Rwanda is a good example of how a country can overcome challenges and obstacles to improve the socioeconomic well-being of citizens. With no reliable healthcare system in 1994, after the genocide against the Tutsi, the country has come a long way in building a decent healthcare system for its people. The purpose of this research is to analyze the changing PPP mixed in health care sector in Rwanda. The study was carried out to reflect/reveal or bring to light the perennial problems of the healthcare mixes within a period of six months. This work looked at the public-private sector mixes in healthcare system using Rwanda as a case study. In Rwanda, the ministry of health began health sector reforms in accordance with the Lusaka declaration in 1995. These reforms included decentralization of the health system, development of the primary healthcare system, and community participation in managing health service financing. Rwanda is one of the few African countries with 90% coverage in all Districts for immunization and access to critical health services including TB treatment and access to ARVs for HIV patients. Within a very short period of 23 years, Rwanda has built a working health system in which even the poor and disadvantaged have access to quality medical care through the Community Based Health Insurance.
Hilaire Zon, Milena Pavlova, Koiné Maxime Drabo, Wim Groot
'Four' types of decentralization are distinguished in health care: deconcentration when the shift in authority is to regional or district offices; devolution when the shift is to state, provincial or municipal governments; delegation when semi-autonomous agencies are granted new powers; and privatization when ownership is granted to private entities. This article systematically reviews the experiences of local governments of Sub-Saharan African countries with the provision of health services during and after decentralization reforms. The article highlights the achievements, challenges and issues associated with decentralization. The review shows that most countries have mainly focused on the process by enacting numerous policies, regulations and standards with mixed outcomes for health services delivery. Decentralization in general, and resource transfer from the central to local governments in particular, are a highly political issue that influences the health reform strategy on decentralization. The literature shows the complexity of implementing decentralization schemes which strongly impact the health service organization and delivery. The theory of decision space applied in a comparative analysis found that some functions, particularly financing, remain under the control of the central state. Despite the numerous challenges, this review identifies some good practices in resources transfer, key determinants being the type of decentralization and the government's will to make legislative and administrative changes required for the effectiveness of decentralization. The literature search, even though systematic, resulted in a limited number of relevant publications with evidence on the link between decentralization and health services delivery. This is a largely unexplored research area, especially the use of financial resources by local governments, the factors that drive local decision-making processes and the effects of decentralization on health care sector performance.
Laura Monteiro de Castro Moreira, Felipe Ferré, Eli Iôla Gurgel Andrade
The Decrees 4279/10 and 7508/11 established norms to guide health politics, with impacts on funding of the Middle and High Complexity Hospital and Outpatient. To verify the effects on the consolidation of care networks in Minas Gerais, we performed an analytical-descriptive study of the National Health Fund from 2006 to 2014. We observed decentralization of responsibilities, accompanied of resources and innovative financing mechanisms, resulting expansion of the network care model. The federal government definitions suggest reduction of the autonomy and limitation of regional solutions.
David Houéto, Graziella Ghesquiere, Maurice Agonnoudé, Amavi Hounouvi · 6 authors
Introduction According to Canavan et al. [1], results-based financing (RBF) is a method of financing focused on the assumption that linking motivations to the performance would help to improve accessibility, quality and equity in the provision of health services. Blanchett quoted by Canavan et al., [1] argues that its impact would vary
The promulgation of the new constitution in Kenya in August 2010 effectively ushered in devolution as the latest and highest form of decentralization in Kenya. The health sector was the largest service sector to be devolved under this new governance arrangement. The rationale for devolving the sector was to allow the county governments to design innovative models and interventions that suited the unique health needs in their contexts, encourage effective citizen participation and make autonomous and quick decisions on resource mobilization and management possible issues. However, the sector in nearly all counties is currently bedevilled with monumental challenges ranging from capacity gaps, human resource deficiency, lack of critical legal and institutional infrastructure, rampant corruption and a conflictual relationship with the national government. The net effect of these challenges is the stagnation of healthcare and even a reversal of some gains according to health indicators. No doubt what is needed to guarantee an all-inclusive rights-based approach to health service delivery is its proper institutionalization to ensure good governance and effective community participation. This must however be accompanied by wider governance reforms as envisaged in the new constitution for the sustainability of Healthcare Reforms. Key Words : Devolution, Healthcare Delivery, Healthcare Financing, Health Workforce, health governance.
