question is approached analytically by employing game theory to model revenue choice on a long road. The road is covered by a series of jurisdictions seeking to maximize local welfare. Jurisdictions are responsible for building and maintaining the local network. Complexity arises because local network users may not be local residents, and local residents may use non-local networks. Key factors posited to explain the choice of revenue mechanism include the length of trips using the road, the size of the governing jurisdiction, the degree of excludability, and the transaction costs of toll collection. These factors dictate the size and scope of the free rider problem. It is hypothesized that smaller jurisdictions and lower collection costs favor tolling policies over taxes.The analytical model is operationalized by assuming jurisdictions have two decisions: the strategic decision to tax or toll, and the tactical decision of setting the rate of tax or toll. Models of user demand as a function of trip distance and monetary cost and of network costs as a function of traffic flow and the number of toll collections are specified. The values of the constants and coefficients of the model are developed from recent cost literature and the estimation of a model of collection costs from California Toll Bridge data.The model is applied to evaluate the dissertation's hypotheses. The application evaluates the welfare implications of a jurisdiction and its neighbors imposing general tax, cordon toll, odometer tax, or perfect toll policies. Sensitivity tests of the model under alternative behavioral assumptions, and with varying model coefficients are conducted. Finally, policy implications from the analysis are drawn. The general trends which bode well for road pricing (electronic toll collection (ETC), decentralization, advanced infrastructure, privatization, and federal rules) are established. Possible scenarios for three cases are presented: deploying ETC and building new toll roads, and converting free roads.
Through analyzing the softness and hardness of budgeting constraints in research and development (R&D) investment under different institutions, we develop a theory of optimal R&D financing. Our theory not only provides a clear comparison of investment efficiency between centralized economies and market economies but also extends the analysis of soft budget constraints to firms in market economy. Based on this theory, we characterize optimal choices of R&D project financing in centralized and decentralized economies. Our results explain why some projects are financed internally by a large firm but others are cofinanced externally by several firms. We also explain what makes a centralized economy inefficient in R&D.
While industrialists are discovering the hidden costs of minimal compliance with environmental regulation, environmentalists assert that EPA regulations contain too many loopholes. Since government regulation pleases neither environmentalists nor the regulated industries, we have to think in new directions. Can financing alternative technology be superior to monitoring pollution? Can local communities play a role in creating cohesion out of decentralization? What are the best new strategies both on the level of local communities and alternative technologies?
Reconstructing Africa's war damaged economies is an urgent task. This is especially so in a group of countries - Angola, Eritrea, Ethiopia, Guinea-Bissau, and Mozambique - which must also complete their economic and political transition from state socialism. Somalia, which shares their common history, must eventually be rebuilt. All of these countries must address their deep problems of underdevelopment and poverty. The challenges are therefore three-fold: to overcome underdevelopment, to make the transition from state socialism, and to reconstruct economies and societies. Socialism was influential across post-independence Africa. But UTR countries drew more explicitly on Marxism-Leninism and the Soviet development model. With the aim of accelerating growth, enterprises and property were nationalized and controls were established. But the result was a fatal over-centralization of political and economic power, and a slide into conflict exacerbated and fuelled by the politics of the cold war. Somalia collapsed into a turmoil from which it is yet to recover. Mozambique has made the most progress and, until their border war this year, Eritrea and Ethiopia were both moving forward. Angola faces urgent reconstruction problems but progress had been slow, and a return to outright war cannot be ruled out. Guinea-Bissau was knocked off course by a military revolt in 1998. Progress has therefore been tentative in the UTR group, and their future prospects depend on them finding political settlements that can secure their prospects for economic development. War, and the uncertainty associated with it, distorts economies; investments with long- term returns, mainly in production activities such as agriculture and manufacturing, are cut back, and the economy becomes dominated by activities with short-term returns, such as commerce in cities and safe areas. Natural resource sectors may continue to operate, however, when protected by their location (for example offshore oil and gas) and when combatants seek to preserve them as the 'prize' for capturing the state. Past failure to achieve broad-based growth contributed to conflict. This implies that reconstruction cannot simply entail the recreation of the pre-conflict economy. Policies, public expenditures, and institutions must be changed, often fundamentally. For this reason the agendas of reconstruction and economic reform (transition) cross over. Well- designed reforms can contribute to reconstruction and vice versa. But too often there is a mismatch between the reform and reconstruction programmes, and the ground for broad-based development is not secured. Aid is important, but success ultimately depends on the actions of three national actors: communities, entrepreneurs, and states. However, communities are impoverished, private sectors are underdeveloped, and state capacities are weak. For communities, the main challenges are to deal with the immediate post-war humanitarian and security problems and, equally important, accelerate programmes for longer-term poverty reduction. Regarding the first of these, the tasks are to resettle displaced populations, disarm and demobilize