This article presents the results from an evaluative longitudinal study with before-after design. The main objective was to determine the effects of health care decentralization on changes in health financing. Taking into account feasibility, political and technical criteria, three Latin American countries were selected as study populations: Mexico, Nicaragua and Peru. 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. Taking into account the changes implemented in the three countries, as well as the strengths and weaknesses of each country in financing and decentralization, a rule for decision-making is proposed that attempts to identify the main financial changes implemented in each country and the basic indicators that can be used in future years to direct the planning, assessment, adjustment and correction of health financing and decentralization.
The Danish health care system The Danish health care system is characterized by free and equal access to health care services. This principle has the same high priority regardless of the party in office. Free and equal access to health care services and universal coverage go hand in hand with a strong determination to control costs. Within the last fifteen years, the freedom to select the hospital of one's choice has also become a very important part of the health care system. The health care system in Denmark is mainly publicly financed through taxes, and is decentralized, with three administrative levels: state, county and municipality. The state's task in health care provision is, first and foremost, to initiate, coordinate, advise, and legislate. The counties are responsible for providing health care services within the limits set by the state. The municipalities are responsible for district nursing, public health care, school health care, and child dental treatment. The provision of health care services by municipalities and counties is negotiated every year in the national budget negotiation. The budget negotiation takes place between the government on the one hand, and the Danish regions (counties) and Local Government Denmark (LGDK) on the other. Agreements are typically in the form of recommendations for local and country tax rates and agreements on injecting capital into specific health care areas or projects, such as cancer treatment or waiting times. Introduction of activity-based financing has also been agreed on in budget negotiations.
Imrana Qadeer, Kasturi Sen, Kesavan Rajasekharan Nayar
Introduction PART ONE: THE POLITICAL ECONOMY OF HEALTH AND DEVELOPMENT Landmarks in the Development of Health Services in India - Debabar Banerji Structural Adjustment and the Poor in Pakistan - Jennifer Bennett Donor-Driven Family Planning Services in Bangladesh - Farida Akhter Impact on Women's Health Changes in Health Care Systems in Europe - Meri Koivusalo Focus on Finland Structural Adjustment Policies and Health in the Plantation Sector in Sri Lanka - Indira Hettiarachchi Dilemmas for Research in Primary Health Care in the Era of Reforms - Marc De Bruycker PART TWO: CONCEPTS AND EVIDENCE Impact of Structural Adjustements Programs on Concepts in Public Health - Imrana Qadeer Health Reforms and Developing Countries - Kasturi Sen A Critique Disability Adjusted Life Years as a Tool for Public Health Policy - Ritu Priya A Critical Assessment Re-Thinking Public Health - Sheila Zurbrigg Food, Hunger and Mortality Decline in South Asian History Biological Stress and History from Below - Lalita Chakravarty The Millet Zone of India, 1970-92 PART THREE: SHIFTS IN HEALTH SERVICES AND HEALTH FINANCING Health Sector Reforms and Structural Adjustment - Rama V Baru A State-Level Analysis Reforms and Their Relevance - V Raman Kutty The Kerala Experience Health Sector and Economic Reforms - K Seeta Prabhu A Study of Maharashtra and Tamil Nadu Structural Adjustment and Economic Slowdown - S Akbar Zaidi Likely Impact on Health Outcomes in Pakistan Health Services in Bangladesh - A Q Khan Development and Structural Reforms Structural Adjustment Programs and Health Care Services in Sri Lanka - Dulitha N Fernando An Overview Evolution of India's Leprosy Program from Control to Elimination - B R Chatterjee Tuberculosis Program in India - A K Chakraborty Current Operational Issues PART FOUR: DECENTRALIZATION IN HEALTH CARE Politics of Decentralization - K R Nayar Lessons from Kerala Promises and Problems of Panchayati Raj - Anwar Jafri Experiences from Madhya Pradesh An Assessment of the Effectiveness of Decentralization of Health Services in Sri Lanka - Nimal Attanayake People's Health Care Initiative in Chhattisgarh District, Madhya Pradesh - Binayak Sen PART FIVE: PERSPECTIVES OF CLINICIANS Prescribing Practices - Anant R Phadke A Comparison of Public and Private Sectors Revisiting the Community Health Worker - Shyam Ashtekar Disturbing Trends in the Treatment of Malaria - Yogesh Jain Public Health in Vellore - Anand Zachariah Experiences with Malaria and Cholera The Revised National Tuberculosis Control Program - Anurag Bhargava A Critical Perspective PART SIX: EXPERIENCES AT THE MICRO-LEVEL The Plague, the Poor and the Health Services - Ghanshyam Shah Public Health Issues of Small Towns - K S Sebastian The Case of Alleppey The Labor Process and Its Impact on the Lives of Women Workers - Meena Gopal The Reproductive Health Package - Alpana Sagar A Chimera for Women's Health The Rhetoric of Reproductive Rights - Mohan Rao Quinacrine Sterilization in India
