China's transition into a market economy has exerted some influence on the health sector in terms of a significant growth of facilities, but it has also produced a range of destabilizing social costs. \n \n \n \nThis thesis analyzes the relations between healthcare pricing and payment reforms and the different delivery aspects such as the exemption program for the poor, public health programs for tuberculosis control and the provision of hospital services. A health economics and systems conceptual framework is used for analyzing aspects of the health systems in terms of market failures and the institutional response from governments and regulators. \n \n \n \nIn study I, the exemption programs for hospitals where the poor are relieved of paying the price or user charges are analyzed. The study is a case study where patient records from nine hospitals were reviewed, together with interviews with key informants and community representatives. The study showed that the discount offered was limited, where only a minority of indigents received discounts and the hospitals lacked incentives for efficiently carrying out the programs. \n \n \n \nStudy II investigates the effect of the new urban health insurance system on hospital charges. The study uses two tracers, acute appendicitis and normal childbirth, at six hospitals from two cities with different insurance systems. The result showed a lower rate of increase in hospitals charges in the city implementing the urban health insurance reform. Regression analysis showed contracting mechanisms and length of stay to be the main determinants for hospital charges. \n \n \n \nStudy III analyzes the operation of TB control programs in a decentralized financial system. A case study was conducted in four counties with different economic developments in the Shandong province. Data was collected from a review of documents and interviews with patients and key informants. The study showed weak government support to the TB control program and less developed DOT (directly observed therapy) programs in the poorer counties. TB patients suffered heavy financial burdens. The decentralized financing system had negatively affected the provision of public health programs such as TB control programs. \n \n \n \nIn study IV, the impact of retail price control of drugs on hospital drug expenditures was examined. The study is a case study at two hospitals. Total drug expenditures were analyzed based on financial records and a tracer, cerebral infarction, was used for an in-depth examination of prices, volume, expenditures and rationality of drug use. Findings showed that after the implementation of the drug pricing policy, total drug expenditures increased as rapidly as before. Drug expenditure per patient for cerebral infarction showed indistinct results, indicating that the regulation was not effective. Utilization rather than price was more determinative for drug expenditures. \n \n \n \nStudy V investigates the development of revenues, costs and performance in the hospital sector. In a sample of 41 hospitals in two cities, the use of inputs, investments and productivity was estimated. The findings showed that hospitals had expanded their staff and invested in new medical equipment. The corresponding change of outputs in terms of outpatient and inpatient performance showed a slower increasing rate, resulting in a diminishing productivity rate over time. \n \n \n \nThe market-oriented health care system in China is faced with different 'market failures' problems such as limited access to health services for the poor and the inaccuracy in relying on market mechanisms for services characterized by positive externalities, such as the public health programs. Financial autonomy has given health providers the incentives to maximize revenues. Government interventions to contain costs and improve efficiency show that a sole reliance on the price mechanism is insufficient and must be combined with other tools set by regulators and insurers.
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.
Following successful establishment of Expanded Program on Immunization
(EPI) in the 1970's as vertical program, the burden of disease for many
of the vaccine preventable diseases was pushed to low levels. The
current round of health reforms in Tanzania calls for decentralization
and integration of vertical programs. This has the potential to assist
or erode generally good performance of EPI. Reforms on the programme
have been undertaken in Tanzania since 1996, and have included 1)
integration of the procurement, storage, and distribution of vaccine
and related equipment into the operations of a quasi-autonomous drug
procurement agency. 2) government financing of procurement of the oral
polio vaccine, cold chain kerosene, and 3) the integration of kerosene
and vaccine distribution, supervision and monitoring to district health
system. Our analysis shows that the integration of the procurement and
distribution of vaccines into the operations of the drug procurement
agency, and privatization of the distribution of the cold chain
kerosene initially stalled EPI reforms for several reasons and had an
adverse effect on EPI decentralization and coverage. The major cause of
the problems was opposition from the EPI providers at district level
who had to accept decreased income consequent to the reforms. We
conclude that greater involvement of all stakeholders in the planning
of the programme, would have presented an opportunity for forecasting
the opposition and developing mitigating strategies.