ex-combatants and assist their reintegration, reduce the level of violence (by filling the security gap and decommissioning weapons), remove land mines which disrupt community livelihoods, and protect food security while phasing out food aid and increasing targeted support. Regarding longer-term poverty reduction, the future pattern of growth is determined by (i) the distribution of human and social capital, access and control over natural capital (including land tenure) and access to physical infrastructure (ii) the policy framework which determines the returns to household investments and (iii) the quality of institutions, including the legal framework. State socialism and conflict altered every aspect of the pattern of growth, and transition and reconstruction alters it again. Focusing public policy more effectively on poverty reduction, in particular on core services of most benefit to the poor, is therefore an urgent task. To support this, the relationship between donors and governments should be changed in order to focus more on monitoring social outputs and less on unworkable policy conditionalities (and to direct aid to governments committed to poverty reduction). More investment in collecting social data is needed to understand the impact of reconstruction and transition on communities. Turning to the second key actor, entrepreneurs, we can see that a new private sector is being created in UTR countries following decontrol and privatization. Overcoming investor uncertainty is a key task; this can persist and limit investment despite a fall in actual country risks. Angola and Mozambique are so far the largest recipients of foreign investment in UTR countries. But the impact of Mozambique's large investment programme is virtually unknown, while foreign investment in Angola is confined to the oil sector, which has few links to the rest of the economy. Privatization is proceeding at different speeds across UTR countries. Privatization in the financial sector is especially important; reconstruction requires a financial sector capable of mobilizing and intermediating savings into private investment. Recapitalizing the banking sector is expensive, and requires private capital, which implies privatization. Political influence can create unsound banks and better financial regulation is needed. But the phenomenon of 'straddling', in which political leaders invest in commercial enterprises, endangers the independence of financial regulation, and can distort the privatization process. Privatization in the agricultural sector has seen the non- transparent privatizations of state farms and the denial of community rights and some inconsistencies between privatization and agricultural policy reform. Encouraging more private investment in agricultural marketing is especially important for food security and rural poverty reduction. The third national actor is the state. A developmental state must be constructed. This is a set of democratically accountable institutions capable of effective policy design and implementation. If this is successful, the new state will look very different to the old state, but it is unlikely to be 'minimal'. The onus is therefore on democratic governments to prove that they provide value for money to communities and entrepreneurs. The new state agenda will remain a wish list unless it is properly financed, which it is not at present. Reconstruction expenditures are high, revenues are low (war reduced tax bases) and distorted (over dependence on trade taxes). Countries are severely indebted; almost all Africa's conflict/post-conflict countries are classified as 'Heavily Indebted Poor Countries' (HIPCs). The fiscal peace dividend is small (at least in the early years) and the high level of insecurity in Africa keeps military budgets high. Budgetary institutions are weak at mobilizing revenues and allocating them to priorities, and non-transparency and the improper use of public funds must be reduced. As a result of these problems, and the sheer scale of reconstruction expenditures, fiscal deficits before grants are very high. Nobody seriously questions the principle of fiscal prudence but the IMF's fiscal policy conditionality may be over-restrictive; certainly many other donor agencies believe that this is the case. This leaves many investments with high social returns on the shelf, implying slower growth and poverty reduction. A much longer time frame is therefore necessary to evaluate fiscal policy in an economy under reconstruction. The IMF's caution in part arises from the observation that real aid flows are in decline, and it therefore advises governments to move to a fiscal position in which any downturn in aid will not affect their recurrent, as opposed to their capital, spending. However, it is still possible for aid flows to individual countries to maintain their present levels or rise, and this is in fact the way the donor community is moving in seeking to redirect aid to countries committed to broad-based development. The IMF's fiscal policy conditionality, when it is over-restrictive, works against the new aid paradigm. Moreover, over-tight fiscal policy can lead to the use of distorting taxes that undermine reconstruction, it can work against improvements in budgeting, and it may be incompatible with democratization. The paper only touches on some of the major challenges facing the UTR group of countries. Decentralizing political and economic power, minimizing macro-economic shocks, and preventing conflict through broad-based development are all crucial. This requires hard choices over resource allocations and public policy. But these choices are a great deal easier to make than those involved in ending a conflict and initiating reconstruction. Ex ante action - good economic policy - is always better and cheaper than ex post crisis management.
This paper is one of eight case studies in the health sector conducted under the project "Population and Urbanization: Managing the Urbanization Process Under the decentralized Governance Framework" jointly undertaken by the Philippine Institute for Development Studies, National Economic and Development Authority and Development Academy of the Philippines. This paper is a case study on Cotabato City recommended by NEDA-Region XII as a model city for health. The city has come up with the Special Project on Health and Sanitation that won a silver Award in the 1997 Health and Management Information System Contest.
