Mohammad Kurniawan, Deni Harbianto, Digna Niken Purwaningrum, Tiara Marthias
Despite Indonesiaâs health status improvement over the last decade, special efforts to achieve the MDGs goals are still warranted, especially in maternal, neonatal, and child health (MNCH). However, the current centrally driven MNCH policies do not address the geographical disparities and the different constraints faced by Indonesian provinces and districts. Moreover, the MNCH slow progress may have been hindered by various funding constraints, for example small local budget allocation specifically for MNCH, lack of evidence-based budget planning leading to unsound health planning and implementation. Therefore, this study aims to assess the current health financing mechanism used in one of Indonesian Province of Papua, that has low MNCH outcome. This was an observational study using mixed-methods. Study subjects were from the Provincial and four selected District Health Offices in Papua Province of Indonesia. overnment official documents analysis and direct observations on the study subjects were done to assess the financing and budgeting for MNCH in Papua. The study shows a low commitment from the local government in MNCH priority areas. The main reason was that the largest share of MNCH funding still comes from Central Government (ABPN), whereas the proportion funded from local sources is relativity low. Furthermore, there is a very limited use of evidence-based financing and budgeting, mainly due to limited capability of the human resources for health as well as the largely undocumented epidemiological and health system data. This limited human resource capability also largely affected by the low commitment of the local government. Despite the relatively large amount of MNCH funding in Papua, human resource limitation poses a serious problem in scaling up for priority interventions. Low local government commitment is still the main obstacle in health budgeting policy. These problems may also applicable to other districts of Indonesia and as unanticipated effects from ill-designed health decentralization.
INTRODUCTION: In recent years, the country of Mongolia (population 2.8 million) has experienced rapid social changes associated with economic growth, persisting socio-economic inequities and internal migration. In order to improve health access for the urban poor, the Ministry of Health developed a "Reaching Every District" strategy (RED strategy) to deliver an integrated package of key health and social services. The aim of this article is to present findings of an assessment of the implementation of the RED strategy, and, on the basis of this assessment, articulate lessons learned for equitable urban health planning. METHODS: Principal methods for data collection and analysis included literature review, barrier analysis of health access and in-depth interviews and group discussions with health managers and providers. FINDINGS: The main barriers to health access for the urban poor relate to interacting effects of poverty, unhealthy daily living environments, social vulnerability and isolation. Implementation of the RED strategy has resulted in increased health access for the urban poor, as demonstrated by health staff having reached new clients with immunization, family planning and ante-natal care services, and increased civil registrations which enable social service provision. Organizational effects have included improved partnerships for health and increased motivation of the health workforce. Important lessons learned from the early implementation of the RED strategy include the need to form strong partnerships among stakeholders at each level of the health system and in the community, as well as the need to develop a specific financing strategy to address the needs of the very poor. The diverse social context for health in an urban poor setting calls for a decentralized planning and partnership strategy, but with central level commitment towards policy guidance and financing of pro-poor urban health strategies. CONCLUSIONS: Lessons from Mongolia mirror other international studies which point to the need to measure and take action on the social determinants of health at the local area level in order to adequately reduce persistent inequities in health care access for the urban poor.
Background: Health financing provided by the government greatly helps the implementation of health system in the decentralized era. General Allocation Fund and Local Revenue and Expenditure Budget are apparently inadequate to finance health service. Some efforts have been made to finance health service such as Community Health Insurance (Jamkesmas), Childbirth Insurance (Jampersal), and Health Operational Fund (Bantuan Operasional Kesehatan/BOK). These are meant to achieve Millennium Development Goals in 2015. The practice of coordination from planning to implementation and stakeholdersâ commitment can affect the process of maternal and child health service. Coordination is definitely needed to run the program policy and prevent the overlapping financing in order that the objective of the program can be achieved. Objective: To evaluate coordination of planning, implementation and stakeholdersâ commitment in relation to maternal and child health (MCH) service in Lombok Tengah District. Method: This was a descriptive-analytical study with a qualitative approach and a case-study design. Samples were taken purposively. The data were obtained through in-depth interview, observation and documentation analysis. Result: The planning coordination of MCH health financing had not been optimal, even despite the involvement of cross sector and program. However, the organizations of health professionals were not involved in program planning. The coordination of health financing implementation had not been optimal as well. Even though there was no overlapping financing from some different sources, in the policy implementation there was cost sharing for referral and drugs. Private sectors were not involved in the implementation of Jampersal. Stakeholdersâ commitment was relatively optimum as reflected from the policy and action in health development acceleration particularly MCH. The process of MCH service at both primary and secondary level could run well. Conclusion: Coordination of MCH financing implementation in Lombok Tengah District through BOK, Jampersal, Jamkesmas, Community Empowerment National Program of Healthy and Smart Generation and Local Revenue and Expenditure Budget had not been optimal; therefore, it needed to be improved to eliminate cost sharing. Professional organizations and private health providers were not yet involved in the program planning and implementation. Keywords: coordination, stakeholdersâ commitment, health financing, maternal and child health, program evaluation