In Lao PDR, lack of skilled manpower and financial resources in the central government, plus the policy urging local authorities to be self-sufficient and self-reliant caused the central government to decentralize all sectors to the provincial level in 1987. After 1987, the provinces took over all responsibilities such as planning, financing and provision of health services, only informing the Ministry of Health (MOH) about their activities. Because of economic differences between the 18 provinces, health services became unequal between the richer and poorer provinces. Some provinces generated high revenues, leading to over spending. The decentralized system had some negative impacts on the health service. The technical and planning functions managed from the ministry level became separated from management and financial decision making at the local level, and the ministry lost influence on the direction of health policy. Salaries from the local government were often delayed. Because health budgets were not allocated centrally by the Ministry of Health, there were no mechanisms by which health resources could be distributed preferentially to poorer areas with greater need. However, donors continued to support health programs through the Ministry of Health, sending drugs, vaccines, and other supplies to the provinces. The implementation of decentralization faced many difficulties due to the lack of experienced staff and insufficient training required for practicing decentralization. Similar problems in other sectors, such as agriculture, education, and communication, caused the central government to retake control from the provinces in 1992. During the recentralization period, utilization of health facilities increased. The Ministry of Health set rules and established regulations to strengthen the health system. A cost-recovery system was introduced to obtain additional funds, and conditions in the provinces gradually improved. The unique situation of decentralization followed by recentralization provides an excellent opportunity for study. We reviewed documents relating to these periods and interviewed officials at all levels who were concerned with the process.
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 ‘Health for All’ initiative on the part of the government akin to the ‘Education for All’ scheme which was launched nation-wide in 2001. The large amount of resources required for scaling up public investment in primary health need not be the constraint it is purported to be. We discuss several options that are available to the government for generating the necessary funds. Among the options that can generate resources domestically are reform of the government’s subsidies regime including implementing life-line tariffs, ear-marking taxes and disinvestment of loss-making public sector units. Health for All can also be financed by raising more resources via external assistance. Official development assistance to India at present is rather low given India’s per capita income and the scale of its needs in human development terms. The scale of official development aid to India should increase several folds and committed use of funds should be made by the government in health and other priority sectors. With the 73rd and 74th amendments to the Indian Constitution which created a third tier of government comprising of elected local bodies at the village and town ward levels, a decentralized system of service delivery will eventually become a reality in India and needs to be a part of any debate on the means and modes of improving human development outcomes in India. The current system of planning and allocation of funds at the sub-national level however needs to be over-hauled if fiscal decentralization is also to become a reality.
Bunnan Men, John Grundy, Jeff Cane, Lon Chan Rasmey · 10 authors
The following study was conducted as part of a review of management systems at a Provincial Health Department (Kampong Cham Province) and a National Health Programme (National Immunization Program) in 2002-2003 in Cambodia. The aim of this paper is to identify, analyse and recommend those management system factors that are critical to the success of health management performance, with a particular focus on provincial management. The review has identified critical success factors associated with health management performance at the sub-national level that include a stronger role for effective human resource management in health sector reform, elevation of the status of planning in senior level management, and the development of a more comprehensive and transparent finance system. These success factors will position the provincial level of health management to respond more effectively to the reform challenges of administrative de-concentration and political decentralization that are currently underway across a range of government sectors in Cambodia.
Armando Arredondo, Emanuel Orozco, Esteban de Icaza
OBJECTIVE: The main objective was to identify trends and evidence on health financing after health care decentralization. STUDY DESIGN: Evaluative research with a before-after design integrating qualitative and quantitative analysis. Taking into account feasibility, political and technical criteria, three Latin American countries were selected as study populations: Mexico, Nicaragua and Peru. DATA SOURCES: The methodology had two main phases. In the first phase, the study referred to secondary sources of data and documents to obtain information about the following variables: type of decentralization implemented, source of finance, funds of financing, providers, final use of resources and mechanisms for resource allocation. In the second phase, the study referred to primary data collected in a survey of key personnel from the health sectors of each country. FINDINGS: The trends and evidence reported in all five financing indicators may identify major weaknesses and strengths in health financing. CONCLUSIONS: Weaknesses: a lack of human resources trained in health economics who can implement changes, a lack of financial resource independence between the local and central levels, the negative behavior of the main macro-economic variables, and the difficulty in developing new financing alternatives. Strengths: the sharing between the central level and local levels of responsibility for financing health services, the implementation of new organizational structures for the follow-up of financial changes at the local level, the development and implementation of new financial allocation mechanisms taking as a basis the efficiency and equity principles, new technique of a per-capita adjustment factor corrected at the local health needs, and the increase of financing contributions from households and local levels of government.