OBJECTIVE: The results of an evaluative longitudinal study, which identified the effects of health care decentralization on health financing in Mexico, Nicaragua and Peru are presented in this article. METHODS: The methodology had two main phases. In the first, secondary sources of data and documents were analyzed with the following variables: type of decentralization implemented, source of financing, funds for financing, providers, final use of resources, mechanisms for resource allocation. In the second phase, primary data were collected by a survey of key personnel in the health sector. RESULTS: Results of the comparative analysis are presented, showing the changes implemented in the three countries, as well as the strengths and weaknesses of each country in matters of financing and decentralization. CONCLUSIONS: The main financing changes implemented and quantitative trends with respect to the five financing indicators are presented as a methodological tool to implement corrections and adjustments in health financing.
Like many developing countries, the Philippines has decentralized its public health system. Despite its supposed advantages, however, the decentralization, has not led to widespread improvements in local provision. This is partly because many local government units are found financially inadequate since the current revenue-sharing scheme does not factor in the distribution of the devolved expenditure responsibilities across LGU. Moreover, this particular flaw in the present revenue-sharing scheme has made corrective policy measures more difficult to undertake since it is no longer sufficient to compensate those LGUs originally with financing difficulties. More crucially, it has also become politically necessary to compensate those adversely affected by the corrective policy measure. If only to avoid the added cost of further adjustments, the experience of the Philippines underscores the importance of a well-designed and carefully implemented decentralization program.
Setting risk-adjusted capitation rates in health systems with centralized financing and decentralized delivery is one of the most intriguing policy issues. The common practice to set capitation group rates is based on individual data collected from either population surveys or medical records, using a single-and in most cases arbitrary-set of relative unit costs of services. This paper presents a method for estimating group-specific mean costs and capitation rates using a panel of aggregate cost data of the competing health plans and the composition of their populations. This method is used to estimate mean costs and capitation rates for the Israeli health care system. The limited data available severely constrains the range of estimable models, however, the results evoke some questions with regards to reimbursement and rates presently used, as well as to the methodology used to estimate them.
OBJECTIVE: Previous economic analyses of tuberculosis control interventions have focused on the provider perspective. To assess the overall economic impact of the disease and the adequacy of current control strategies from a societal viewpoint, the determination of direct and indirect patient costs is required. SETTING AND DESIGN: In a cross-sectional survey, all adult tuberculosis patients who completed treatment between August 1996 and February 1997 at 16 randomly selected government health care facilities in Thailand (n = 673) were interviewed using a structured questionnaire. Information were obtained on direct and indirect patient costs before and after diagnosis, and on financing methods and changes in household consumption patterns. All results were stratified for three levels of patient household income: above national average, below national average but above the poverty line, and below the poverty line. RESULTS: Illness-related costs particularly affected patients with incomes below the poverty line (n = 153). In this group, average out-of-pocket expenditures for the disease amounted to more than 15% of annual household income, while incomes were reduced by 5 % due to illness-related effects. Expenditures were most frequently financed from household savings or transfer payments from community members and relatives. However, 11.8% of patient households took out bank loans, and 15.9% sold part of their property. CONCLUSION: The current low case detection and treatment completion rates for tuberculosis patients in Thailand may partly be due to the inability of poor patients to cope with the economic consequences of diagnosis and treatment. Suggested improvements include the strict enforcement of an existing government policy of free care, the further decentralization of services to reduce travel costs and work absences, and social security payments for patients undergoing treatment.