INTRODUCTION: In Sub-Saharan Africa (SSA) sound planning is required as interest increases in the decentralization of healthcare financing and the implementation of a sector-wide approach to health care. For this, improved knowledge of national morbidity and mortality is essential. Data from remote areas of SSA are needed to ensure that public health priority-setting and actions reflect the situation in all regions, not just those easily accessed and readily researched. In order to understand the causes, circumstances and changes over time of death in a remote and underserved region, this study sought information on all deaths in a district hospital over a 17 year period. METHODS: The study design was a retrospective review of the hospital records (in registers) of all patients hospitalized in Kolofata District Hospital, a rural public hospital in the Far North Region of Cameroon, 1 January 1993 to 31 December 2009. A line listing was extracted of all 1281 inpatient deaths, and this included dates of admission and death; patient name, address, sex and ethnic group; presenting complaint; duration of symptoms; summary of physical examination; and the diagnosis presumed to be the cause of death. RESULTS: Children under the age of 15 years and males comprised the majority of deaths (63.9% and 56.0%, respectively). Causes of death were related to the seasons. Infectious diseases including acute lower respiratory tract infection, malaria and diarrhoeal diseases were the leading causes of death; AIDS caused most adult deaths. A total of 67% of patients presented within 1 week of symptom onset, and 56.8% of deaths occurred on or before the day after admission. Deaths due to AIDS, malaria and complications of pregnancy increased over time. Among Kolofata District residents, death from vaccine-preventable measles and neonatal tetanus were rare, particularly in the later study years. The proportion of deaths attributed to non-communicable diseases did not increase in the 17 year period. CONCLUSIONS: To reduce mortality in this world region, priority should be given to the prevention and management of lower respiratory tract infections, malaria, diarrhoeal diseases, AIDS, and the complications of pregnancy. The planning of health resources and activities should take into account seasonal variations in the causes of death. Improvements to emergency services and community education that emphasises the need for earlier presentation when ill should reduce deaths that occur soon after hospital admission. Death due to measles and neonatal tetanus has become rare, a reflection of the effectiveness in this area of the national vaccination program.
There is an avalanche of interest in health systems with countries, donors, international experts and academic institutions all rushing to promote, fund or build capacity to address this wave of interest. As Anne Mills documents in an article in this volume, there is also a growing literature on how to think about health systems, how to use research on health systems to improve their performance, and pleas for greater investment in knowledge about health systems. We are probably riding on the crest of this new wave and it will be important to make use of it to further our knowledge about how to achieve health system effectiveness. With continuing global economic uncertainty, this wave may pass if we do not take advantage of it now. It is useful to reflect on why there is such interest in this theme now. There are probably many converging causes but the most important, to my mind, is a replay of an old debate between vertical programmes and horizontal, integrated approaches that has experienced swings of interest at least since the Alma Ata Conference in 1978 emphasized the integrated primary health care approach. During the last decade or more, there has been a major focus on vertical disease-specific programmes supported by greatly increased funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Alliance for Vaccines and Immunisation (GAVI), US Presidentâs Emergency Plan for AIDS Relief (PEPFAR), Bill and Melinda Gates Foundation, among other donors. The major claim of these programmes was that by focusing on clear disease-specific objectives they would be more effective in shorter time periods and they could be held more accountable to donors (since the results could be more measurable) than the difficult and diverse efforts to improve the many elements of a health system through the horizontal integrated approach. While there were evident successes in these programmes, there was also a growing recognition that health system constraintsâespecially in human resources and logistics systemsâwere becoming major obstacles to achieving even their limited objectives of increased coverage of HIV/AIDS, tuberculosis, malaria and immunizations. With the added emphasis on the Millennium Development Goals (MDGs) and the slow progress toward their achievement in many countries, the international community and national governments have turned increasingly toward attempting to reduce the health system constraintsâan approach that is closer to the integrated horizontal approach. Both GAVI and the Global Fund have added a separate fund for health systems interventions. In 2008, the G8 called for greater attention to health system strengthening as compatible with the prior focus on vertical programmes (Reich et al. 2008). In 2009, the World Bank convened a seminar on health system strengthening attended by representatives from the World Health Organization (WHO), GAVI and Global Fund. A task force on Healthy Women and Healthy Children calling for a health system funding platform was initiated at the UN General Assembly. In 2010, the WHO and others sponsored the First Global Symposium on Health Systems Research in Montreux, Switzerland. While many observers are trying to argue that the two approaches are now more compatible, at least in rhetorical terms it seems that the pendulum is shifting toward greater attention to health system strengthening. So how do we, the readers of Health Policy and Planning, take advantage of this interest? Health Policy and Planning is dedicated to the publication of high quality research that, as the name implies, improves decisions on policy and planning. This poses for us a central question: how can we do research that will improve health systems? The answer is complex for it requires attention to the kind of knowledge that is both researchable and leads to practical, implementable recommendations. The place to start is with a framework of analysis that is both analytical, in that it provides empirically based categories