Armando Arredondo, Emanuel Orozco, Gerardo Mora, René Ramos · 5 authors
Abstract The main objective of this study was to identify trends and results associated with health financing and governance indicators in the context of health systems reform. Evaluative research integrating qualitative and quantitative analysis was performed. The three Latin American countries of Mexico, Nicaragua, and Peru were selected as the universe of study. The research methodology had two main phases. In the first phase, the study referred to secondary sources of data and documents to obtain information about the following variables: type of decentralization implemented, source of finance, funds of financing, providers, final use of resources and mechanisms for resource allocation. In the second phase, the study referred to primary data collected in a survey of key personnel from the health sectors of each country. Results showed that evidence reported in all five financing and governance indicators may identify the major weaknesses and strengths in health financing. In addition, there was a lack of human resources trained in health economics who can implement changes, a lack of financial resources independence between the local and central levels, negative behavior of the main macro-economic variables, and difficulty in developing new financing alternatives. However, other results showed that there was a sharing between the central and local government levels in the financing health services, the implementation of new organizational structures for the follow-up of financial changes at the local level, the development and implementation of new financial allocation mechanisms taking into account efficiency and equity principles, new technique of a per-capita adjustment factor corrected at the local health needs, and the increase of financing contributions from households and local levels of government. Introduction New health financing policies and changes in health financing indicators after decentralization are the principal elements of health sector reform in a number of countries. It has increasingly been recognized, at both national and international levels, that management, financing, planning, and policy functions in the health sector may be carried out more efficiently and effectively if they are decentralized, transferring responsibility to a local level. However, there is growing concern that decentralization has failed to achieve the objectives for which it was introduced and can indeed have effects that limit health sector development (Hurley, 1995; Arredondo, 2000, 2005). The relationship between decentralization and financial changes in the process of health care reform in Latin American countries is complex. Analysis of recent attempts at decentralization and financial changes requires an understanding of the contradictory forces at work within the political systems, particularly, bureaucracies of Latin American countries (De Souza et al, 2002). In these countries strong centralizing tendencies coexist with particular forms of bureaucratic decentralization (Arredondo, 1997). Centralizing tendencies remain predominant, with decentralizing forces both being caused by and serving to reinforce them. The type and degree of decentralization is strongly influenced by dynamic financial aspects, including sources of finance, agents, providers, final destination and mechanisms of financial allocation at the local, regional and national level. Local governments usually have authority to levy taxes. However, in developing countries, much of the national revenue comes from indirect taxes, especially customs and excise revenues, while buoyant local sources of revenue are hard to find (Collins, 1994; Abel-Smith, 1988). The local governments in these countries are often by necessity heavily dependent on grants from the central government. In addition, governments often retain central control over finance in order to promote geographical equity. The sources for financing local government may therefore not differ significantly from those of local offices of central ministries, though the way the grant is made is likely to differ (Quentin, 2004). …
OBJECTIVE: To assess the equity and fairness of the Mexican health system reform that occurred in the late 1990's. MATERIAL AND METHODS: The Mexican reform process was evaluated using the benchmark-system designed by Daniels et al. This benchmark system was adapted to the Mexican setting by adding specific indicators. A documentary review of the Mexican reform process was conducted to score its performance for each benchmark. RESULTS: Except for housing and nutrition components, the reform included few actions related to health determinants. For health care, the main reform initiatives were those related to extending the coverage of essential health services and decentralizing health care provision to the states. Reform initiatives included few activities related to fair financing, tiering, emphasis on second and third level care, accountability, and transparency. CONCLUSIONS: The late nineties reform of the Mexican health system had some positive effect on access of the poor to health care and administrative efficiency, but little impact on fair financing, quality of care, and democratic governance. The English version of this paper is available at: http://www.insp.mx/salud/index.html.
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.
Samuel S. Lieberman, Joseph J. Capuno, Hoàng Văn Minh
This paper examines decentralization experiences in Indonesia, the Philippines and Vietnam during the last 18 years (1985-2003). The analysis suggests that decentralization dividends so far have been modest and concentrated in some areas in the country. This is partly macroeconomic and political context in which decentralization was introduced. More importantly, however, current arrangements within the health sector have not worked well as hoped, including ensuring access for the poor to quality health services. To improve the gains, a stewardship role for the MOH is suggested. In this role, the MOH would focus on critical health functions, namely: communicable disease surveillance and control; standard setting and quality assurance for devolved health services; and pharmaceuticals; ensuring access of the poor to health services; and, sustaining health financing.
