Abstract Since the 1980s user fees for government services have become an accepted financing option for the health and social sectors in developing countries. Even countries which had a tradition of providing health services free of charge have now introduced fees and the focus of debate has shifted from whether or not to introduce them, to when and how they should be introduced. Proponents of user fees stress that equity and efficiency gains can be achieved through the implementation of a cost‐recovery policy package. Within this package user fees are complemented by decentralization and combined with two targeting mechanisms favouring low income groups: exemptions, and the use of fee revenue to improve the services offered to them. The extension and improvement of primary health care, for example, will disproportionately benefit low income groups by addressing their health needs in a cost‐effective way. However, targeting mechanisms, and exemptions in particular, have received little attention in theoretical debates within the health sector and current practices have rarely been reviewed. Relatively little is known about their effectiveness or about the conditions required to ensure and enhance it. This paper seeks to contribute to health financing policy debates by reviewing targeting options and assessing the available evidence concerning these issues. Success in protecting the poor appears to be limited and there are considerable informational, administrative, resource and socio‐political constraints undermining the development of effective targeting mechanisms. The paper, therefore, urges‐caution in developing health care financing policy and identifies a relevant research agenda.
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.
Abstract Equity and solidarity are key issues in the current political debate concerning the Swiss health care system and possible reforms to it. Equal access to medical care has always been a basic principle which has been strongly supported by all political parties and is reflected in the legal framework. Because the health care system is highly decentralized, assigning most of the responsibilities to the 26 cantons, these legal statements exist predominantly on the cantonal level. For example, the communities are compelled by cantonal law to guarantee access to those who need it but cannot afford it (Undritz 1987, p. 21). However, no such consensus exists with respect to health care financing. The conservative parties favour financing schemes which promote efficiency but are regressive (such as a high share of private financing, high co-insurance rates, and deductibles). By contrast, the parties with a strong social committment support financing schemes which are progressive (high share of tax-financing, low co-insurance rates, and deductibles, free care). In the 1980s, the actual development was characterized by a decreasing share of tax-financing and increased co-insurance rates, thus increasing the regressiveness of the financing system. However, this development is likely to be reversed in the near future. A referendum is pending, proposing a massive increase in the share of tax-financed health care, and seems to have a good chance of winning the vote. These developments should be kept in mind when interpreting our empirical findings which related to the situation in 1982.
The British National Health Service (NHS) has, since its inception, aimed to make health care available to all regardless of income, and it has managed to achieve this goal while keeping costs lower as a proportion of the gross domestic product than many Western countries and at the same time assuring equitable distribution of resources regionally. Until the reforms introduced by the 1989 White Paper, the NHS was characterized by centralized financing and regulation; despite some problems in the delivery and management of care, the system was a popular one. The new reforms hope to enhance efficiency in the NHS by stimulating competition and further decentralizing the management of health care. However, it is not at all certain that in practice the reforms will have the desired effect. Initial costs will be high, people may not respond to incentives as predicted, and the quality of care and access to it could well deteriorate. Nations planning to use the U.K. system as a model are advised to use caution.
A conceptual framework and a blueprint of the health-financing reform have been proposed to the Soviet Parliament by a group of economists and health policy analysts. The draft law offers a new pattern of health financing that is expected to increase both the volume and quality of medical care through raising additional funds, decentralizing health policies and management, providing medical facilities with higher motivation for productive and cost-effective performance, and creating economic incentives for employees and individuals for better labor conditions, pollution abatement, and healthy lifestyles.
The Soviet Union is undergoing a peaceful—but massive—revolution. Everywhere, old institutions are being challenged, and old beliefs are being rejected. Soviet society is beginning to ferment with entrepreneurial zeal, a thrust toward decentralization and democratization of decision making, and a blossoming of interest in competition and free enterprise as a way of reviving the stagnant economy. The health care sector is no exception.<sup>1</sup>Although the Soviet Union was the first country in the world to guarantee free medical care as a constitutional right to all its citizens,<sup>2</sup>the quality and accessibility of that care are now in question. In the face of deteriorating health status indicators and dissatisfaction among Soviet citizens, restructuring the health care system has been joined to the economic reform. The major goal is to infuse new resources into the system and make it part of the self-supporting economy. This reform initiative has been
The empirical evidence available for OECD countries suggests that economic factors play a major role and that demographic factors play a minor role in explaining differences in health care spending across countries. When countries are grouped on the basis of their health care systems, some significant cross-country differences result: countries with higher transfer rates (a larger share of collective financing) are not generally characterized by higher health care expenditures, and conversely, countries with a larger share of private financing (including higher coinsurance rates) do not have lower expenditures. Rather, the opposite holds true. Similar conclusions apply to the share of public versus private production of health goods. Furthermore, the results do not support the claims of those critics of universal public insurance systems who consider the expansion of the coverage to be a major source of expenditure growth. These findings cast serious doubt on the claim that cost containment can be achieved via market reforms that rely heavily on direct consumer payments and cost sharing as instruments of financing. A comparative analysis of the historic record of the United States, Canada, and the Federal Republic of Germany generally supports these conclusions; it also suggests that a greater degree of public penetration offers a better chance for control of health spending, particularly in periods of austerity. There is a strong presumption that health care systems relying on some overall control of spending generally are more cost-effective than those relying more on decentralized mechanisms of control. Services are more equitably distributed in relation to health and payment for health services is far more progressive in the former type of system.