about health systems, and purposive, in that it is oriented toward how to improve the system. Many of the frameworks that are available provide a recognizable set of functional issues whose boundaries help focus attention on specific interactions that can be studied, such as financing, service delivery, human resources, governance (Mills et al. 2001). The WHO Building Blocks framework is a very popular approach that is guiding much of the discussion and research in health systems (WHO 2007). Another approach developed by Harvard School of Public Health faculty is oriented toward using analytical categories in a purposive manner that starts with an ethically derived vision of what we would like to achieve, and works back toward finding the reasons why we have not achieved those objectives. It then focuses our attention on what we can change using evidence on the effectiveness of changing different âcontrol knobsâ or policy levers, including financing, payments, organization, regulation and persuasion (Roberts et al. 2004). There is a great deal of overlap in these models and they are compatible in many ways that can guide research toward practical recommendations for policy. A second question is about levels of analysis. Should we attempt to research whole national systems, with typologies of systems and comparisons of the achievements of the different models? We often hear this orientation used in policy arguments such as the recent arguments over whether the USA should adopt the Canadian single payer model. However, this approach suffers from methodological challenges such as the âsmall numberâ problem (which limits the ability to use sophisticated quantitative analysis due to the few comparable national systems) and the many different characteristics and historical trajectories that confound the analysis. Few countriesâChile, China, Colombia, Ghana, Taiwan, Turkey and Eastern European countriesâhave even attempted broad multifaceted health system reforms and they have tended to develop their own reform models rather than copying others. Nevertheless, there are many country studies of health reforms that provide evidence and much can be gained by detailed evaluation of the effectiveness of these models that can inform policy choice in different contexts. An alternative means of assessing health systems is to focus on sub-systems or analysis of specific policy changes, focusing on different social health insurance approaches, pay for performance, contracting, decentralization or other reforms, and assessing their performance in terms of achieving health system objectives like the MDGs, reduction in catastrophic expenditures caused by paying for illness, or broader responsiveness and accountability to citizens. The advantage of this approach is that, if the research is well designed, the causality of the impact of the changes on health system objectives can be more clearly demonstrated, and it allows a more focused attention to policy changes that different countries can adopt in an incremental way. This approach can address both systems issues and vertical programme needs. For instance, the work that I am involved in on decentralizationâlooking at the relationship between choice, capacity and accountability at different levels of a health systemâcan be used to make policy recommendations on general health system reform as well as specific reforms of logistic systems, vertical immunization or family planning programme effectiveness (Bossert et al. 2007). The challenge in this approach is to account for the general national context factorsâpolitical, economic, social and culturalâwhich may influence the performance of these initiatives. What works in Chile may not work in China due to many different characteristics of the country contexts. This is a major lacuna in the current research in health systems often covered over by focusing only on the differences in average income levels, assuming for instance that health system changes in low-income countries are all relatively similar. However, governance issues, cultural and ethical differences, past histories with different health systems, all play a role in constraining the lessons learned from one country to another. The recent concern with political economy and political institutionalism may inform future work in this area (Fox and Reich, forthcoming). In addition, focus on one subsystem or one policy lever is likely to miss the interactions among different subsystems changes that synergistically influence outcomes. For instance, changes in decentralization may be enhanced by changes in social insurance programmes, or the creation of a new cadre of health workers. Focusing on one in order to evaluate its separate impact will miss the role of the combined changes on achieving objectives. However, if we are aware of these limitations, it might be possible to move collectively toward setting a research agenda in which multidisciplinary researchers assess the different subsystems in ways that inform each other. Those of us who focus on organizational issues like decentralization and human resources need to be aware of and incorporate in our studies, the work of experts in economics, ethics, politics and other behavioural sciences, as well as epidemiologists and biostatisticians who help us understand the underlying population and social processes underpinning those systems. There is also an imbalance of research on functional areas of analysis with a much greater body of knowledge on financing and payment issues than on organizational issues and governance and regulation. In recent years, there has been greater interest in governance, politics and human resources issues, but these areas are so complex that they require much greater attention and more funded research than is currently in the pipeline. This poses an additional requirement for multidisciplinary studies that address these under-researched areas to bring the level of knowledge up to that of the more economic themes. This is a huge task of course and current funders have little patience for large research projects in health systems. Indeed there is considerable pressure for evaluating the performance of programmes and projects that have been funded in a very short and unrealistic time frame. It suggests that we need to be nimble and develop cadres of multidisciplinary experts to be able to quickly do the solid research necessary but within limited funds and short time horizons to provide well-documented policy recommendations. If we do not, we are likely to have missed the opportunities of this wave of interest as funding for health systems declines due to alternative priorities, donor fatigue or general global economic restrictions. None declared.