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.
Decentralization policies are an integrated component of health sector reform in an increasing number of countries. The ability of such policies to improve the health system's quality and efficiency is backed up by limited scientific evidence. This study intends to evaluate the impact of decentralization on a specialized field of disease control (leprosy control) in Colombia and Brazil. It analyses the respective juridical base, epidemiological indicators and local publications. Furthermore, 39 semi-structured interviews with key informants were conducted. In both countries, the devolution of technical responsibility and financial resources to the municipalities was the implemented form of decentralization. Access to preventive and curative health care and the community participation in decision-making improved clearly only in Brazil. The decentralization to private providers in Colombia had dubious effects on service quality in general and still more on public health. The flow of finances (including finance collection through state-owned taxes instead of insurance companies) seemed to be better controlled in Brazil. Leprosy control in Brazil took advantage of the decentralization process; in Colombia, it came close to a collapse.
Peter Waalwo Kajula, Francis Kintu, John Barugahare, Stella Neema
The aim of this study was to assess the political and social dynamics resulting from the rapid change in user-fee reforms in Uganda and the effects on service delivery for malaria control. Using political mapping and political risk analysis techniques, the study analysed qualitative and quantitative data obtained from secondary data sources and key actors in the policy arena. The results have shown that the feasibility of user-fees in Uganda was undermined by the absence of strong central government leadership and strategies to manage the politics of the reforms. The resultant rapid change in policy adversely affected the recurrent expenditures of health units that previously relied heavily on cost sharing, which led to a chronic shortage of malaria drugs and undermined the ability of health facilities to hire and motivate staff. The study results demonstrate that in order to contribute positively to healthcare delivery goals for malaria control in endemic countries, user-fees require full ownership and strong political leadership by the central government. Decentralization, when merely used as a strategy to navigate the political risks associated with user-fees, is unlikely to succeed without a centrally coordinated and managed process of policy formulation and acceptance involving wider consultations and political management of interest groups.
Latin American social medicine (LASM) emerged as a movement in the 1970s and played an important role in the Brazilian health care reform of the 1980s, both of which focused on decentralization and on health care as a social right. The dominant health care reform model in Latin America has included a market-driven, private subsystem for the insured and a public subsystem for the uninsured and the poor. In contrast, the Mexico City government has launched a comprehensive policy based on social rights and redistribution of resources. A universal pension for senior citizens and free medical services are financed by grants, eliminating routine government corruption and waste. The Mexico City policy reflects the influence of Latin American social medicine. In this article, I outline the basic traits of LASM and those of the prevailing health care reform model in Latin America and describe the Mexico City social and health policy, emphasizing the influence of LASM in values, principles, and concrete programs.
Nicaragua has embarked on a reform of the way in which publicly provided medical care is organized and financed. A principal feature of the reforms includes a decentralization of decision-making authority coupled with an increase in local accountability. Local decision-making authority has been increased by allowing managers more freedom to allocate inputs. Accountability has been strengthened by stipulating what is expected of hospitals and health centres in the form of performance agreements, and tying rewards (i.e. bonuses) to the satisfaction of these requirements provides incentives. This paper provides a critical assessment of these reforms, and presents some early evidence of their effects.
Nazmul Chaudhury, Jeffrey S. Hammer, Edmundo Murrugarra
This study examines the impact of a fee-waiver program for basic medical services on health care utilization in Armenia. Due to the reduction in public financing of health services and decentralization and increased privatization of health care provision, private out-of-pocket contributions are increasingly becoming a significant component of health costs in Armenia. To help poor families cope with this constraint, the Government of Armenia provided a free-of-charge basic package service to eligible individuals in vulnerable groups, such as the disabled and children from single parent households. Drawing upon the 1996 and 1998/99 Armenia Integrated Survey of Living Standards (AISLS), which allows the identification of eligible individuals under this program, we estimate the impact of the fee-waiver program on utilization of health services, particularly among the poor. Across the two survey rounds utilization rates have indeed declined despite comparable levels of income, and this decline has occurred among both the poor and the rich, with average utilization falling by 12 percent between the two surveys. However, families with four or more children, the largest beneficiary group under the "Vulnerable Population" program, have decreased their usage of health care services in a disproportionate manner -- 21 percent reduction in usage between the two survey rounds. This precipitous drop in health care usage by this vulnerable group despite being eligible for free medical services, suggests that the program just by itself was inadequate in stemming the decline in the usage of health services. We furthermore present evidence to suggest that the free-of-charge eligibility program is acting more like an income transfer mechanism, particularly to disabled individuals. Contents...
