OBJECTIVE: The results of an evaluative longitudinal study, which identified the effects of health care decentralization on health financing in Mexico, Nicaragua and Peru are presented in this article. METHODS: The methodology had two main phases. In the first, secondary sources of data and documents were analyzed with the following variables: type of decentralization implemented, source of financing, funds for financing, providers, final use of resources, mechanisms for resource allocation. In the second phase, primary data were collected by a survey of key personnel in the health sector. RESULTS: Results of the comparative analysis are presented, showing the changes implemented in the three countries, as well as the strengths and weaknesses of each country in matters of financing and decentralization. CONCLUSIONS: The main financing changes implemented and quantitative trends with respect to the five financing indicators are presented as a methodological tool to implement corrections and adjustments in health financing.
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.
OBJECTIVES: This paper reviews Russia's health crisis, financing, and organization and public health reform needs. METHODS: The structure, policy, supply of services, and health status indicators of Russia's health system are examined. RESULTS: Longevity is declining; mortality rates from cardiovascular diseases and trauma are high and rising; maternal and infant mortality are high. Vaccine-preventable diseases have reappeared in epidemic form. Nutrition status is problematic. CONCLUSIONS: The crisis relates to Russia's economic transition, but it also goes deep into the former Soviet health system. The epidemiologic transition from a predominance of infectious to noninfectious diseases was addressed by increasing the quantity of services. The health system lacked mechanisms for epidemiologic or economic analysis and accountability to the public. Policy and funding favored hospitals over ambulatory care and individual routine checkups over community-oriented preventive approaches. Reform since 1991 has centered on national health insurance and decentralized management of services. A national health strategy to address fundamental public health problems is recommended.
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.
On behalf of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section on Disorders of the Spine and Peripheral Nerves, it is my great privilege to introduce these Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. These guidelines represent the initial installment of a more comprehensive guidelines initiative from the Joint Section on behalf of all practicing neurosurgeons and their patients. The Section is grateful to the small working group who devoted considerable time and effort to the generation of this outstanding document. We would like to formally recognize the Joint Section on Trauma for their important collaboration on this project. The Section would also like to acknowledge and thank the parent organizations, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, for their guidance of and support for this project, most notably through the efforts of the American Association of Neurological Surgeons/ Congress of Neurological Surgeons Guidelines Committee. The Section is also deeply indebted to Michael Apuzzo and the staff of Neurosurgery for their advice and editorial assistance in preparing this document for publication. The application of Neurosurgery’ s rigorous peer-reviewed editorial process has clearly enhanced the quality, balance, and stature of this document. Perhaps most importantly, Neurosurgery has provided an extraordinary vehicle for the widespread dissemination and ultimate incorporation of these guidelines to improve the care and enhance the outcomes of patients with traumatic cervical spine and spinal cord injuries. One of the truly important functions of organized neurosurgery is the generation of evidenced-based clinical practice guidelines. Properly developed, such guidelines can answer important questions, resolve uncertainty, identify areas of deficient knowledge and opportunities for future scientific investigation, standardize treatment, and improve the quality of care and the outcomes for patients. The now widely disseminated head trauma guidelines, for example, have clearly made a difference in the outcomes of patients with severe head injury. Guidelines development is a highly structured process with rigorous methodological criteria and exacting standards. It is a time-, labor-, and resource-intensive process that has served as a significant obstacle to more widespread guidelines development throughout neurosurgery. In the past, clinical practice guidelines have been developed by publicly supported epidemiologists and methodologists who understood study design, data analysis, and the guidelines process, but not the disease. This absence of context and clinical perspective significantly limited the value and relevance of their results. Alternatively, clinician-generated guidelines often took the form of methodologically flawed consensus panels and expert opinion, also of limited value. The Joint Spine Section recognized the importance of evidence-based clinical practice guidelines and the challenges of their development. The appropriate clinical expertise, strict adherence to established methodological standards for guidelines development, and considerable resource investment for the development, dissemination, and maintenance of the guidelines documents were deemed crucial to our guidelines initiative. Cervical spine and spinal cord injury was chosen as the initial guidelines topic because of the personal, social, and economic devastation of these injuries, their complex nature, and the high level of uncertainty, as reflected in wide practice variations, as to the value and indications for many of the aspects of evaluation and treatment. The clinical practice guidelines contained in this supplement to Neurosurgery represent a remarkable effort. They address the key issues related to the evaluation and management of these complex conditions that are relevant to the treating physician. In every chapter, the pertinent issues are succinctly stated, the published data are comprehensively presented in the evidentiary tables, and the evidence is thoroughly discussed and critically evaluated throughout the text. The linkage between the quality of the evidence and the strength of the recommendations was not a “black box” process but an open, deliberative exercise by skilled experts guided by a rigorous set of standards. Despite the strength and potential value of this document, it is important to acknowledge the inherent limitations of clinical practice guidelines. This, or any other, evidence-based clinical practice guidelines document does not represent the definitive source of knowledge on the stated topic. Rather, it represents recommendations of varying strength and certainty based on an analysis of the best available published data. These data, however, are often conflicting, flawed, or incomplete, and there are unavoidable elements of potential bias from subjectivity, perspective, and experience of the individuals and group involved in the analysis and interpretation of these data. In essence, proof is a relative term based on the interpretation of evidence. Furthermore, it is subject to different standards. A relevant example comes from the field of jurisprudence, where the standard of proof (i.e., guilt) for criminal trials is “beyond a reasonable doubt,” whereas the standard for civil courts must simply reflect “a preponderance of evidence” or “more likely than not.” These different standards evolved because of the perceived different consequences of a wrongful verdict. Moreover, as Stephen Haines likes to note, the verdict “not guilty” does not mean innocent; it merely says not proved. Such are the vagaries associated with the interpretation of even scientific evidence. Principled people can look at the same evidence and come to different conclusions subject to their own personal perspective, experience, and stake in the result. Nevertheless, the Joint Section and Guidelines Development Group went to great lengths to identify and avoid—or at least minimize—these potential problems. The working group adopted the most widely recognized and rigorous standards for guidelines development. A diverse panel of experts with expertise in spine, trauma, and epidemiology brought relevant clinical, scientific, and methodological competence to enhance both the analytical and the deliberative aspects of this process. Periodic outside reviews were routinely obtained for topics or areas of contention or uncertainty to add additional perspective and balance. Above all, the process was accountable and transparent at every stage. Ultimately, we offer these guidelines as a living document to those professionals who treat patients with traumatic spinal injury. We hope each practitioner will critically evaluate these guidelines and come to his or her own conclusion on how, whether, and when to implement its recommendations. It may be used either as a reference or as a basis for standardized protocols of evaluation and management of the patients with traumatic spinal injury. For clinical and basic science researchers, we hope that it will identify and catalyze scientific investigation in areas of deficient knowledge. As a Section, we stand firmly behind this important document and will continuously update the recommendations as new knowledge and understanding is developed. We sincerely believe that these guidelines can improve the care and enhance the outcomes of patients with traumatic injuries to the cervical spine and spinal cord.