Honoratha Mushi, K. Mullei, J. Macha, Francis Wafula · 7 authors
Health worker training is a key component of the integrated management of childhood illness (IMCI). However, training coverage remains low in many countries. We conducted in-depth case studies in two East African countries to examine the factors underlying low training coverage 10 years after IMCI had been adopted as policy. A document review and in-depth semi-structured interviews with stakeholders at facility, district, regional/provincial and national levels in two districts in Kenya (Homa Bay and Malindi) and Tanzania (Bunda and Tarime) were carried out in 2007-08. Bunda and Malindi achieved higher levels of training coverage (44% and 25%) compared with Tarime and Homa Bay (5% and 13%). Key factors allowing the first two districts to perform better were: strong district leadership and personal commitment to IMCI, which facilitated access to external funding and encouraged local-level policy adaptation; sensitization and training of district health managers; and lower staff turnover. However, IMCI training coverage remained well below target levels across all sites. The main barrier to expanding coverage was the cost of training due to its duration, the number of facilitators and its residential nature. Mechanisms for financing IMCI also restricted district capacity to raise funds. In Tanzania, districts could not spend more than 10% of their budgets on training. In Kenya, limited financial decentralization meant that district managers had to rely on donors for financial support. Critically, the low priority given to IMCI at national and international levels also limited the expansion of training. Levels of domestic and donor support for IMCI have diminished over time in favour of vertical programmes, partly due to the difficulty in monitoring and measuring the impact of an integrated intervention like IMCI. Alternative, lower cost methods of IMCI training need to be promoted, and greater advocacy for IMCI is needed both nationally and internationally.
Decentralization involves the dispersion of power, functions and finances from a central authority to regional and local authorities. Decentralization reforms have become widespread in low- and middle-income countries, mainly due to movements towards democratiza-tion, the spread of multi-party electoral systems and transitions towards market economies. In particular, decentraliza-tion of financing systems, particularly for health, is now a common aspect of reform in these countries. The main advantage is the dynamism it can bring into the resource allocation mechanism; it also can facilitate re-allocation of funds through a visible, vibrant and bottom-up approach.
This article addresses several issues pertinent to health systems governance for health equity. It argues the importance of health systems using measures of positive health (well-being), discriminating in favour of historically less advantaged groups and weighing the costs of health care against investments in the social determinants of health. It cautions that the concept of governance could weaken the role of government, with disequalizing effects, while emphasizing the importance of two elements of good governance (transparency and participation) in health systems decision-making. It distinguishes between participation as volunteer labour and participation as exercising political rights, and questions the assumption that decentralization in health systems is necessarily empowering. It then identifies five health system roles to address issues of equity (educator/watchdog, resource broker, community developer, partnership developer and advocate/catalyst) and the implications of these roles for practice. Drawing on preliminary findings of a global research project on comprehensive primary health care, it discusses political aspects of progressive health system reform and the implications of equity-focused health system governance on health workers' roles, noting the importance of health workers claiming their identity as citizens. The article concludes with a commentary on the inherently political nature of health reforms based on equity; the necessary confrontation with power relations politics involves; and the health systems governance challenge of managing competing health discourses of efficiency and results-based financing, on the one hand, and equity and citizen empowerment, on the other.
BACKGROUND: In recent years there have been innovations in immunization financing and new technologies, and the scaling up of investment by the Global Alliance for Vaccines and Immunization (GAVI) in the Asia region. The main mechanism for coordination of this global health initiative (GHI) investment is country-level 'Inter-Agency Coordination Committees' (ICCs). AIM: The aim of the evaluation was to determine the utility and future perspectives of stakeholders regarding the role of ICCs in improving immunization services in the Asian Region. METHODS: A literature review, documentary analysis and semi-structured interviews (n = 65) were undertaken in five countries (India, Bangladesh, Nepal, Sri Lanka and Indonesia), with senior level members of Ministries of Health and the GAVI partnership. RESULTS: The evaluation has identified that there have been significant changes recently in the strategic environment for immunization, including developments in new vaccines, increasing GAVI investment, trends towards health system integration and decentralization, and institutional development of the non-government sector. This evaluation found that ICCs are functioning well in relation to information sharing and GAVI application processes. However, they are performing less well in the areas of evaluation, strategic gap analysis and coordination of immunization technical co-operation. CONCLUSIONS: There are high levels of institutional and contextual complexity at country level that require a more focused global response by GAVI to the governance challenges of institutions and partners implementing GHIs at the country level. ICCs should be maintained and strengthened in the more pluralistic context of an 'immunization coordination system' that is represented by the wider health sector, regulatory authorities, and civil society and private sector interests. Managing through systems, rather than being over-reliant on committees, will broaden participation in implementation and, in doing so, expand the reach of immunization and maternal and child health care services in developing countries.