Banque Interaméricaine de Développement, Banco Interamericano de Desenvolvimento
This Breve is based on the original thesis work and on a webinar presented by Dr. Fábio Ferride-Barros regarding the "Ethics of Health Resources Allocation in the Publicly Financed Health Care System in Brazil." The perspective offered in this Breve complements a previously published issue documenting the use of health technology evaluation in decision-making in Brazil's health sector (IDB, 2015). The Breve introduces the challenges of priority setting in the context of a large and decentralized national universal health care system, which confronts resource scarcity and substantial inequalities.
Open access
2 source records
Public Health in Brazil
Health Systems, Economic Evaluations, Quality of Life
BACKGROUND: Universal Health Coverage (UHC) has emerged as a major goal for health care delivery in the post-2015 development agenda. It is viewed as a solution to health care needs in low and middle countries with growing enthusiasm at both national and global levels. Throughout the world, however, the paths of countries to UHC have differed. South Africa is currently reforming its health system with UHC through developing a national health insurance (NHI) program. This will be practically achieved through a decentralized approach, the district health system, the main vehicle for delivering services since democracy. METHODS: We utilize a review of relevant documents, conducted between September 2014 and December 2015 of district health systems (DHS) and UHC and their ideological underpinnings, to explore the opportunities and challenges, of the district health system in achieving UHC in South Africa. RESULTS: Review of data from the NHI pilot districts suggests that as South Africa embarks on reforms toward UHC, there is a need for a minimal universal coverage and emphasis on district particularity and positive discrimination so as to bridge health inequities. The disparities across districts in relation to health profiles/demographics, health delivery performance, management of health institutions or district management capacity, income levels/socio-economic status and social determinants of health, compliance with quality standards and above all the burden of disease can only be minimised through positive discrimination by paying more attention to underserved and disadavantaged communities. CONCLUSIONS: We conclude that in South Africa the DHS is pivotal to health reform and UHC may be best achieved through minimal universal coverage with positive discrimination to ensure disparities across districts in relation to disease burden, human resources, financing and investment, administration and management capacity, service readiness and availability and the health access inequalities are consciously implicated. Yet ideological and practical issues make its achievement problematic.
Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública. Cuernavaca, México., Emanuel Orozco, Jacqueline Elizabeth Alcalde‐Rabanal, Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública. Cuernavaca, México. · 8 authors
OBJECTIVE:: To show that the administrative regime of specialized hospitals has some influence on the administrative processes to operate the Mexican Fund for Catastrophic Expenditures in Health (FPGC, in Spanish), for providing health care to breast cancer, cervical cancer and child leukemia. MATERIALS AND METHODS:: The variable for estimating administrative efficiency was the time estimated from case notification to reimbursement. For its estimation, semistructured interviews were applied to key actors involved in management of cancer care financed by FPGC. Additionally, a group of experts was organized to make recommendations for improving processes. RESULTS:: Specialized hospitals with a decentralized scheme showed less time to solve the administrative process in comparison with the model on the hospitals dependent on State Health Services, where timing and intermediation levels were higher. CONCLUSIONS:: Decentralized hospitals administrative scheme for specialized care is more efficient, because they tend to be more autonomous.
-Within the last two decades, the Nigerian government has committed to strengthening its primary health care system, through reforms addressing institutional restructuring, deepening decentralized governance, and the incorporation of an alternative health care financing strategy. One of these reforms prescribed the establishment of state primary health care agencies/boards (SPHCDBs) as an integral part of the national health system, with the principal responsibility "for the coordination of planning, budgeting, provision and monitoring of all primary health care services that affect residents of the state." Central to this reform is the integration of primary health care (PHC) governance and management, popularly called primary health care under one roof. Another reform, piloting results-based financing, has been implemented since 2011 in three states under the Nigeria State Health Investment Project. This study assesses the implementation of the Primary Health Care Under One Roof (PHCUOR) policy as part of the broader PHC reforms, with a specific focus on how this policy has been strengthened through the Nigeria State Health Investment Project (NSHIP) in Adamawa, Nasarawa, and Ondo states, documenting the evolution of SPHCDB and PHC service delivery, with a focus on management, accountability, and incentives. The study shows that, in the above-mentioned states, significant milestones were achieved in the establishment of the SPHCDB, the strengthening of PHC systems, the improvement of accountability linkages, and an increase in service utilization. The authors therefore argue that integrated PHC systems through SPHCDBs, as enshrined in the PHCUOR guidelines, are a panacea for effective provision of primary health care and a potential game changer for health outcomes, especially when reinforced with a results-based financing approach.