The current need and enthusiasm for health reforms open an important arena for deeper analysis of the policy process with a view to understanding the political determinants of reforms and strengthening implementation. The studies described in this thesis analyse positions of different actors in the reform process, their actions in support or opposition of the process, and their impact on the health sector reform process. Globally and especially in developing countries health sector reforms have been implemented over long periods. Although there have been improvements in health, the remaining burden of disease in many countries is still very high. Reasons for the high burden of disease have been classified into lack of resources and poor organizational and managerial capacity. Good stewardship was needed to facilitate improvement in the performance of health systems. Stakeholders’ alignment and support was one of the most important components of good stewardship. However, stakeholder analysis had not been a common undertaking in developing countries despite the reforms that were being implemented in most of them. It was the aim of this study to answer the question: What has been the role and importance of stakeholders in supporting or opposing the health sector reform process? The study was conducted in Tanzania as one of the poorest countries in Africa, using the decentralization of the Expanded Programme on Immunization (EPI) as a case reference. The study units were the Ministry of Health Headquarters, Medical Stores Department, Expanded Programme on Immunization, national archives, regions and districts. At district level the study units were District Council, Council Health Management Team, EPI managers at regional and district levels, ward and village authorities, health facility, facility providers and households. Qualitative and quantitative methods were used to collect data from January 2000 to June 2002. Relevant data collection instruments were prepared and pre-tested. The qualitative data collection methods included document review, \nin-depth interviews, key informants interviews and observations. Quantitative \nmethods involved retrieval of secondary data, health facility survey and \nhousehold surveys. Regular discussions with key informants and data \ncollectors were held to verify the findings. Qualitative data was analysed \nmanually. Quantitative data was captured and analysed using Epi Info version \n6.1 and STATA version 6.0. The study involved answering five main questions. The first question was: Do \nreforms learn from history? Analysis of the waves of health reforms prior to \nthe current reforms from 1926 was done to answer the question. The main \nstakeholders in the reforms were the political party in power, the government \nand donors who supported the reforms each time. Each wave of health sector \nreforms provided information on health provision, financing and resource \ngeneration. Due to the political contexts, information on failures of health \nfinancing did not provide lessons for succeeding reforms of the health sector. \nStakeholders’ political interests opposed lessons that did not match the \npolitical ideology at the time i.e. free public services versus privatization and \npaying for social services. Lessons from previous health reforms were \nselective, and did not consider health-financing needs among others. The \nongoing health reforms needed to use information from all functional aspects \nof the health system to provide lessons for improving the health system. The second question was: Who were the stakeholders in the current health \nreforms and what were their interests and reactions? The main stakeholders \nwere donors, and the government. The two had a very high support for the \nreforms evidenced by their participation in problem identification, justification, \nreform design, planning and implementation. The health sector reforms thus \nhad high political support at central level. In the implementation process, \nissues that triggered stakeholders’ reaction included sectoral versus local \ngovernment decentralization. Another issue was the donor modality in \nfinancing the health sector and need for adopting new financial management \nsystems. Among the donors there was hesitancy to join the common financing \nmodalities that included a Sector Wide Approach (SWAp) and Basket \n Funding. As a result, there was delay in the process in order to reach better \nconsensus. \nThe third question was: What was the impact of stakeholders in the process of \nreforming a vertical programme like EPI? Health Sector Reforms in EPI \nincluded integration of generic functions, for example, vaccine procurement to \nmedical stores department. Qualitative and quantitative data was collected \nand analysed from the Ministry of Health, EPI management unit. This again \nrevealed that EPI reforms were well supported by the government and donors \ncentrally. EPI managers at both district and regional levels opposed some of \nthe EPI reforms. They argued that coverage was falling due to the reforms. \nHowever, there was no concrete evidence relating reforms in the EPI \nprogramme and falling coverage. The primary aim of certain actors was to \nmake sure that they continued receiving extra income from EPI functions. One \nof the effects of stakeholders’ reaction was reversal of reforms (recentralization) \nand return to the status