AIM: To evaluate the results of current reforms in Macedonian health sector. METHOD: Description and situation analysis, covering the period 1991-1997, are focused on demographic and vital indicators, morbidity and mortality data, elements of health care system, legislation, health insurance, health care financing, and elements of health care reforms. RESULTS: The Republic of Macedonia experienced changes in the social and economic situation, similar to those in other countries in transition. The growing number of dependents (young and old persons) impact high health expenditures. High priority health problems were infant and premature adult mortality. As an inheritance of the former political system, the development of different parts of health care services was unbalanced and insurance and local network of health facilities were highly decentralized. The reforms addressed health financing and reimbursement, organization and management of health services, and pharmaceutical policies and supply. The legislation was revised, but new revision is needed. CONCLUSIONS: Health care reforms were needed in Republic of Macedonia in order to overcome the problems associated with early phase of transition. The disadvantages of the current reforms are: lack of proper political will for the implementation of activities according to the planned schedule, initial over-utilization of hospital care, and no significant changes in financing of the public sector facilities. The advantages are that the health system did not disintegrate, universal access to health services was maintained, free choice of physician was promoted, and public/private mix of services was established and financed by the Health Insurance Fund.
David Collins, Grace Njoki Njeru, Julius S. Meme, William Newbrander
An increasing number of countries are exploring the introduction or expansion of autonomous hospitals as one of the numerous health reforms they are introducing to their health system. Hospital autonomy is one of the forms of decentralization that is focused on a specific institution rather than on a political unit. It has gained much interest because it is an attempt to amalgamate the best elements of the public and private sectors in how a hospital is governed, managed and financed. This paper reviews the key elements of the concept of hospital autonomy, the reasons for its expanded use in many countries and a specific example of making a major teaching hospital autonomous in Kenya. A review of the successful experience of Kenyatta National Hospital and its process of introducing autonomy, with regard to governance, operations and management, and finances, lead to several conclusions on replicability. The legal framework is a critical element for successfully structuring the autonomous hospital. Additionally, success is highly dependent on the extent to which there is adequate funding during the process of attaining autonomy due to the length of the transition period needed. Autonomy must be granted within the context of the national health system and national health objectives and be consistent with those aims and their underlying societal values. Finally, as with decentralization, success is dependent upon the preparation done with the systems and management necessary for the proper governance and operation of autonomous hospitals.
There are three main problems at present in the area of health care: — an imbalance between the amounts of state financing for health care and the guarantees offurnishing medical assistanceto the citizenry at no charge; — a lack of coordination in the activities and contradictions in the mutual relations of the entities receiving state financing for health care, engendered by the decentralization of management and transition to a system of mandatory medical insurance; — an absence of competitive behavior among insurance organizations and medical institutions, despite the adoption of the institutions of a market economy into the system of health care.
