Blockchain Papers

Malcolm Segall

District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a 'second generation' reform--to be superseded by third generation reforms with a market orientation--flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass campaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor.

George W. Kivumbi

The introduction of user-payment for health services is frequently followed by concern about the impact on equity of access for poor people. Decentralizing governments often try to remedy the created inequities by putting in place safety nets in the form of exemptions and waivers in the user-fee systems. However, where user payments merely operate as local government strategies for health financing, without national policy they are likely to be self-defeating, as local governments are frequently more interested in raising revenue to meet recurrent costs of devolved services than in promoting equity. Thus guidelines put in place by the central government to operationalize safety nets are seen by local governments as being contradictory to this goal, and are thus ignored or altered to suit the district revenue aims. This study was carried out to investigate the context and the constraints in implementing exemption schemes. Data were collected in two selected administrative districts of Uganda (Mbarara and Mukono). Qualitative approaches to data collection were adopted, namely focus group discussions and key informant interviews with policy-makers, health administrators, service providers and community members. These methods were combined with document review. We found little evidence of safety-net guidelines initiated by decentralized/local governments, since district local governments had little motivation to extend exemptions, waivers or credits. The conclusion is that safety nets such as waivers and exemptions will only be effective if they are backed by a national health financing policy, they reconcile the often competing demands of local government revenue needs, and are strictly enforced and supervised by both the local and central governments. The implications of the findings for remedying the tension between the needs for cost recovery and for attainment of equity goals through exemption policies for the poor and indigent are discussed.

Djalma Freire Borges, Kaio César Fernandes

This paper addresses the decentralization of health services financed by the Unified Health System (SUS) in the city of Natal initiated in the mid 90s. This decentralization primarily involved the transference of health services financed by SUS, which had previously been developed by the state of Rio Grande do Norte, to the city government of Natal. Based on the data gathered mainly from SUS¿ Ambulatory Information System (SIS/SUS), the authors attempted to verify to what extent this decentralization of health services provided by SUS in the city of Natal had improved public access to health services or, on the contrary, had resulted in a privatization process, implying more difficult access to those services.

Lawrence H. Thompson

No abstract is available for this record.

Colin Sindall

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. Public–private 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 ‘how to sustain a public commitment to a comprehensive range of health services for all citizens’. 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 ‘intellectual acid rain’, 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 ‘care’, and hence perhaps focused too ‘downstream’ 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 ‘devise social arrangements which engender healthy populations’. 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 ‘Governing Health’, 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 ‘Health, Health Care and Social Cohesion’ 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 ‘markets may be back with a vengeance but health care remains a stabilizing instrument of citizenship at a time of global instability’. 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 ‘health promoting’ 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 ‘fallacy of demand reduction’, 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 ‘upstream’ public policy change, can themselves become both victim blaming and ineffective. In their chapter, ‘The Virus of Consumerism’, Feldberg and Vipond argue that health promotion itself represents one of the instances in which market-oriented health care systems treat people as ‘consumers’ 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 ‘population health’ 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 ‘population health’ rather than ‘health promotion’.1 For those who have not been engaged with this peculiary Canadian debate see Frank, J. W. (1995) why “population health?” 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 ‘whole of system’ 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, ‘Methods for Assessing Evidence and Effectiveness’, 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, ‘Methods for Assessing Quality’ 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, ‘Approaches to Synergism’ 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 ‘state of the art’, 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 ‘stakeholder-focused’ 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 ‘evidence-based’ 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 ‘new public management’ 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 ‘third way’ in British politics championed by intellectuals, such as Anthony Giddens. Hunter suggests a way of thinking about ‘managing for health’, 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 ‘whole systems’ way of thinking and to actively promote ‘joined up solutions to joined up problems’. 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 ‘package’. 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 ‘at the forefront of local, national and international health policy development and investment ...’ 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.

Germano Mwabu, Mwabu, Germano

The paper reviews the theoretical basis for the application of user fees in the public health sector in low-income countries with particular reference to the special characteristics of medical care as a commodity. The general equilibrium efficiency result of the market mechanism is shown to be the theoretical justification for the financing of health services via a system of user charges. If markets for all goods and services exist, and are perfect in a very strict sense, the welfare outcome of the price mechanism cannot be improved upon by any other resource allocation device. Furthermore, the decentralized and impersonal nature of this mechanism renders it more convenient to use in the allocation of commodities, health care included, than its alternatives such as a system of centrally administered prices or a system of administrative controls and directives. However, since many of the assumptions of the price system are rarely met in actual situations, especially in the health sector, it should be applied with caution. In particular, problems of information asymmetry and consumption externalities in health care markets necessitate a simultaneous use of fees with government interventions in order for fees to achieve their often intended aim of efficiency and equity improvement in health care provision. The most important intervention of the government here is the enactment and enforcement of institutions that reduce costs of transacting in health care markets and that in addition facilitate the emergence of new markets such as the markets for medical insurance. A striking finding of the paper is that health services in low-income countries are best financed primarily by revenue from general taxation, supplemented by a system of moderate user fees. Since medical insurance markets are generally non-existent in low-income areas, it is argued that financing health services primarily through user fees in such areas would be inefficient and inequitable. However, to mitigate the moral hazard problem as well as the problem of the commons, both of which characterize publicly financed health care, imposition of modest user fees is required. The importance of fees in this proposal increases with economic growth and with evolution of institutions that facilitate market transactions. Strategic interaction among economic agents is shown to affect the structure and implementation of user fees. A game-theoretic analysis of the general problem of health care financing shows that this problem is best tackled by harnessing the efforts of households, private health care providers, the government and civil society. These entities form what might be called a winning coalition in health care financing game of society. It is argued that the government is better placed to provide an institutional framework for coordinating the efforts of the various players to the desired end.

Marschall W. Raffel, Norma K. Raffel

Before World War II, Czechoslovakia was among the most developed European countries with an excellent health care system. After the Communist coup d'etat in 1948, the country was forced to adapt its existing health care system to the Soviet model. It was planned and managed by the government, financed by general tax money, operated in a highly centralized, bureaucratic fashion, and provided service at no direct charge at the time of service. In recent years, the health care system had been deteriorating as the health of the people had also been declining. Life expectancy, infant mortality rates, and diseases of the circulatory system are higher than in Western European countries. In 1989, political changes occurred in Czechoslovakia that made health care reform possible. Now health services are being decentralized, and the ownership of hospitals is expected to be transferred to communities, municipalities, churches, charitable groups, or private entities. Almost all health leaders, including hospital directors and hospital department heads, have been replaced. Physicians will be paid according to the type and amount of work performed. Perhaps the most important reform is the establishment of an independent General Health Care Insurance Office financed directly by compulsory contributions from workers, employers, and government that will be able to negotiate with hospitals and physicians to determine payment for services.