This paper analyses health reforms in Tanzania since 1924 to 1993 to determine how each paradigm influenced the next by using the recent World Health Organization (WHO) framework of health system. Published and gray documents were reviewed and analyzed for the four discrete attempts at reforming the health sector, focusing on the district health system decentralization. The findings revealed that for each wave, there was a review of the health system, making information from preceding efforts to be available to the subsequent reforms. After independence the political party in power played a major role in ensuring availability of information and its utilization. Predominant information in each wave showed that the health system was underfinanced, there was poor performance of PHC strategies, non-integration of DMO and poor health workers income. Health reforms should focus on health system finance, integrated district health system, health workers welfare and community participation.
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.
The right to participation is the "the right of rights"--the basic right of people to have a say in how decisions that affect their lives are made. All legally binding international human rights treaties explicitly recognize the essential role of participation in realizing fundamental human rights. While the substance of the human right to health has been extensively developed, the right to participation as one of its components has remained largely unexplored. Should rights-based health advocacy focus on participation because there is a relationship between an individual's or a community's active involvement in health care decision-making and the highest attainable standard of health? In the context of the human right to health, does participation mean primarily political participation, or should we take the right to participation to mean more specifically the right of persons, individually and as a group, to shape health care policy for society and for themselves as patients? Decentralization of health care decision-making promises greater participation through citizen involvement in setting priorities, monitoring service provision, and finding new and creative ways to finance public health programs. Between 1999 and 2008, Indonesia decentralized health care funding and delivery to regional governments, resulting in substantial exclusion of its poor and uneducated citizens from the health care system while simultaneously expanding the opportunities for political participation for educated elites. This article explores the tension between the right to participation as an underlying determinant of health and as a political right by reviewing the experience of Indonesia ten years after its decision to decentralize health care provision. It is ultimately argued that rights-based advocates must be vigilant in retaining a unified perspective on human rights, resisting the persistent tendency to separate and prioritize the civil and political aspects of participation over its social component.
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.
Elmer S. Soriano, David M. Dror, Erwin Gaspar A. Alampay, Jolande
A sustainable health reinsurance system can be fashioned for the informal sector by mobilizing social and economic forces operating within individual communities. The economic analysis in part 1 of this book draws conclusions from success stories in industrial countries and failures in low- and medium-income countries. This analysis leads to the premise that decentralized development of microinsurance units, operating in a market segment left out by for-profit health insurance firms and by national schemes, can be stabilized financially through their affiliation with a reinsurance facility-Social Re' (part 1, this volume; Dror and Duru 2000, pp. 30-40; Dror 2001). Dror, Preker, and Jakab, in chapter 2 of this book, explain how the sociological dimension would theoretically affect the performance of a microinsurer. Findings of the Institute of Medicine reaffirm the active interplay of biology, psychology, behavior, and society in determining people's health attitudes. The institute further reports that, although people's attitudes and actions can readily be altered, these changes need support and reinforcement over time to guarantee better health. Attitudinal and behavioral changes are best prolonged through interventions at multiple levels, from the individual to society at large (Institute of Medicine 2001, pp. 1-1-1-8). Efforts are required to address the psychosocial factors that influence health status, including, for example, proposing measures such as microinsurance to persuade individuals to accept a healthy way of life and permanently modify their health behavior. Microinsurance schemes provide individuals, households, and communities mechanisms for financing their health through group risk-pooling mechanisms, leading to a sustained improvement in their access to health services. Higher up on the social scale, well-evaluated interventions at the organizational level should be encouraged, giving credit to organizations' vital role in influencing individual behavioL Still farther up the scale, community involvement in health-promotion strategies should not be overlooked, because some disease-related factors that are beyond an individual's capacity to modify can be significantly minimized through community efforts. Community empowerment, social support, and other values that protect members from stress are strengthened through community-level interventions. Finally, interventions at the societal level recognize the role of collective organizations influencing individuals' everyday existence (Institute of Medicine 2001, pp. 1-1-1-8). Underlying assumptions are that members' affiliation with microinsurers is voluntary (individuals can join, stay enrolled, or withdraw at will) and that microinsurers will voluntarily join Social Re. A clue is therefore needed about the considerations that shape individual and collective choices. According to one opinion, The underlying economic motivation for joining a microinsurance unit is assumed to be a desire to seek reciprocity in sustaining risk-sharing arrangements among essentially self-interested individuals (Dror and jacquier 1999, p. 79). This assumption implies that joining a microinsurance unit (and Social Re) is a predictable, rational economic choice by self-interested individuals to maximize total utility (optimal choice theory), and an act of reciprocity, in which giving and getting are somehow linked. According to the utility motive, people will join if they can benefit from joining. However, considering that many people will pay a health insurance premium without getting any cash benefits (if they stay