BACKGROUND: During the Suharto era public funding of health in Indonesia was low and the health services were tightly controlled by the central government; district health staff had practically no discretion over expenditure. Following the downfall of President Suharto there was a radical political, administrative and fiscal decentralization with delivery of services becoming the responsibility of district governments. In addition, public funding for health services more than doubled between 2001 and 2006. It was widely expected that services would improve as district governments now had both more adequate funds and the responsibility for services. To date there has been little improvement in services. Understanding why services have not improved requires careful study of what is happening at the district level. METHODS: We collected information on public expenditure on health services for the fiscal year 2006 in 15 districts in Java, Indonesia from the district health offices and district hospitals. Data obtained in the districts were collected by three teams, one for each province. Information on district government revenues were obtained from district public expenditure databases maintained by the World Bank using data from the Ministry of Finance. RESULTS: The public expenditure information collected in 15 districts as part of this study indicates district governments are reliant on the central government for as much as 90% of their revenue; that approximately half public expenditure on health is at the district level; that at least 40% of district level public expenditure on health is for personnel, almost all of them permanent civil servants; and that districts may have discretion over less than one-third of district public expenditure on health; the extent of discretion over spending is much higher in district hospitals than in the district health office and health centers. There is considerable variation between districts. CONCLUSION: In contrast to the promise of decentralization there has been little increase in the potential for discretion at the district level in managing public funds for health - this is likely to be an important reason for the lack of improvement in publicly funded health services. Key decisions about money are still made by the central government, and no one is held accountable for the performance of the sector - the district blames the center and the central ministries (and their ministers) are not accountable to district populations.
In this article, the determinants of health care expenditure per capita in Spanish regions are analysed. The coexistence of several models concerning the degree of spending power decentralization and financing systems makes Spain a singular case and allows us to draw conclusions relevant for other countries decentralizing their health care systems. Analysing the Spanish case also serves to show a number of pitfalls affecting econometric estimation of the effects of income and demographic structure on health expenditure. Because the reliability of parameter estimates is a key issue in the literature on the determinants of health expenditure, these potential problems should be taken into account when estimating and interpreting results.
Two papers in this volume focus on public finance and decentralization as central to resolving India's systemic public health crisis. However, some states and districts have achieved success despite serious financial and administrative deficits; this suggests that factors such as political commitment, community participation, human resource management, women's empowerment, and governance may be as or more important. The success of the National Rural Health Mission will depend on state and local institutional capacity, including strong partnerships with civil society organizations and private-sector actors. Increased resources and decentralization will not be sufficient by themselves.
El Sistema Nacional de Salud (SNS) presenta una compleja situación de equilibrio, que aunque puede ser satisfactorio a corto plazo, plantea grandes problemas de sostenibilidad y gobernabilidad; el incierto balance del proceso de descentralización sanitaria en España señala claramente la senda de buscar nuevas alternativas organizativas para hacer efectivas las ventajas de la descentralización, a la vez que ser capaces de aprovechar las economías del sistema y conseguir la equidad pretendida. Se proponen cuatro líneas de actuación: redefinición del SNS en torno al aseguramiento público y derecho cívico igual para todos; replanteamiento del sistema de financiación y del papel del fondo de cohesión; redefinir el papel del gobierno central y el Ministerio de Sanidad, y crear un nuevo organismo, la Agencia del SNS con un Comisionado que de soporte organizativo e identidad al SNS como ámbito de acción cooperativa. The Spanish National Health System (SNHS) is currently in a complex equilibrium which, even if acceptable in the short term, faces major sustainability and governance challenges; the so far inconclusive outcome of the SNHS decentralization process clearly underlines the importance of seeking new alternatives to effectively bring about the real benefits of decentralization, while taking advantage of the system's economies of scale and achieving its equity objectives. To this end, four lines of action are proposed in this paper: first, redefine the SNHS based on universal public coverage, as a civic right and equal for all; second, reframe the financing system and the role of the Cohesion Fund; third, review the role of central government and its Ministry of Health, and fourth, create of a SNHS Agency headed by a Commissioner, for providing an organizational framework and identity for the SNHS, and serving as the cooperative body of the seventeen Autonomous Communities’ Health Services.