This analysis of the Romanian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Romanian health care system is a social health insurance system that has remained highly centralized despite recent efforts to decentralize some regulatory functions. It provides a comprehensive benefits package to the 85% of the population that is covered, with the remaining population having access to a minimum package of benefits. While every insured person has access to the same health care benefits regardless of their socioeconomic situation, there are inequities in access to health care across many dimensions, such as rural versus urban, and health outcomes also differ across these dimensions. The Romanian population has seen increasing life expectancy and declining mortality rates but both remain among the worst in the European Union. Some unfavourable trends have been observed, including increasing numbers of new HIV/AIDS diagnoses and falling immunization rates. Public sources account for over 80% of total health financing. However, that leaves considerable out-of-pocket payments covering almost a fifth of total expenditure. The share of informal payments also seems to be substantial, but precise figures are unknown. In 2014, Romania had the lowest health expenditure as a share of gross domestic product (GDP) among the EU Member States. In line with the government's objective of strengthening the role of primary care, the total number of hospital beds has been decreasing. However, health care provision remains characterized by underprovision of primary and community care and inappropriate use of inpatient and specialized outpatient care, including care in hospital emergency departments. The numbers of physicians and nurses are relatively low in Romania compared to EU averages. This has mainly been attributed to the high rates of workers emigrating abroad over the past decade, exacerbated by Romania's EU accession and the reduction of public sector salaries due to the economic crisis. Reform in the Romanian health system has been both constant and yet frequently ineffective, due in part to the high degree of political instability. Recent reforms have focused mainly on introducing cost-saving measures, for example, by attempting to shift some of the health care costs to drug manufacturers by claw-back and to the population through co-payments, and on improving the monitoring of health care expenditure.
Ernest Mensah, Moses Aikins, Margaret Gyapong, Francis Anto · 6 authors
BACKGROUND: The global health system has a large arsenal of interventions, medical products and technologies to address current global health challenges. However, identifying the most effective and efficient strategies to deliver these resources to where they are most needed has been a challenge. Targeted and integrated interventions have been the main delivery strategies. However, the health system discourse increasingly favours integrated strategies in the context of functionally merging targeted interventions with multifunctional health care delivery systems with a focus on strengthening country health systems to deliver needed interventions. Neglected Tropical Diseases (NTD) have been identified to promote and perpetuate poverty hence there has been global effort to combat these diseases. The Neglected Tropical Diseases Programme (NTDP) in Ghana has a national programme team and office, however, it depends on the multifunctional health delivery system at the regional and district level to implement interventions. The NTDP seeks further health system integration to accelerate achievement of coverage targets. The study estimated the extent of integration of the NTDP at the national, regional and district levels to provide evidence to guide further integration. METHODOLOGY/PRINCIPAL FINDINGS: The research design was a descriptive case study that interviewed key persons involved in the programme at the three levels of the health system as well as extensive document review. Integration was assessed on two planes-across health system functions-stewardship and governance, financing, planning, service delivery, monitoring and evaluation and demand generation; and across three administrative levels of the health system-national, regional and district. A composite measure of integration designated Cumulative Integration Index (CII) with a range of 0.00-1.00 was used to estimate extent of integration at the three levels of the health system. Service delivery was most integrated while financing and planning were least integrated. Extent of integration was partial at all levels of the health system with a CII of 0.48-0.68; however it was higher at the district compared to the national and regional levels. CONCLUSIONS/SIGNIFICANCE: To ensure further integration of the NTDP, planning and finance management activities must be decentralized to involve regional and district levels of the health system. The study provides an empirical measure of extent of integration and indicators to guide further integration.