healthy), is it really clear what each individual would consider as his or her exact utility from being insured? As Herrnstein points out, because utility cannot be directly observed, it must be inferred from behavior, from the choices individuals make. Thus, utility is synonymous with the modem concept of reinforcement in behavioral psychology (Herrnstein 1997, p. 226). Dror and Jacquier mention a second motive for joining a microinsurance unit: people's desire to improve their health by controlling their living and working conditions. This control is linked to a deep-rooted human need to seek voluntary and repeated interaction with others in daily life (Dror and Jacquier 1999, p. 80). These interactions may provide material reciprocity or they may reflect altruistic, nonmaterial interactions. The three authors mentioned above suggest that, to understand how microinsurers can attract and retain their clients, they have to know what shapes their clients' behavior in their specific operating context. The same reasoning applies to a microinsurer's decision to affiliate with Social Re. Since Social Re will be piloted in the Philippines, this examination will be done with reference to that country and culture. The rest of this chapter will provide an overview of the social and institutional structure of Philippine rural and informal society and the attitudes toward solidarity, risk, and insurance that influence choices and help shape the role of microinsurance. This role is quite different from what could be conjured from classical economic theory on utility, as will be shown. This analysis leads to the conclusion that in the rural Philippines, the introduction of insurance and reinsurance hinges as much, perhaps more, on the structure of society than on the profile of risks and the existence of a market for insurance.
Bangladesh has made significant progress in health indicators in recent years in spite of her low level of income. This is mainly due to the commitment of the state supported by donors in providing preventive care with respect to child health and family planning. However, there are serious problems related to both access and quality of curative care that hurt the poor most. Infrastructures for service delivery exist at local level in rural areas but they function inefficiently. This paper deals with the systemic weaknesses of decentralized service provision of primary healthcare in Bangladesh and focuses on accountability links between different actors and functions of delegation, finance, performance, information and enforcement. The study is based on facility- and household-based data collected during 2005 in Khulna Division. The main findings of the study are: the health system in rural areas represents deconcentration rather than decentralization of central government functions where inter-sectoral discipline works poorly; local health providers are not accountable to local government, and poor citizens/clients are neither aware of their rights nor are capable of expressing their needs as effective channels do not exist.
Contracting is one of the tools increasingly being used to enhance the performance of health systems in both developed and developing countries; it takes different forms and cannot be limited to the mere purchase of services. Actors adopt contracting to formalize all kinds of relations established between them. A typology for this approach will demonstrate its diversity and provide a better understanding of the various issues raised by contracting. In recent years the way health systems are organized has changed significantly. To remedy the under-performance of their health systems, most countries have undertaken reforms that have resulted in major institutional overhaul, including decentralization of health and administrative services, autonomy for public service providers, separation of funding bodies and service providers, expansion of health financing options and the development of the profit or nonprofit private sector. These institutional reshuffles lead not only to multiplication and diversification of the actors involved, but also to greater separation of the service provision and administrative functions. Health systems are becoming more complex and can no longer operate in isolation. Actors are gradually realizing that they need to forge relations. The simplest way to do that is through dialogue, although some prefer a more formal commitment. Interaction between actors may take various forms and be on different scales. There are several types of contractual relations: some are based on the nature of the contract (public or private), others on the parties involved and yet others on the scope of the contract. Here they are classified into three categories according to the object of the contract: delegation of responsibility, act of purchase of services, or cooperation.
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.
OBJECTIVE: To identify the effects of decentralization on health financing and governance policies in Mexico from the perspective of users and providers. METHODS: A cross-sectional study was carried out in four states that were selected according to geopolitical and administrative criteria. Four indicators were assessed: changes and effects on governance, financing sources and funds, the final destination of resources, and fund allocation mechanisms. Data collection was performed using in-depth interviews with health system key personnel and community leaders, consensus techniques and document analyses. The interviews were transcribed and analyzed by thematic segmentation. RESULTS: The results show different effectiveness levels for the four states regarding changes in financing policies and community participation. Effects on health financing after decentralization were identified in each state, including: greater participation of municipal and state governments in health expenditure, increased financial participation of households, greater community participation in low-income states, duality and confusion in the new mechanisms for coordination among the three government levels, absence of an accountability system, lack of human resources and technical skills to implement, monitor and evaluate changes in financing. CONCLUSIONS: In general, positive and negative effects of decentralization on health financing and governance were identified. The effects mentioned by health service providers and users were related to a diversification of financing sources, a greater margin for decisions around the use and final destination of financial resources and normative development for the use of resources. At the community level, direct financial contributions were mentioned, as well as in-kind contributions, particularly in the form of community work.