Through the recent National Health Insurance Act (NHIA), the Philippines have committed themselves to introducing a social health insurance with universal coverage within 15 years. Germany was the first country to introduce a social health insurance system more than 100 years ago. Its system is based on the principles of corporatism, federalism and a mandate for equity. Based on a long-term German experience with equity, quality, cost and efficiency issues, the Philippines' NHIA is analysed concerning the entitlement to benefits and the benefit package, the organization of the health insurance programme, health insurance financing, and provider payment mechanisms. It is suggested that the Philippines could profit from including preventive and promotive services as well as pharmaceuticals in the benefits package. The organization of the health insurance system could be decentralized using the 13 regions as its principal units. To achieve financial equity between regions and health funds, a contribution compensation scheme is proposed. To prevent over-utilization in over-served areas and to promote utilization in under-served areas, a relative value scale for fee-for-service payments seem advisable.
The paper reviews the theoretical basis for the application of user fees in the public health sector in low-income countries with particular reference to the special characteristics of medical care as a commodity. The general equilibrium efficiency result of the market mechanism is shown to be the theoretical justification for the financing of health services via a system of user charges. If markets for all goods and services exist, and are perfect in a very strict sense, the welfare outcome of the price mechanism cannot be improved upon by any other resource allocation device. Furthermore, the decentralized and impersonal nature of this mechanism renders it more convenient to use in the allocation of commodities, health care included, than its alternatives such as a system of centrally administered prices or a system of administrative controls and directives. However, since many of the assumptions of the price system are rarely met in actual situations, especially in the health sector, it should be applied with caution. In particular, problems of information asymmetry and consumption externalities in health care markets necessitate a simultaneous use of fees with government interventions in order for fees to achieve their often intended aim of efficiency and equity improvement in health care provision. The most important intervention of the government here is the enactment and enforcement of institutions that reduce costs of transacting in health care markets and that in addition facilitate the emergence of new markets such as the markets for medical insurance. A striking finding of the paper is that health services in low-income countries are best financed primarily by revenue from general taxation, supplemented by a system of moderate user fees. Since medical insurance markets are generally non-existent in low-income areas, it is argued that financing health services primarily through user fees in such areas would be inefficient and inequitable. However, to mitigate the moral hazard problem as well as the problem of the commons, both of which characterize publicly financed health care, imposition of modest user fees is required. The importance of fees in this proposal increases with economic growth and with evolution of institutions that facilitate market transactions. Strategic interaction among economic agents is shown to affect the structure and implementation of user fees. A game-theoretic analysis of the general problem of health care financing shows that this problem is best tackled by harnessing the efforts of households, private health care providers, the government and civil society. These entities form what might be called a winning coalition in health care financing game of society. It is argued that the government is better placed to provide an institutional framework for coordinating the efforts of the various players to the desired end.
Drawing from the public finance literature on expenditure assignment, this paper analyzes how devolution in the health sector is being operationalized in the Philippines. A central issue is how the central government can ensure that national and local objectives coincide. The pattern of health spending after devolution is described, and the financing of national health priorities at the local level through the Comprehensive Health Care Agreements is examined. The paper concludes by suggesting some guidelines for a financing mechanism for locally implemented health projects.
In May 1993 the Grameen Bank in Bangladesh ‐ one of the most successful and internationally best‐known self‐help projects ‐ launched a programme to provide poor people in rural areas with basic health care. The first four medical centres were followed by six more by July 1995. The organization and methods of operation of the Grameen Health Programme are based on the tried and tested self‐help principles underlying the loan programme which has been in operation since 1976. The services offered include medical care at reduced fees and free counselling. Target groups are primarily poor women, to whom the programme's women field workers initially give information on simple preventive measures plus advice on avoidance of unwanted pregnancies. This article presents a provisional evaluation based on two primary inquiries conducted in 1994 and 1995. The overall conclusion was that the health programme has still far to go in order to attain the longer‐term objective of becoming self‐financing. Nevertheless, it demonstrates that decentralized access to health services, and preventive healthcare counselling in particular, can be of real assistance to poor people in rural areas.