Suncica Dimitrijoska, Svetlana Trbojevik, Наташа Богоевска, Vladimir Ilievski
The Republic of Macedonia experienced a rapid growth in drug addiction after its independents in 1991. The complexity of the problem represents a serious challenge for all relevant factors involved in creation of policies as well as actors in delivery of health, education and social services. Provision of necessary service required appropriate amendments of relevant laws based on the adopted international legislation. The most significant legal changes were introduction of the principles of pluralisation of social protection (Law on Social protection, 2004), that enabled emerging of new private for profit and nonprofit actors as providers of services as well as introduction of the principle of decentralization, enabling establishment of services on local level. Additionally, a number of national and local strategies and programs were developed and adopted within the system of health and social protection. These changes contributed to an increase in the number of available services offering variety of treatments responding to the individual needs of beneficiaries. Despite the increase in offered service, the state has yet to respond to the ever rising problem of addicted children. So far, little has been done for this age group of addicts that requires specialized and adjusted service provision. Provided social services are facing the problem in the sustainability of the available services provided within the nongovernmental sector that is mainly financed from foreign funds.
This Note addresses the implementation of health insurance reform in Yemen. As a result of a system of user fees and a lack of health insurance, the current regime poses serious barriers to health care access for Yemen's uninsured citizens. When the dust settles from the ongoing conflict with Houthi rebels, the time will be ripe for replacing Yemen's health financing system. In order to rebuild trust and curb abuse in the public health system, legal reforms are required to implement health insurance through decentralized decision-making and accountability measures. The Welfare Regime Framework accommodates these general reforms through policies that reflect the particular circumstances of Yemen. The implementation of health insurance reform will require policy reforms that bring together local, national, and international stakeholders to finance and develop management capacity for community-based health insurance in Yemen.
In recent years, global governance institutions have operationalized their commitment to the right to health by advocating for universal health coverage (UHC) – particularly in the Global South. UHC aims to develop health systems that are efficient, well staffed, and capable of providing affordable and appropriate medical care and essential medicines to rich and poor alike (World Health Organisation, 2014). The political priority afforded to this goal is driven by an acknowledgement that people in wealthy and poor countries alike are priced out of the “market” for health care. This has caused concern because of the negative economic effects associated with inadequate access to care. Academic research and scholarly rhetoric often justifies UHC on the grounds that it will strengthen the economic position of households (particularly households living below or just above the poverty line) and contributes to the growth prospects of national economies (World Health Organisation Commission on Macroeconomics and Health, n.d.). UHC is thus framed as an investment in human capital: Healthier citizens are more productive citizens. They are more capable of investing in their own well-being, and that of their dependents, through participation in the labor market rather than relying on public assistance. Why is it problematic to justify UHC, and health promotion more generally, on the basis of its economic value, that is, on the basis of the contributions it makes to growing markets and improving economic productivity? Research on the reconfiguration of welfare regimes in the Global North suggests that globalization is undermining their social, political, and economic foundations. These countries – much like their counterparts in the Global South – are experiencing a rise in unemployment, coupled with an increase in flexible and precarious work. Globalization has also been associated with an increase in human migration from the Global South to the Global North and within the Global South. As a result, states are simultaneously faced with increased demands for welfare from the unemployed and the working poor, an erosion of their tax base, and increasingly heterogeneous societies. States are responding to these changes by adopting welfare policies that expand the influence of market actors and market logics on social welfare. Consequently, decisions about how to define and promote the public good are increasingly made in a decentralized fashion by private actors operating in households or markets rather than in democratic political institutions. For example, in many countries, access to public assistance is now contingent on welfare recipients' efforts to find employment (i.e., the shift from welfare to “workfare”) and pay for basic services, on private and public sector providers' ability to provide social services efficiently and cost effectively, and on the state's ability to efficiently coordinate interactions between citizen consumers and social services providers (Roche, 2002). Advocacy for UHC reflects these political and normative shifts. It de-emphasizes the importance of collective democratic decision-making about how the health needs of populations should be addressed. Instead, public institutions are primarily responsible for solving a “technical” problem: financing health consumption for all. As public institutions become