Open access
Global Health Care Issues
Health Systems, Economic Evaluations, Quality of Life
A major shift appears to be underway in Europe in the relationship between national, regional, and local control over health sector decision-making. Since World War II, a central thrust of health policy has been to decentralize key dimensions of decision-making authority to increasingly lower levels of government, as well as (in Social Health Insurance systems and recently in some tax-based systems) to private sector organizations.1 This strategy, to adapt Kondratiev's business-cycle framework,2 has been one of two overlapping ‘long waves’ that helped frame structural decisions in most Western European health systems. The second wave—market-influenced-entrepreneurialism—has run simultaneously with decentralization since the late 1980s. However, while this second, market-oriented wave has generated considerable controversy in some health policy circles, the concept of decentralization was readily accepted in many national policy contexts. As a result, over the second half of the 20th century, expanded decentralization of authority to regional, municipal and non-governmental control has become part of the ‘received wisdom’ about what good health policy should include. In the tax-funded health systems in Nordic countries, for example, most administrative and managerial responsibility as well as substantial political (policy) and fiscal decision-making control has been decentralized inside the public sector: from national to regional level (somatic hospitals in Norway in 1970; mental hospitals in Sweden in 1967), from regional to municipal level (elderly residential care in Sweden in 1992), and from national to municipal level (effective decision-making control over central hospitals in Finland in 1993). In the tax-funded health systems in Southern Europe, most administrative and managerial as well as many political (but not key fiscal) responsibilities were devolved from national to regional governments in Spain (to the 17 autonomous communities from 1981 to 2003), and in Italy (to 22 regional governments starting in the late 1980s). In social health insurance funded countries in continental Europe such as Germany and the Netherlands, most administrative and managerial as well as many fiscal (but not key political) decisions have long been delegated to private not-for-profit bodies (sickness funds and hospitals), under a form of ‘enforced self-regulation’ grounded in explicit national statutory responsibilities.3 In many cases, this particular form of decentralization has been in place since those systems’ inception. In the more state-based social insurance systems that have emerged since 1990 in many Central European countries, various forms of decentralization have been utilized. Reacting strongly to the prior highly centralized Semashko model, countries decentralized ownership of hospitals from national to regional (Hungary) and local (Estonia, Poland) governments. The Czech Republic even termed its decentralization of hospital ownership to municipal governments as ‘privatization’. In similar fashion, centralized funding structures of the Communist period were decentralized into regional social health insurance funds in countries such as Poland, the Czech Republic and Slovakia. The strategic role of decentralization was further strengthened by changes in overall governmental structures in Europe. During the 1980s and 1990s, national governments increasingly ceded areas of sovereign power upward to European Union bodies, while at the same time that they were losing responsibilities downward to increasingly assertive regions—a process captured by the popular 1990s discussion about a ‘Europe of Regions’. This overall reduction in the role of national governments served to reinforce the health sector experience that the era of centralized power at the national level in Europe was fast receding. In the first years of the 21st century, however, this conventional wisdom has started to come undone. Far from continuing to recede, the role of the state in the health sector has begun to strengthen measurably. Instead of reinforcing the continued decentralization of authority away from national governments, state institutions have reversed course and are seizing responsibility for substantive political and fiscal decision-making in European health care systems. It now appears that in the near-term future only administrative and managerial authority—e.g. day-to-day operating decisions—will remain decentralized to lower level and/or non-governmental organizations. These counter-indications can be observed in many of the health systems noted earlier. In the tax-funded system in Norway, the national government took over political and administrative/managerial responsibility for all hospitals in the entire country in January 2002, removing control from the 19 regional governments (counties) that had previously owned and operated the public hospitals and transferring the administrative role to five newly created regional bodies appointed from Oslo. The national government also set out new rules for how these regions were to manage their hospitals—as ‘public enterprises’. Fiscal responsibility for health care remained, as before, a national responsibility. In Denmark, the national government initiated a major re-structuring of the health sector in January 2006. In the new configuration, the number of regional governments was reduced from 14 to 5, and their powers were greatly reduced. Fiscal and most political responsibilities were centralized back to the national government, with certain prevention and chronic care