Medical care in Hungary has made significant progress since World War II in spite of other social priorities which have limited financial support of the health system. A shortage of hard currency in a high technological era is now having a particularly severe adverse impact on further development. Decentralized administration and local finance have, however, provided some room for progress. Preventive efforts are hampered by a deeply entrenched life style which is not conducive to improving the population's health status.
The Word Bank Study "Financing Health Services in Developing Countries: An Agenda for Reform" is centered on a thesis of decreased government responsibility for financing health services. The study points out that more basic medical services are needed for the poor, but the aged and increased urbanization are forcing the application of more finances into hospitalization services. The World Bank study incorrectly assumes that the above problem is due to an epidemiologic polarization of rich vs. poor and that the only benefits from curative medicine are private, not societal, benefits. The proposal stemming from these assumptions financially separates curative from preventative services, regardless of its proven costliness and inefficiency. The 4 suggested specific World Bank reforms are: 1) charging fees for the use of health services; 2) provision of insurance or other risk coverage; 3) effective use of nongovernment resources, i.e. private practices, midwives; and 4) decentralization of government health services. These are interesting, although imperfect, solutions to the pressing problem of health care finance. The largest issues may be problems from the fragmentation of health services, cost inflation, and lack of effective controls--issues that are not dealt with in the World Bank study.
In the current environment of general budget stringency in developing countries it is unrealistic to push for more spending for health services. The answer to this health crisis is to relieve government of much of the responsibility for financing those kinds of health services for which the benefits to society as a whole (as opposed to direct benefits to the users of the service) are low freeing resources to finance those services for which benefits are high. The intent is to relieve government of the burden of spending on health care for the rich freeing resources for more spending for the poor. Individuals with sufficient income should pay for their curative care. The financing and provision of these private health services should be shifted to a combination of the nongovernment sector and a sector reorganized to be more financially self-sufficient. A shift such as this would increase the resources available for those types of health services which are goods and currently are underfunded public health programs such as immunization vector control some prenatal and maternal care sanitary waste disposal and health education. Also such a shift would increase the resources available for simple curative care and referral for the poor who now only have limited access to low quality services of this nature. Government efforts to cover the full costs of health care for everyone from general revenues have contributed to 3 sets of problems in the health systems of many countries: an allocation problem -- insufficient spending on cost-effective health activities; an internal efficiency problem -- inefficient programs; and an equity problem -- inequitable distribution of benefits from health services. 4 policies for health financing are proposed to raise revenues for important health programs increase the efficiency of health services and make the system better serve the poor. These are: charging users of health facilities; providing insurance or other risk coverage; strengthening nongovernmental health activities; and decentralizing government health services. A table summarizes the effects of each of the 4 options for reform in alleviating health sector problems.
Decentralization of public program administration and financing to subnational units of government is examined in the context of hospital and nursing home assistance programs in the United States. Do subnational governments (i.e., states) adapt service utilization controls and tighter program eligibility during periods of fiscal austerity? Are these actions affected by expenditure levels, state budget balances, tax revenues, and the state's proportion of low income persons? Published data covering the period 1978-1982 from each of the 50 U.S. states were analyzed using multiple regression. States with a low proportion of low-income persons and a high per capita tax base were likely to increase minimum income eligibility standards to keep pace with inflation. All other states, regardless of fiscal condition, tended toward more restrictive income standards. States were equally likely to adopt utilization controls for health and long-term care services regardless of state revenue or health expenditures.
Today's China, still a developing country with per capita health expenditure of 50 cents to one dollar (U.S.), has established a complex network of health facilities and well-distributed health personnel through the efforts of the existing political structure. The curative health services are decentralized and provide care through a variety of plans which combine capitation prepayment and modified fee-for service. Each plan is striving for the goal of making health care accessible to all at low cost, and hence, efforts of cost containment for self-sufficiency are widely practiced. The responsibility of the preventive health services (such as health education, screening, family planning, food distribution, etc.) are assumed by the central government and they are provided without charge to encourage maximal utilization. Other features of the Chinese system discussed include self-reliance, self-sufficiency, mass orientation, regionalization and innovative utilization of existing facilities, and personnel.
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.