more focused on policing health financing, they reduce the services they provide and, in so doing, strengthen the market power of private players (Global Health Watch, 2014). Private actors – philanthropic foundations and for-profit providers of medical services, health insurance, and medicines – now routinely constrain the ability of governments to decide the terms on which the right to health should be advanced. Their influence is legitimated by the World Bank and IMF austerity policies that frame debt repayment and economic growth as the direct and primary responsibilities of democratic governments. Although governments in the Global South are particularly vulnerable to these pressures, similar pressures are present in the Global North – as demonstrated by private sector opposition to Obamacare (Kirsch, 2013) and patent law reform in South Africa (De Wet, 2014). In contrast, these institutions frame the obligation to promote the social dimension of citizenship as something that can be outsourced to private actors and/or achieved through market logics. Additionally, the value of social policies is often justified in economic terms, for example, in terms of their ability to improve the productivity of worker citizens and the revenues of public and private sector service providers. This discourse de-emphasizes the intrinsic value of formal and substantive equality and meaningful participation in collective decision-making about the public good. Political institutions feature in it primarily as mechanisms that mediate the efficacy of investments in health care. Their significance is determined by their ability to maximize returns on investments in health (Jack and Lewis, 2009). What are some of the consequences of advancing the right to health in this manner? Research shows that the shift from universalistic welfare regimes to regimes that target “especially vulnerable” or “especially deserving” populations undermines social solidarity by stigmatizing welfare recipients as people who violate the liberal ethos of contemporary welfare states. Vulnerable populations (e.g., non-citizens, people of color, indigenous peoples, working class women, and able-bodied unemployed people) are stigmatized as being reluctant to (or incapable of) succeeding in market societies on their own “merit” and as unfairly benefiting from welfare policies that advance their particularistic group interests rather than overall well-being (Brown, 2003). The low social status of these groups obstructs their ability to access appropriate and effective medical care, even when it is available at no or little cost to patients (Bassett, 2015). Globalization is a politically and socially mediated process. The harmful effects of globalization on social inclusion, and the limits of the policy responses to these dynamics, point to the urgent need for collective action and research aimed at addressing the dimensions of globalization that undermine the social determinants of health by privatizing, stigmatizing, and instrumentalizing the management of health – and in some cases, life itself. Collective action is needed to democratize decision-making about health care at the local, national, and global levels in a meaningful way to foster social solidarity and address status inequalities that lead to disproportionate rates of illness and death among stigmatized social groups and to politicize the priority placed on economic growth, given its sometimes harmful effects on human and planetary health. Global Challenges is a journal that welcomes scholarly contributions on these tough issues and insightful commentary that points toward strategies for addressing them.
Aku Kwamie, Han van Dijk, Evelyn Ansah, Irène Akua Agyepong
The district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the influence of path-dependent administrative, fiscal and political decentralization processes on development of the district health system and district manager decision-space. Methods included a non-exhaustive literature review of democratic governance in Ghana, and key informant interviews with high-level health system officials integral to the development of the district health system. Through our analysis we identified four periods of district health system progression: (1) development of the district health system (1970-85); (2) Strengthening District Health Systems Initiative (1986-93); (3) health sector reform planning and creation of the Ghana Health Service (1994-96) and (4) health sector reform implementation (1997-2007). It was observed that district manager decision-space steadily widened during periods (1) and (2), due to increases in managerial profile, and concerted efforts at managerial capacity strengthening. Periods (3) and (4) saw initial augmentation of district health system financing, further widening managerial decision-space. However, the latter half of period 4 witnessed district manager decision-space contraction. Formalization of Ghana Health Service structures influenced by self-reinforcing tendencies towards centralized decision-making, national and donor shifts in health sector financing, and changes in key policy actors all worked to the detriment of the district health system, reversing early gains from bottom-up development of the district health system. Policy feedback mechanisms have been influenced by historical and contemporary sequencing of local government and health sector decentralization. An initial act of administrative decentralization, followed by incomplete political and fiscal decentralization has ensured that the balance of power has remained at national level, with strong vertical accountabilities and dependence of the district on national level. This study demonstrates that the rhetoric of decentralization does not always mirror actual implementation, nor always result in empowered local actors.