The socio-economic reforms launched in China in the late 1970s led to rapid economic growth and, with it, health sector resources expanded rapidly. The rural health services have benefited from the policies of economic reform, but not in an optimal way, particularly in poor areas. This article uses a case study of a poor county--Donglan--to illustrate that the fiscal decentralization combined with the financial responsibility system have resulted in a weakening of financing and provision of rural health services in poor areas. The need for health facilities to generate revenue has had unfortunate consequences for the style of medical care, such as over-prescription. In addition, the collapse of the cooperative medical system and the weakening of the three-tier network of rural health care in Donglan have jeopardized preventive programs and threaten access to basic health care for the peasants, especially the poor. The study found evidence that preventive programs have deteriorated over the past years, the poor had financial difficulty in access to services, particularly hospital care, health facilities at township and village levels have been run down, and less training and supervision have been provided by upper-level health facilities. The article concludes with recommendations for a strategy for rebuilding and strengthening the three-tier network of rural health care, and for establishing a cooperative medical and health care scheme to ensure that the majority of peasants in Donglan can be guaranteed access to basic health services. Limited health resources will therefore be better used.
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.
New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost-effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements.
<h3>ABSTRACT</h3> <h3>Introduction:</h3> Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition. <h3>Methods:</h3> We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas. <h3>Findings:</h3> In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level. <h3>Conclusion:</h3> Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.
Over the past twenty years, Thailand has undergone rapid economic and health (demographic, epidemiological) transitions. While on the one hand the economic outlook is bright, even to the extent of Thailand's emerging status as a Newly Industrialized Country, persisting health development challenges remain as targets for future research and international support. This paper documents Thailand's current economic and health development situations, their transitions and challenges. Special reference is made towards emerging post-transitional health/epidemiological problems, reorientation of health services and the referral system, community participation, health care financing, public-private health care partnerships, decentralization of the health service system and essential national health research.
Abstract Papua New Guinea decentralized a wide range of health functions to provincial governments between 1977 and 1983. The national Department of Health (DOH) was given no role in provincial budget and staffing decisions, and the national health budget was fragmented into the health components of provincial budgets. The impact of decentralization on health workforce development was particularly severe and largely unforeseen. Many difficulties were inherent in the manner in which decentralization regulations structured power relationships. Others arose as a result of the administrative confusion and inflamed relationships that accompanied the forceful transfer of power from a very reluctant national DOH to the provinces. Even though policy formulation and planning were retained as national functions, decentralization hampered their effective execution. Human resource data bases deteriorated, responsibility for planning became confused, and the ability of the DOH to implement its planning decisions was compromised. In reality, health workforce planning was carried out by the Departments of Finance and Planning, and Personnel Management through the annual budgetary process of provincial financial limits and staff ceilings, without any attempt to assess health service needs, either in the country as a whole or between the provinces. Decentralization brought a need for new management skills, and it complicated administrative relationships between training institutions and the provinces. The Papua New Guinea experience has shown that in a decentralized health service, there is a great potential for conflict between national goals and the aspirations of individual provinces. To achieve an equitable, appropriate and effective staffing of services, standards must be formulated as the basis for planning and conflict resolution. Effective linkages between central government departments and between the national and provincial health authorities must be developed, and management and technical skills of health managers improved.
The article first proposes a framework within which to assess the potential of health sector reforms in Latin America for primary health care (PHC). Two dimensions are recognized: the scope of the reforms, content, and the means of participation that are put into play. This framework is then complemented through a critique of the often-sought but little-analyzed PHC reform strategies of decentralization and health sector integration. The analytical framework is next directed to the financing of health services, a chief aspect of any reform aiming toward PHC. Two facets of health service finance are first distinguished: its formal aspect as a means for economic subsistence and growth, and its substantive aspect as a means to promote the rational use of services and thus improvement of health. Once finance is understood in this microeconomic perspective, the focus shifts to the analysis of health care reforms at the macro, health policy level. The article concludes by positing that PHC is in essence a new health care paradigm, oriented by the values of universality, redistribution, integration, plurality, quality, and efficiency.