issues being re-allocated to the municipalities (also consolidated, from 271 to 98). At the end of these changes, the new regions retained little more than administrative and managerial responsibility for hospitals. A similar pattern of regional consolidation and a strengthening of the state role appears to be underway in Sweden and Finland. In Sweden, a royal commission is expected to recommend that the number of regional level governments (which have responsibilities for hospital and also primary care) be reduced from the current 21 to between 6 and 8. Similarly, in Finland, the national government is expected to propose that the number of central hospital districts, currently 22, be reduced to 18, and also that the number of municipalities (responsible for primary, nursing home and home care services) be reduced from 450 to about 250. In the United Kingdom, similar recentralization can be seen in the transformation of England's Regional Health Authorities from line to support functions, as well as in current plans to reduce the number of Primary Care Trusts from 300 to 150. In Ireland, key operating responsibilities were recently shifted from regional health care boards to a health executive at central level and the regional boards were abolished. A parallel, if less aggressive, thrust toward more state control over both political and fiscal decisions can also be observed in several social health insurance funded countries. In the Netherlands, the national government in 2006 changed the health system's funding structure from a sliding 50% employee/50% employee paid model to a 100% individually paid fixed premium, supplemented by social assistance funds (e.g. taxes) for low income citizens. The Dutch government also, since the late 1990s, has been ratcheting up the percentage of total expenditures for which the private not-for-profit sickness funds are at risk, forcing funds to manage their money more efficiently. In Germany, the federal government in 2009 is scheduled to take on responsibility for pooling all social health insurance contributions and then allocating them to the sickness funds on a prospective, risk adjusted, capitation basis. While this funding model has been in place in the neighboring Netherlands for many years, in Germany it would represent a major move toward centralizing fiscal responsibilities away from the private not-for-profit sickness funds and into the hands of a national government body. In Central Europe, Poland, in 2003, pulled operating control over its social health insurance system away from 17 regional funds and back into the Ministry of Health. From the perspective of national health policymakers, this process of re-centralization appears to reflect a complex set of concerns. Structurally, there is substantial worry about the aging of their populations (e.g. more elderly), the rapid growth of expensive new clinical technologies, and the economic constraints on health sector funding generated by European regionalization as well as the globalization of markets. Administratively, there is evidence in countries like Finland and Norway (also concerns in Denmark) that local control over health sector decision-making has led to increased disparities in services provided and in outcomes to vulnerable populations—in short, that decentralization has heightened equity problems. Economically, there are worries that local finance bases are insufficient to fund expensive future care needs, and that local administrative arrangements are inefficient and duplicative. Politically—an important factor in Northern European tax-funded countries—there is a sense among national politicians that they are being blamed when the health system fails to meet the expectations of the citizenry, and that national policymakers need to have the necessary organizational levers to correct these problems. Technically, the introduction of electronic medical records and other computerized reporting systems has reduced the transaction costs of information and made it feasible to more closely monitor health system performance from a central level. While many of these dilemmas with decentralization were predicted earlier in theoretical assessments,4 one can see strong elements of their concrete manifestation in the current movement toward re-centralization. Moreover, since these causal factors are long-term in nature, their recent importance lends strength to the argument that re-centralization may indeed represent a long-term structural shift in national health strategies. Several important questions arise from these examples of re-centralizaton in both tax funded as well as social health insurance funded health systems. One is whether the observed changes represent more than just the normal ebb-and-flow of policy development in European health systems, and instead signal a fundamental shift in the overall pattern of these decisions. A related question is whether political and fiscal authority will continue to migrate from regional and municipal to national government, leaving mostly administrative and managerial forms of control at the lower levels. The underlying issue here concerns the mix of national and local authority that typically exists within most European health care systems, and whether the main bias in structuring that mix might be changing from one favouring decentralizing to local governments into one that favors centralizing authority back to national governments. Posed more provocatively, one might ask whether a new “long wave” of re-centralization has now begun, pointing toward a health policy future of stronger national governments and weaker regional, local, and delegated private (SHI) institutions. There are—as Kuhn's theory about the complexities of paradigm shift would predict5—several confounding factors in arriving at satisfactory answers to these questions. One issue concerns whether a new ‘long wave’ of re-centralization can co-exist comfortably—as decentralization did—with the parallel long-wave pattern of market-influenced entrepreneurial measures, particularly in tax-funded health systems. Will re-centralization and entrepreneurialism reinforce each other, as happened previously with decentralized local units? Second, there are several exceptions to this broad pattern of increasing re-centralization across European health systems. One clear exception is in countries with serious ethnic conflicts, for example Bosnia-Herzegovina and Macedonia in the Balkans, and also in Belgium. Recent history suggests that decentralization may be essential in these highly charged political environments, in that various forms of local control are typically linked to the survival of the state itself. Another conceptually messy question concerns the pattern of continued regional decentralization of health sector decisions in Southern European countries like Italy and Spain. Regional governments in these two countries have fiercely defended their recently gained authority in the health sector, and have forced their less convinced central governments (Spain in 2003, for example) to tread carefully in designing new national programs to monitor performance or set standards for quality and outcomes. Of course, Spain and Italy both have histories of earlier regional sovereignty. Moreover, both are geographically larger and have bigger populations than Nordic countries—although they are roughly equal in size to the United Kingdom and also Poland. There is, further, within both Italian and Spanish regions a tendency toward greater internal centralization inside the regions themselves. Despite these caveats, however, it appears that Italy and Spain are pursuing greater decentralization at the same point in time that Northern European countries are shifting away from decentralization in their health systems. This brief review of recent health sector patterns raises a series of questions that do not allow for easy answers. A further complicating factor is the apparent lack of fit between continued local control over services to the elderly (home care, social assistance, also nursing home care) and increasing central control over fiscal and policy decisions in the overall health sector, which implies that re-centralization may soon confront key structural limitations. The current distribution of health sector evidence does suggest, however, that many European health systems will continue to see a tightening of state controls, especially over fiscal and quality-related matters. In this clash between national and local governments, it would appear that, on balance, democratic control at the national level will strengthen, taking increased authority over political and fiscal decisions, while democratic control at the regional and municipal level will weaken, and be increasingly focused only on administrative and managerial decisions. Moreover, given the rapid melting of public–private boundaries within many European health systems, this greater state role will likely be combined with growing public as well as private sector entrepreneurialism, despite the appearance that greater reliance on market-oriented decisions contradicts tighter state control over health system behaviour. While the particular balance between increased state controls and increased entrepreneurial initiatives will vary from country to country, this new blend of two ‘long waves’, with increasing levels of state authority over key health sector decisions, will likely define the future policymaking framework for many European health systems in the near-term future. Earlier versions of this argument were presented at the Third International Health Policy Conference in Jerusalem (December 2006) and the Annual Meeting of the European Public Health Association in Helsinki (October 2007). This version has benefited from comments made by a number of colleagues at both meetings, and especially from Josep Figueras, David Chinitz and Charles Phelps. An earlier version of this article is included in the conference proceedings of the Jerusalem meeting.
Open access
Health Systems, Economic Evaluations, Quality of Life
BACKGROUND: The Ministry of Defense budget constitutes 16% of the state budget. The budget for the Ministry of Health and for civilian health care is derived from the state budget. The health care funds receive their budgets from several sources. The capitation formula, which is determined by law, is the main factor that affects the size of the budget each fund receives. OBJECTIVE: The objective of this study is to describe the manner of planning, managing, monitoring, and controlling the budget allocated to medical services, which is a public budget for soldiers. METHODS: Several parameters are suggested for comparison, including the interface with the civilian health system, the method for budgeting a health care system, possible results of managing a medically centered budget, and the possibilities for monitoring the provided services. We also examine the potential for decentralization of authority. CONCLUSIONS: Managing the budget and locating appropriate alternatives, as well as the availability and accessibility of medical services, are important for procurement and for forming contracts with both military and civilian systems. Turnover based on updated information might serve to improve future health services.