OBJECTIVE: To summarize the expectations held by World Health Organization programme personnel about how the introduction of the Integrated Management of Childhood Illness (IMCI) strategy would lead to improvements in child health and nutrition, to compare these expectations with what was learned from the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE-IMCI), and to discuss the implications of these findings for child survival policies and programmes. DESIGN: The MCE-IMCI study designs were based on an impact model developed in 1999-2000 to define how IMCI would be implemented at country level and below, and the outcomes and impact it would have on child health and survival. MCE-IMCI studies included: feasibility assessments documenting IMCI implementation in 12 countries (1999-2001); in-depth studies using compatible designs in Bangladesh, Brazil, Peru, Tanzania and Uganda; and cross-site analyses addressing the effectiveness of specific subsets of IMCI activities. RESULTS: The IMCI strategy was successfully introduced in the great majority of countries with moderate to high levels of child mortality in the period from 1996 to 2001. Seven years of country-based evaluation, however, indicates that some of the basic expectations underlying the development of IMCI were not met. Four of the five countries (the exception is Tanzania) had difficulties in expanding the strategy at national level while maintaining adequate intervention quality. Technical guidelines on delivering interventions at family and community levels were slow to appear, and in their absence countries stalled in their efforts to increase population coverage with essential interventions related to care-seeking, nutrition, and correct care of the sick child at home. The full weight of health system limitations on IMCI implementation was not appreciated at the outset, and only now is it clear that solutions to larger problems in political commitment, human resources, financing, integrated or at least coordinated programme management, and effective decentralization are essential underpinnings of successful efforts to reduce child mortality. CONCLUSIONS: This analysis highlights the need for a shift if child survival efforts are to be successful. Delivery systems that rely solely on government health facilities must be expanded to include the full range of potential channels in a setting and strong community-based approaches. The focus on process within child health programmes must change to include greater accountability for intervention coverage at population level. Global strategies that expect countries to make massive adaptations must be complemented by country-level implementation guidelines that begin with local epidemiology and rely on tools developed for specific epidemiological profiles.
Decentralization of health services in Uganda, driven by the structural adjustment programme of the World Bank, was embraced by government as a means to change the health institutional structure and process delivery of health services in the country.Arising from the decentralization process, the transfer of power concerning functions from the top administrative hierarchy in health service provision to lower levels constitutes a major shift in management, philosophy, infrastructure development, communication as well as other functional roles by actors at various levels of health care.This study focused its investigation on ways and levels to which the process of decentralization of health service delivery has attained efficient and effective provision of health services.The study also examined the extent to which the shift of health service provision has influenced the role of local jurisdictions and communities.Challenges faced by local government leaders in planning and raising funds in response to decentralized health service delivery were examined.The study used a descriptive survey research design employing qualitative techniques, namely questionnaires, structured interviews, observation, and document analysis to establish the extent to which the decentralized approach to health service delivery has impacted on local governments and the vulnerable target groups such as the rural and urban poor, children, mothers, HIV/AIDS victims, orphans and refugees.Key respondents were government officials in health related management in the country at various levels.Health workers and beneficiaries of health services were interviewed to share their views and experiences of decentralized health care service provision.iii Using a conceptual framework of "Community as Client", the findings illustrate that while some local governments in the country have extended health units closer to some communities, the pursuit of a decentralized health service delivery system in Uganda over-assumed the benefits of decentralizing health care.The observations indicated that health care is not better organized; neither has decentralization provided greater involvement of local communities in mobilization and capacity building of community-based health workers.The acclaimed cost containment and reduction through duplication of services, reduction of inequities, integration of activities of different agencies and organizations involved in health care have not been achieved in concert with original expectations and assumptions of decentralization.These include: strengthened health policy and planning functions of the ministry of health, improved implementation of health programmes, greater community control and financing (ownership) and improved inter-sectoral coordination.From the findings, it would appear that the motivation for decentralizing health care was not intrinsically guided by how the decentralized health system can better serve the poor majorities in the country.The study concludes that the decentralization of health services in Uganda was not matched with commitment for provision of necessary health supplies, and delivery of health care services through a centrally coordinated national network of health facilities.The Ugandan Government in particular Ministry of Health and the government needs to evaluate the achievements and challenges faced by the health care system under decentralization within the broader perspective of health for all, as a means to establish appropriate refocusing of health care delivery for optimal benefit of the client communities.
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 âHealth for Allâ initiative on the part of the government akin to the âEducation for Allâ 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 governmentâs 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 Indiaâs 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.