Devolution, as other types of decentralization, profoundly changes governance relations in the health system. Devolution is meant to affect performance of the health system by transferring responsibilities and authority to locally elected governments. This study aimed to establish the effect of devolved governance on the performance of the health sector in Kenya. The guiding objectives included: To establish the influence of devolved procurement on the performance of the health sector; to determine the effect of devolved leadership on the performance of the health sector; to evaluate the effect of devolved resources on the performance of the health sector; and to establish the effect of devolved policy and regulatory framework on the performance of the health sector in Kenya. The study adopted the descriptive survey research design. The target population was 572 patients and health care providers from Nairobi and Mombasa County. Stratified sampling method was adopted at the rate of 10% to come up with a sample size of 57 respondents. Primary data was collected using questionnaires from all the respondents. Secondary data was sourced from health sector reports in Kenya from the year 2010 to 2014. The collected data was then analyzed through frequencies and percentages to enable the research come up with conclusions and recommendations for the study. The researcher employed the assistance of some computer tools, including the Statistical Programmes for Social Sciences (SPSS) and excel version 16 to analyze the data quantitatively. The analyzed data was presented in the form of graphs tables and charts. The Study established that devolution process has not been fully implemented and its effect has not been fully experienced in the health sector. The sector performance was averagely rated in the study and its contribution to GDP reduced by 0.5 percent by the end of the year 2013. The devolved procurement process, organizational leadership, resources allocation and availability as well as policy and regulatory framework had a significant influence on the performance of the level four hospitals and the overall health sector. It was recommended that the health sector players should improve in financing of critical health investment areas, particularly those relating to improving quality of care.
Evelyn Waweru, Catherine Goodman, Sarah Kedenge, Benjamin Tsofa · 5 authors
In many African countries, user fees have failed to achieve intended access and quality of care improvements. Subsequent user fee reduction or elimination policies have often been poorly planned, without alternative sources of income for facilities. We describe early implementation of an innovative national health financing intervention in Kenya; the health sector services fund (HSSF). In HSSF, central funds are credited directly into a facility's bank account quarterly, and facility funds are managed by health facility management committees (HFMCs) including community representatives. HSSF is therefore a finance mechanism with potential to increase access to funds for peripheral facilities, support user fee reduction and improve equity in access. We conducted a process evaluation of HSSF implementation based on a theory of change underpinning the intervention. Methods included interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. We found impressive achievements: HSSF funds were reaching facilities; funds were being overseen and used in a way that strengthened transparency and community involvement; and health workers' motivation and patient satisfaction improved. Challenges or unintended outcomes included: complex and centralized accounting requirements undermining efficiency; interactions between HSSF and user fees leading to difficulties in accessing crucial user fee funds; and some relationship problems between key players. Although user fees charged had not increased, national reduction policies were still not being adhered to. Finance mechanisms can have a strong positive impact on peripheral facilities, and HFMCs can play a valuable role in managing facilities. Although fiduciary oversight is essential, mechanisms should allow for local decision-making and ensure that unmanageable paperwork is avoided. There are also limits to what can be achieved with relatively small funds in contexts of enormous need. Process evaluations tracking (un)intended consequences of interventions can contribute to regional financing and decentralization debates.
Renate Hartwig, Robert Sparrow, Sri Budiyati, Athia Yumna · 7 authors
We exploit variation in the design of subnational health-care financing initiatives in Indonesian districts to assess the effects of these local schemes on maternal care from 2004 to 2010. The analysis is based on a district pseudopanel, combining data from a unique survey among District Health Offices with the Indonesian Demographic and Health Surveys, the national socioeconomic household surveys, and the village census. Our results show that these district schemes contribute to an increase in antenatal care visits and the probability of receiving basic recommended antenatal care services for households that are not targeted by the national health insurance programs. We observe a decrease in home births. However, there is no effect on professional assistance at birth. We also observe variation in scheme design across districts as well as constraints to the effectiveness of local schemes. Including antenatal and delivery services explicitly in benefits packages and contracting local rather than national health-care providers increases the effects on maternal care. Increasing population coverage reduces effectiveness, delineating limitations to local funding and risk pooling. Furthermore, we do not find any effects for districts outside Java and Bali, where access to basic health care remains a key policy concern.
Decentralization is assumed to be an important tool for a quality health care service delivery. The objective of the study was to assess the impacts of decentralization on the health care service delivery Gozamin District, Amhara State, Ethiopia. Primary data for this study were collected through questionnaire, interview, and focus group discussions. Whereas secondary data were collected from annual official health sector reports and documents. The analysis part was supported by legal and official documents. The findings of the study revealed that the health care service accessibility and coverage of the District in terms of expansion of health care institutions has shown an improvement, and it reaches 100 percent. However, shortage of health personnel (midwifery, lab technician and pharmacy technician), shortage of finance for duty service and perdiem payment, and drugs shortage are the challenges of the District health care delivery system that affects the quality of the services. The costs of health care treatment is high as compared to the ability of most beneficiaries incomes, the free service scheme-which is very impressive were abused by kebele officials are the challenges of Gozamin District health care service delivery system. Keywords: Decentralization, Health Care Service Delivery, health center, and health posts
Primary health care is an essential part of the health care system whose basic principles equality, health promotion and disease prevention, community involvement, appropriate technology and multisectoral approach and the key elements of organizational and managerial decentralization strategy, strategic management, coordination and development of control systems. In the mid 80s, the World Health Organization initiated the program 'Promotion of Health', which is considered to be an essential strategy for achieving the common goal of 'Health for All' - improving the health of the population. Promotional preventive measures require the support of health policy, engagement of the whole society, multisectoral cooperation and political support. A special place in these measures has a health service, but need a reorientation of the entire health care system in terms of changes in work, health care financing and training of health workers. .