quo. The fourth question was: What was the immediate reaction of stakeholders to \ndecentralization at district level and how might it have affected performance of \nEPI functions and the challenges? The immediate reaction of stakeholders \nwas reduced cooperation between the Council Health Management Team \n(CHMT) and the District Council who were politically supreme in the district. \nWithin the Council Health Management Team there was inadequate \ncommunication, which led to poor teamwork. The result of this was reduced \nsupervisory visits to peripheral health facilities. The EPI coverage in the study \ndistrict was 52.8 per cent, which was well below the previous national average \n(80 per cent). A logistic regression model for EPI service quality variables on \nchildren between 12 months and 23 months who had completed vaccination \nwas applied. Certain EPI quality of service variables predicted significant \nchanges in the odds ratio for completing vaccination. It was then suggested \nthat strategies were needed to improve management skills among the CHMT \nand District Council members. Also there was a need of hastening the \nprocess of increasing remuneration and motivation of peripheral health \nworkers. The fifth and final question was: What was the interest of the stakeholders \nand prospects of increasing EPI coverage at district level? Decentralization \nand integration of EPI functions were among the reforms at district level. The \nanalysis revealed that active stakeholders at district level were the Ministry of \nHealth, CHMT, EPI managers at district and regional levels and facility \nproviders. The Ministry of Health opposed integration of EPI at district level by \nissuing the directive that DCCOs and MCHCOs (EPI manager at district level) \nshould resume their tasks. However, the CHMT had no option but to comply. \nThis action reversed some of the health reforms at district level. Analysis of \nthe importance the community attached to EPI, using willingness to pay for \nEPI cold chain kerosene, was done. The support was low (48.7 per cent). EPI \nservice quality variables were significantly negatively associated with odds \nratio for willingness to pay for EPI input. Simulation with Policy Maker \ncomputer software predicted that an increased number of stakeholders \nthrough community participation would significantly improve the current low \nlevel of EPI coverage. It was then proposed to do a similar analysis in other \nvertical programmes and implement on a trial basis the results of the \nsimulation. \nIn conclusion, stakeholders were found to be active and influential in the \nhealth sectors of developing countries like Tanzania but poorly considered in \nimplementation of reforms. Stakeholders are important since some strongly \nsupport while others oppose the reforms. The reaction of stakeholders is \nevident through deployment or non-deployment of information depending on \ninterest and context. This would result in poor management leading to \ninefficiency in resource use, which would then be followed by poor quality of \nservices, poor support by communities and consequently poor utilization of \nhealth services. It is suggested that stakeholder analysis be conducted in \nother vertical programmes in the process of integration. Promotion of \nstakeholder analysis and also Policy Maker as a tool to manage stakeholders \nwill facilitate the management of reforms in the health sector.
The introduction of user-payment for health services is frequently followed by concern about the impact on equity of access for poor people. Decentralizing governments often try to remedy the created inequities by putting in place safety nets in the form of exemptions and waivers in the user-fee systems. However, where user payments merely operate as local government strategies for health financing, without national policy they are likely to be self-defeating, as local governments are frequently more interested in raising revenue to meet recurrent costs of devolved services than in promoting equity. Thus guidelines put in place by the central government to operationalize safety nets are seen by local governments as being contradictory to this goal, and are thus ignored or altered to suit the district revenue aims. This study was carried out to investigate the context and the constraints in implementing exemption schemes. Data were collected in two selected administrative districts of Uganda (Mbarara and Mukono). Qualitative approaches to data collection were adopted, namely focus group discussions and key informant interviews with policy-makers, health administrators, service providers and community members. These methods were combined with document review. We found little evidence of safety-net guidelines initiated by decentralized/local governments, since district local governments had little motivation to extend exemptions, waivers or credits. The conclusion is that safety nets such as waivers and exemptions will only be effective if they are backed by a national health financing policy, they reconcile the often competing demands of local government revenue needs, and are strictly enforced and supervised by both the local and central governments. The implications of the findings for remedying the tension between the needs for cost recovery and for attainment of equity goals through exemption policies for the poor and indigent are discussed.