This paper examines the concept and practice of community participation in World Bank-supported health sector reforms in Asia, and how far such participation has strengthened accountability with regard to provision of sexual and reproductive health (SRH) services. It argues that the envisaged scope of community participation within a majority of reforms in Asia has been limited to programme management and service delivery, and it is occurring within the boundaries of priorities that are defined through non-participatory processes. Setting up of community health structures, decentralization and community financing are three important strategies used for promoting participation and accountability within reforms. The scant evidence on the impact of these strategies suggests that marginalized groups and sexual and reproductive rights based groups are poorly represented in the forums for participation, and that hierarchies of power between and amongst health personnel and the public play out in these forums. Community financing has not lead to enhanced service accountability. As a result of the above limitations, community participation in health sector reforms has rarely strengthened accountability with respect to provision of comprehensive SRH services. In this context, rights (including sexual and reproductive) based groups and researchers need to engage with design, monitoring and evaluation of health sector reforms, both from inside as participants and outside as pressure groups. Participation contracts enhancing powers of civil society representatives, quotas for participation (for women, other marginalized groups and rights-based organizations), and investment in capacity building of these stakeholders on leadership and sexual reproductive rights and health are pre-requisites if participation is to lead to health and SRH service accountability. Community participation and service accountability hence requires more and not less investment of resources by the state.
Each year, up to three million deaths due to malaria and close to five billion episodes of clinical illness possibly meriting antimalarial therapy occur throughout the world, with Africa having more than 90% of this burden. Almost 3% of disability adjusted life years are due to malaria mortality globally, 10% in Africa. New information is presented in this supplement on malaria-related perinatal mortality, occurrence of human immunodeficiency virus in pregnancy, undernutrition, and neurologic, cognitive, and developmental sequelae. The entomologic determinants of transmission and uses of modeling for program planning and disease prediction and prevention are discussed. New data are presented from the Democratic Republic of the Congo, Tanzania, Ethiopia, and Zimbabwe on the increasing urban malaria problem and on epidemic malaria. Between 6% and 28% of the malaria burden may occur in cities, which comprise less than 2% of the African surface. Macroeconomic projections show that the costs are far greater than the costs of individual cases, with a substantial deleterious impact of malaria on schooling of patients, external investments into endemic countries, and tourism. Poor populations are at greatest risk; 58% of the cases occur in the poorest 20% of the world's population and these patients receive the worst care and have catastrophic economic consequences from their illness. This social vulnerability requires better understanding for improving deployment, access, quality, and use of effective interventions. Studies from Ghana and elsewhere indicate that for every patient with febrile illness assumed to be malaria seen in health facilities, 4-5 episodes occur in the community. Effective actions for malaria control mandate rational public policies; market forces, which often drive sales and use of drugs and other interventions, are unlikely to guarantee their use. Artemisinin-based combination therapy (ACT) for malaria is rapidly gaining acceptance as an effective approach for countering the spread and intensity of Plasmodium falciparum resistance to chloroquine, sulfadoxine/pyrimethamine, and other antimalarial drugs. Although costly, ACT ($1.20-2.50 per adult treatment) becomes more cost-effective as resistance to alternative drugs increases; early use of ACT may delay development of resistance to these drugs and prevent the medical toll associated with use of ineffective drugs. The burden of malaria in one district in Tanzania has not decreased since the primary health care approach replaced the vertical malaria control efforts of the 1960s. Despite decentralization, this situation resulted, in part, from weak district management capacity, poor coordination, inadequate monitoring, and lack of training of key staff. Experience in the Solomon Islands showed that spraying with DDT, use of insecticide-treated bed nets (ITNs), and health education were all associated with disease reduction. The use of nets permitted a reduction in DDT spraying, but could not replace it without an increased malaria incidence. Baseline data and reliable monitoring of key outcome indicators are needed to measure whether the ambitious goals for the control of malaria and other diseases has occurred. Such systems are being used for evidence-based decision making in Tanzania and several other countries. Baseline cluster sampling surveys in several countries across Africa indicate that only 53% of the children with febrile illness in malarious areas are being treated; chloroquine (CQ) is used 84% of the time, even where the drug may be ineffective. Insecticide-treated bed nets were used only 2% of the time by children less than five years of age. Progress in malaria vaccine research has been substantial over the past five years; 35 candidate malaria vaccines are in development, many of which are in clinical trials. Development of new vaccines and drugs has been the result of increased investments and formation of public-private partnerships. Before malaria vaccine becomes deployed, consideration must be given to disease burden, cost-effectiveness, financing, delivery systems, and approval by regulatory agencies. Key to evaluation of vaccine effectiveness will be collection and prompt analysis of epidemiologic information. Training of persons in every aspect of malaria research and control is essential for programs to succeed. The Multilateral Initiative on Malaria (MIM) is actively promoting research capacity strengthening and has established networks of institutions and scientists throughout the African continent, most of whom are now linked by modern information-sharing networks. Evidence over the past century is that successful control malaria programs have been linked to strong research activities. To ensure effective coordination and cooperation between the growing number of research and control coalitions forming in support of malaria activities, an umbrella group is needed. With continued support for scientists and control workers globally, particularly in low-income malarious countries, the long-deferred dream of malaria elimination can become a reality.
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.