Svetlana Jovanović, Srđan Milovanović, Jelena Mandić, Sinisa Jovović
The health system is one of the most complex systems in any country. Each state has an obligation to take care and care about the health of its population. The health care system includes the health infrastructure that provides a range of programs and services, and provides health care to individuals, families and communities. The health system must ensure the physical, geographical and economical accessiblity and affordability of integrated and quality health care. It should also provide for the development of health personnel, finance sustainability, decentralization of management and financing of health care and placing the citizens at the centers of the health system. The purpose of the health care system is the preservation and improvement of human health by providing health services, modern as well as traditional medicine, in an efficient manner and at the same time accessible and acceptable to the people. Due to its importance and impact on the population of each country, as well as its large economic impact, the government implemented a series of measures in planning and managing the health care system to ensure stable funding and rational and a quality health care delivery system, and all this in order to provide within the available resources a basic health care. In all the countries, the aging of the population and the introduction of new and expensive technologies present a constantly increasing cost of health care delivery. Modern health care systems differ from each other mainly in the methods of raising funds for health care, as well as in methods of payment for the service providers in the health sector. Problems of health care systems rarely, if ever, can be solved forever. As countries develop, their health care systems must respond to new challenges.
This issue marks a transition point in the life of this journal. Readers who peruse the inside cover of the journal (or our website) will notice that the editorial board has been (thoroughly) renovated. Self-questioning, self-criticism and even a penchant for self-subversion have been constitutive of the identity of the European Law Journal since its foundation. The new editorial board will contribute to keep this identity alive. I am extremely happy to report that the new board is close to complete gender balance (and hopefully will be rather soon in full gender balance). The new board is also more inclusive of the different legal, political and cultural traditions that make up the European legal mosaic. This will certainly lead to new ideas, new debates and new sections, in all cases reflecting an invariable commitment to thinking law in its economic, political, historical, social and cultural context. Never before was the reporting of the content of European law an act so pregnant of radical implications. Never before so much was at stake in Europe: socially, economically and politically. Not since the end of the Second World War was the very identity of European societies as open and cooperative, democratic and socially just societies so much challenged. If the proof of the cake is in the eating, the proof of the journal is in its contents. Both Gareth Davies and Marija Bartl break new ground on subsidiarity. Both authors focus on the structural constitution of power allocation in Europe. Separately, each piece challenges not only the existing literature, but also the practice (and discourse) of European institutions. Jointly, Davies and Bartl redefine the very terms in which the debate on subsidiarity should proceed from now onwards. Tanja Ehnert draws major theoretical and constitutional lessons from the study of what is at first sight the rather specialised if not esoteric subject of nanotechnologies in food (including nanofood). She acknowledges that European institutions produce lots of expertise, but she puts forward powerful reasons to doubt that this expertise amounts to the kind of knowledge which could justify the claim to legitimacy implicit in European practice. The point she raises goes far beyond the specific subject she studies. Nanofood may be physically tiny, but after you read the paper, you will be forced to agree that its legal implications are far from small. Fabien Terpan offers a systematic and theoretically grounded reconstruction of soft law. After the inflation (and recent devaluation) of the concept, it is high time we come to terms with what exactly soft law is and with what we mean when we characterise law as soft. Terpan puts us on a promising track. Marek Szydlo revisits one of the key affirmative action policies in European law: gender equality on company boards. He makes us rethink the legal framework and suggests some reasons why we should be careful when drawing conclusions on the matter. Finally, William Phelan invites us to revisit the very first European ‘troika’, namely the trio of founding cases of European constitutional law. Phelan's work is both a piece of legal history and a very contemporary plea for a different understanding of European law.