Albert J. Jovell, Robert J. Blendon, María Dolors Navarro, Channtal Fleischfresser · 7 authors
BACKGROUND: Fifteen years ago, public opinion surveys in Spain showed substantial dissatisfaction with the health-care system. Since that time, health-care in Spain has undergone significant changes, including a decentralization of the system, an increase in spending and a change in the way the system is financed. OBJECTIVE: This study examines how Spanish citizens rate the performance of their health system today, both as compared with other sectors of society and as compared with earlier time periods. METHODS: Data are drawn from nationally representative telephone surveys of the non-institutionalized adult Spanish population (age 18 years and over). The study was carried out in two phases: October-November 2005 (n = 3,010) and January 2006 (n = 2,101). RESULTS: The majority of the Spanish population thinks the health system needs to be changed. The problems cited relate mostly to long wait times to get health-care. Nevertheless, over the last 15 years, the proportion of people who have very negative views about the health system has decreased by half. The majority believes that not enough money is spent on health-care, but few people would support an increase in taxes to provide additional funding. The survey finds the National Health System's institutions and health professionals to be more highly trusted than other institutions and professional groups in the country. CONCLUSIONS: Government policy-makers in Spain face a dilemma: the public wants more health spending to decrease wait times, but there is substantial resistance to increasing taxes as a means to finance improvements in the system's capacity.
The Russian Federation has undergone a process of major constitutional change in the post-communist period, as a strong central government has ceded extensive powers to the regions. This has important implications for the organization of the health care system which, as with other elements of the Soviet system, had previously been highly centralized. Although it is now well-recognized that the powers of the Federal Health Ministry have weakened considerably, the precise scale and nature of the process of decentralization remain imperfectly understood. This paper provides new evidence on the nature of decentralization in the Russian Federation since the breakdown of the USSR, reporting the results of case studies undertaken in six regions of Russia (Samara, Tver, Tula, Chelyabinsk, Sverdlovsk and Moscow oblasts) to describe the organization of health care financing, regulation and delivery. It shows that while there is a common model of health system (with the exception of Samara, where an innovative model was implemented), there are many minor variations. The study confirms the limited scope for action by Federal authorities, but also shows that the power vested in the regional governments is more limited than was previously thought. Instead, the municipalities (rayons) emerge as important bodies, as they own the facilities in which much of the routine health care is delivered and, both directly and indirectly, by virtue of their contributions of insurance premiums for the non-working, provide a substantial amount of health care financing. The study demonstrates the complexity of the Russian health care system and identifies the widespread absence of mechanisms that might be used to bring about much needed change.
China's transition into a market economy has exerted some influence on the health sector in terms of a significant growth of facilities, but it has also produced a range of destabilizing social costs. \n \n \n \nThis thesis analyzes the relations between healthcare pricing and payment reforms and the different delivery aspects such as the exemption program for the poor, public health programs for tuberculosis control and the provision of hospital services. A health economics and systems conceptual framework is used for analyzing aspects of the health systems in terms of market failures and the institutional response from governments and regulators. \n \n \n \nIn study I, the exemption programs for hospitals where the poor are relieved of paying the price or user charges are analyzed. The study is a case study where patient records from nine hospitals were reviewed, together with interviews with key informants and community representatives. The study showed that the discount offered was limited, where only a minority of indigents received discounts and the hospitals lacked incentives for efficiently carrying out the programs. \n \n \n \nStudy II investigates the effect of the new urban health insurance system on hospital charges. The study uses two tracers, acute appendicitis and normal childbirth, at six hospitals from two cities with different insurance systems. The result showed a lower rate of increase in hospitals charges in the city implementing the urban health insurance reform. Regression analysis showed contracting mechanisms and length of stay to be the main determinants for hospital charges. \n \n \n \nStudy III analyzes the operation of TB control programs in a decentralized financial system. A case study was conducted in four counties with different economic developments in the Shandong province. Data was collected from a review of documents and interviews with patients and key informants. The study showed weak government support to the TB control program and less developed DOT (directly observed therapy) programs in the poorer counties. TB patients suffered heavy financial burdens. The decentralized financing system had negatively affected the provision of public health programs such as TB control programs. \n \n \n \nIn study IV, the impact of retail price control of drugs on hospital drug expenditures was examined. The study is a case