Decentralization is commonly championed as a means for achieving equity. To date, however, there has been little discussion of the mechanisms underlying this relationship, and several of the few empirical investigations that have addressed the topic have found the converse; that decentralization has exacerbated inequalities. This article examines the performance and equity in financing of the Honduras Ministry of Health's (MOH) decentralized user fee system. The MOH of Honduras established a national user fee policy in 1989. It provided a framework of rules and regulations and decentralized administration of the system to the regional offices. A survey conducted under the auspices of this study provided detailed information about the structures and operations of MOH user fee systems. The survey revealed that the systems vary markedly by region, creating horizontal inequities, and that they have numerous other shortcomings. The average price of a consultation is low, US dollars 0.16, and revenues have consistently equalled just 2% of MOH expenditures. The systems' administrative costs are equal to 67% of their revenues. Eliminating the user fee systems in all but the national and regional hospitals would actually save money and/or enable the MOH to provide more care. Average consultation prices are highest in health posts, intermediate in centres and lowest in the national hospitals, thereby encouraging the inappropriate use of the MOH's pyramidal referral system and fostering MOH inefficiency. Fee levels and exemption practices are horizontally and vertically inequitable. The likelihood of paying for an ambulatory visit is highest at a health post, 89%, and lowest at a hospital, 49%. Individuals from the poorest one-fifth of households are the most likely to have to pay for care. Honduras' experience demonstrates that a decentralized user fee system is not necessarily equitable, and that, more generally, the gains that can be realized from decentralizing user fee systems are not automatic. They must be anticipated, planned for and cultivated by a well-designed and well-implemented initiative that is not a single, one-time event, but rather a dynamic, on-going enterprise.
The Province of the Punjab underwent a number of attempts to decentralize the health sector in the 1990s. Among the most important were the decentralization of financial management within the district, the Sheikhupura PHC Pilot Project, the establishment of the District Health Authorities and District Health Management Teams, the creation of semi-autonomous hospitals and the programme of District Health Government (DHG). These usually received donor support and promotion, and emerged from within the provincial Department of Health, and more specifically the Secretariat and the internationally supported Second Family Health Project (FH2). Of particular significance was the DHG change, which involved a decentralization to the district, the appointment of powerful Chief Executives, the formation of District Management Committees and purchaser-provider separation. The paper reviews these proposals, focusing on the need to build on experiences and learning lessons from pilot projects, reform continuity, developing consultation and involvement and policy analysis. The latter indicates the importance of developing more in-depth policy analysis around the role of the central organization, the form of decentralization and the purchaser-provider separation. The paper concludes by underlining the need to ensure that political strategy and in-depth policy are appropriately coordinated in the policy process.
CONTEXT: In the 1990s, the Republic of Georgia instituted health care reforms to convert the centralized, state-operated health care system inherited from the Soviet Union to a decentralized, market-driven system of health care delivery. Under the new system, 87% of health care expenditures are financed through out-of-pocket payments at the point of service. OBJECTIVE: To describe the effects of health care reforms on access to care and health care financing among ill residents of Tbilisi, Georgia. DESIGN, SETTING, AND PARTICIPANTS: A probability-proportionate-to-size cluster survey conducted in 1999 of 248 households containing 306 household members who had been ill in the past 6 months in Tbilisi, Georgia. MAIN OUTCOME MEASURES: Reported health care utilization, out-of-pocket expenditures, and financing practices. RESULTS: Of sick household members, 51% used official health care services at hospitals and clinics; 49% did not use official services and sought advice from relatives or friends, used traditional medicines, or did nothing. Those with serious illness were more likely to seek care through official services (82%) than those with nonserious illness (27%). Ninety-three percent of respondents said costs were the major deterrent to obtaining health care. Ten percent of ill household members reported that they were unable to obtain health care because of high costs; 16% reported being unable to afford all the medications necessary to treat their illness. Sixty-one percent of ill household members used savings to pay for health care expenditures and 19% of those able to obtain care had to use strategies such as borrowing money or selling personal items to pay for health care. Total out-of-pocket health care expenditures (53%) were paid for by borrowing money or selling personal items. A significant portion of households with ill members (87%) reported an interest in purchasing health care insurance. CONCLUSIONS: Economic disruption and health care reforms have led to access problems and out-of-pocket financing strategies that include reliance on personal savings, selling personal items, and borrowing money. Future reforms should consider an appropriate system for health care insurance risk pooling for the population of Tbilisi, Georgia.