Decentralization of welfare policy for the elderly in recent Japan made local municipalities have responsibility to provide services. This means, however, the varieties in the quantity and the quality of services between municipalities. It is difficult to obtain the land for institutions especially in urban municipalities because of the high price of land. Therefore, the shortage of provision is serious problem in urban administration. Furthermore, the demand for services can not be satisfied in own municipality and affects neighborhood municipalities.From these problems, the present paper aims to clarify how the institutional care services were provided and the needs for services were satisfied in and out of one municipality. Nagoya City, the study area, is one of the major metropolitan city in Japan, with over two million population and it is divided into 16 wards. The object of this study is nursing home for the elderly, which is the most major service in institutional care in Japan.The results of the study can be summarized as follows:1) The locations of nursing homes are remarkable in peripheral than central wards of the city relatively. The capacity of beds by wards is not proportional to the population 65 and above.2) Each nursing homes bases on a variety of types of the organizations; public, welfare facilities, hospital, religious group, private person and so on. Since 1994, the outer organization of the administration, which had financed half by the administration, had built many homes remarkably. Consequently, the location of homes proceeded also in the central wards, where there were no homes so far. This means that unless positive policy for the provision of homes by the administration is adopted it is not easy to increase homes in urban region, where the availability of land is low.3) Regarding use of nursing homes, many of migrations to enter homes leave for own or neighbor wards. There are more immigrations from other wards where the degree of congestion of homes (the number of beds per 100 people aged 65 years and over) is relatively loose.4) Correlation coefficient between the provision of nursing homes (the number of persons entered in homes) and the demand (the number of entered and waiting lists) was not significantly different from zero at the 0.05 level. Therefore, the level of territorial justice on nursing homes in Nagoya City is not high.5) As a result of the principal component analysis on the migrations to enter homes in Nagoya City, six components (cumulative percentage of the total variance; 73.3%) were extracted. By the interpretation of the components, major patterns of immigrants were toânortheast wardsâ, âsouthwest wardsâandâeastern wardsâ.6) Although immigrations to other municipalities leave for the whole of Aichi Prefecture, municipalities in western region of the prefecture had accepted many people from Nagoya City. Immigrations to the municipalities in the next region, policy for provision of services for the elderly, of Nagoya City is surpassing from the peripheral ward which locates on a line from the central of Nagoya City toward to a municipality of destination.7) Although by municipalities in the prefecture the degree of congestion of homes doesn't have relations with the number of persons from Nagoya City, by the policy district it was obviously proportional to ones. Consequently, most of eleven cities with populated above 100 thousand people had so congested that immigrations from Nagoya City were not so many, except for Toyohashi and Toyokawa where the degree of congestion of homes were loose.8) Finally, horizontal intergovernmental relations between Nagoya City and its next municipalities were evaluated through the comparison the number of immigrations from Nagoya City and each of their own demand for homes.
H A ElZein, Maureen Birmingham, Z. A. Karrar, A A Elhassan ¡ 5 authors
In 1993 a large outbreak of paralytic poliomyelitis occurred in Sudan as a result of an accumulation of large numbers of susceptible children that was accelerated by faltering immunization services. The extent of the outbreak led to the rapid rehabilitation of Sudan's Expanded Programme on Immunization (EPI); the government began financing vaccine purchase, operational aspects of EPI were decentralized, vaccine delivery was changed from a mobile to a fixed-site strategy, a solar cold chain network was installed, inservice training was resuscitated, and social mobilization was enhanced. National immunization days (NIDs) for poliomyelitis eradication were conducted throughout the country, including the southern states during a cease fire in areas of conflict. Measles immunization coverage was increased by offering measles vaccine during the second round of NIDs and subsequently through routine immunization services. Supplemental tetanus toxoid immunization of women of child-bearing age began in three provinces at high risk for neonatal tetanus. From 1994 to 1996 reported immunization coverage increased and the incidence of all EPI target diseases fell. Trends in coverage, disease incidence, financing, and the implementation of WHO-recommended disease-control strategies suggest that more sustainable immunization services have been re-established in Sudan.
National leprosy control programmes currently face a number of changes to the environment within which they operate. This paper examines the issues arising from these. It focuses, in particular, on those arising from changes in the structure of the health sector as a result of policies of health sector reform which are being considered or adopted in many developing countries. These include decentralization, financing strategies, greater role for the private and NGO sectors and the integration of vertical programmes. The paper is structured around a number of key steps in the development of a strategy for sustainability of appropriate leprosy services. These are the assessment of the epidemiological, social and health services context, development of programme objectives, planning of human and financial resources, development of the strategy, mapping the roles of potential actors, development of regulatory and incentive mechanism, action planning and managing change and, finally, re-evaluation of the programme objectives and service delivery organization. The paper stresses the importance of process in developing ownership of a strategy. It concludes with a set of key questions which it suggests need to be addressed by leprosy programme managers in the development of a proactive response to the changes.