study at two hospitals. Total drug expenditures were analyzed based on financial records and a tracer, cerebral infarction, was used for an in-depth examination of prices, volume, expenditures and rationality of drug use. Findings showed that after the implementation of the drug pricing policy, total drug expenditures increased as rapidly as before. Drug expenditure per patient for cerebral infarction showed indistinct results, indicating that the regulation was not effective. Utilization rather than price was more determinative for drug expenditures. \n \n \n \nStudy V investigates the development of revenues, costs and performance in the hospital sector. In a sample of 41 hospitals in two cities, the use of inputs, investments and productivity was estimated. The findings showed that hospitals had expanded their staff and invested in new medical equipment. The corresponding change of outputs in terms of outpatient and inpatient performance showed a slower increasing rate, resulting in a diminishing productivity rate over time. \n \n \n \nThe market-oriented health care system in China is faced with different 'market failures' problems such as limited access to health services for the poor and the inaccuracy in relying on market mechanisms for services characterized by positive externalities, such as the public health programs. Financial autonomy has given health providers the incentives to maximize revenues. Government interventions to contain costs and improve efficiency show that a sole reliance on the price mechanism is insufficient and must be combined with other tools set by regulators and insurers.
India has set out ambitious goals for itself in the health sector in its Tenth Five Year Plan (2002-07). It is also a signatory to the United Nations Millennium Development Goals. Attainment of these goals which are time-bound will require a massive scaling up of investment in health, especially in public primary health care. We argue for a ‘Health for All’ initiative on the part of the government akin to the ‘Education for All’ scheme which was launched nation-wide in 2001. The large amount of resources required for scaling up public investment in primary health need not be the constraint it is purported to be. We discuss several options that are available to the government for generating the necessary funds. Among the options that can generate resources domestically are reform of the government’s subsidies regime including implementing life-line tariffs, ear-marking taxes and disinvestment of loss-making public sector units. Health for All can also be financed by raising more resources via external assistance. Official development assistance to India at present is rather low given India’s per capita income and the scale of its needs in human development terms. The scale of official development aid to India should increase several folds and committed use of funds should be made by the government in health and other priority sectors. With the 73rd and 74th amendments to the Indian Constitution which created a third tier of government comprising of elected local bodies at the village and town ward levels, a decentralized system of service delivery will eventually become a reality in India and needs to be a part of any debate on the means and modes of improving human development outcomes in India. The current system of planning and allocation of funds at the sub-national level however needs to be over-hauled if fiscal decentralization is also to become a reality.
One of the limitations of cross-country health expenditure analysis refers to the fact that the financing, the internal organization and political restraints of health care decision-making are country-specific and heterogeneous. Yet, a way through is to examine the influence of such effects in those countries that have undertaken decentralization processes. In such a setting, it is possible to examine potential expenditure spillovers across the geography of a country as well as the influence of the political ideology of regional incumbents and institutional factors on public health expenditure. This paper examines the determinants of public health expenditure within Spanish region-states (Autonomous Communities, ACs), most of them subject to similar financing structures although exhibiting significant heterogeneity as a result of the increasing decentralization, region-specific political factors along with different use of health care inputs, economic dimension and spatial interactions.
The severe acute respiratory syndrome (SARS) crisis in China revealed not only the failures of the Chinese health-care system but also some fundamental structural deficiencies. A decentralized and fragmented health system, such as the one found in China, is not well-suited to making a rapid and coordinated response to public health emergencies. The commercial orientation of the health sector on the supply-side and lack of health insurance coverage on the demand-side further exacerbate the problems of the under-provision of public services, such as health surveillance and preventive care. For the past 25 years, the Chinese Government has kept economic development at the top of the policy agenda at the expense of public health, especially in terms of access to health care for the 800 million people living in rural areas. A significant increase in government investment in the public health infrastructure, though long overdue, is not sufficient to solve the problems of the health-care system. China needs to reorganize its public health system by strengthening both the vertical and horizontal connections between its various public health organizations. China's recent policy of establishing a matching-fund financed rural health insurance system presents an exciting opportunity to improve people's access to health care.
ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.
ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.
John Grundy, Valentine Healy, L Gorgolon, E Sandig
INTRODUCTION: In 1991 the Philippines Government introduced a major devolution of national government services, which included the first wave of health sector reform, through the introduction of the Local Government Code of 1991. The Code devolved basic services for agriculture extension, forest management, health services, barangay (township) roads and social welfare to Local Government Units. In 1992, the Philippines Government devolved the management and delivery of health services from the National Department of Health to locally elected provincial, city and municipal governments. AIM: The aim of this review is to (i) Provide a background to the introduction of devolution to the health system in the Philippines and to (ii) describe the impact of devolution on the structure and functioning of the health system in defined locations. METHOD: International literature was reviewed on the subjects of decentralization. Rapid appraisals of health management systems were conducted in both provinces. Additional data were accessed from the rural health information system and previous consultant reports. RESULTS: Subsequent to the introduction of devolution, quality and coverage of health services declined in some locations, particularly in rural and remote areas. It was found that in 1992-1997, system effects included a breakdown in management systems between levels of government, declining utilization particularly in the hospital sector, poor staff morale, a decline in maintenance of infrastructure and under financing of operational costs of services. CONCLUSION: The aim of decentralization is to widen decision-making space of middle level managers, enhance resource allocations from central to peripheral areas and to improve the efficiency and effectiveness of health services management. The findings of the historical review of devolution in the Philippines reveals some consistencies with the international literature, which describe some negative effects of decentralization, and provide a rationale for the Philippines in undertaking a second wave of reform in order to 'make devolution work'.
Nazmul Chaudhury, Jeffrey S. Hammer, Edmundo Murrugarra
This study examines the impact of a fee-waiver program for basic medical services on health care utilization in Armenia. Due to the reduction in public financing of health services and decentralization and increased privatization of health care provision, private out-of-pocket contributions are increasingly becoming a significant component of health costs in Armenia. To help poor families cope with this constraint, the Government of Armenia provided a free-of-charge basic package service to eligible individuals in vulnerable groups, such as the disabled and children from single parent households. Drawing upon the 1996 and 1998/99 Armenia Integrated Survey of Living Standards (AISLS), which allows the identification of eligible individuals under this program, we estimate the impact of the fee-waiver program on utilization of health services, particularly among the poor. Across the two survey rounds utilization rates have indeed declined despite comparable levels of income, and this decline has occurred among both the poor and the rich, with average utilization falling by 12 percent between the two surveys. However, families with four or more children, the largest beneficiary group under the "Vulnerable Population" program, have decreased their usage of health care services in a disproportionate manner -- 21 percent reduction in usage between the two survey rounds. This precipitous drop in health care usage by this vulnerable group despite being eligible for free medical services, suggests that the program just by itself was inadequate in stemming the decline in the usage of health services. We furthermore present evidence to suggest that the free-of-charge eligibility program is acting more like an income transfer mechanism, particularly to disabled individuals. Contents...
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.
Open access
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
Carlos Centeno, S. Hernansanz, Luis Alberto Flores, Álvaro Sanz Rubiales · 5 authors
Abstract This chapter offers an in-depth look at health politics and the tax-financed, universal health system in Spain. It traces the development of the Spanish healthcare system, focusing in particular on its double transition in the 1980s and 1990s from a centralized social insurance system, mostly funded through workers’ and employers’ contributions, to a decentralized universal model financed by general taxation. The new national health system aimed at covering all residents and transferred healthcare competences to the regions, i.e. the seventeen Autonomous Communities, a process completed in 2001. Key issues include rationalization, harmonization, and territorial equity-building of the decentralized healthcare system; efficiency improvement through the introduction of private management elements; and cost containment to bolster the system’s financial sustainability in the context of growing demand and scarce resources. As the chapter argues, these challenges along with the remarkable changes in the political party system have increased the political salience of healthcare in public debate in the 2010s, but the prospects for developing consensual healthcare policies have worsened, such that structural problems are likely to persist.