Since 1978, China's economic reforms and her pursuit of modern technology have significantly opened the scope of her hospital services and financing. While the decentralization and higher incomes have given Chinese hospitals new freedoms, they have also raised the specter of new limitations on access to healthcare. The authors review these changes and consider what the future holds for the Chinese hospital system.
Thailand has a long history of primary health care (PHC) development which started before the Declaration of Alma Ata in 1978. The National PHC programme was implemented nation-wide as part of the Fourth National Health Development Plan (1977–1981) focusing on the training of ‘grass-root’ PHC workers consisting of village health communicators and village health volunteers. Since then PHC has evolved through many innovative health activities: community organization, community self-financing and management, the restructuring of the health system and multisectoral co-ordination. Many of the essential elements of PHC have been achieved. Improvements in the nutritional status of children under five households accessiblity to clean water, immunization coverage, and the availablity of essential drugs have been observed. PHC has been successful in Thailand because of community involvement in health, collaboration between govermment and non-govermment organizations, the integration of the PHC programme, the decentralization of planning and management, intersectors collaboration at operational levels, resource allocation in favour of PHC, the management and continuous supervision of the PHC programme from the national down to the district level, and the horizontal teaining of villagers to villagers.
Abstract Thailand's public health system is in transition, reflecting the economic status of the country. The decentralized system has made great strides in improving the health of its people. But paradoxes exist. While some urban areas have an oversupply of CT Scanners, rural villages still cope with hygiene‐related illnesses. Malaria and Yellow Fever no longer dominate health resources. Now AIDs, heart disease and accidents top the problem list. Like other countries, Thailand also struggles with health financing to address the unmet needs.
Miguel Ángel González-Block, René Leyva Flores, OSCAR ZAP ATA, Ricardo Loewe · 5 authors
This article provides a critique of decentralization of health care systems in underdeveloped countries, taking the Mexican case as an example. The formulation, implementation and interruption of integrative decentralization in the 1980s is analysed in the context of the interests served in Mexico by administrative centralization and institutional fragmentation. The short-term results of decentralization upon state-level politics, finance, planning and health service distribution and equity are analysed in their relationship to bureaucratic and political interests. Initially the most underdeveloped region of the country was selected for a special comparative study of the effects of decentralization upon health service planning and equity. One state of this region became decentralized, while the other underwent only minor changes. It was therefore possible to compare the specific effects of administrative changes in the two states. Decentralization was interrupted at the national level, with only 14 states actually undergoing administrative change. The policy was also short of its devolutionary intentions, actually becoming an attempt towards recentralizing power around a different administrative structure. Regional disparities in the distribution of health services were accentuated due to the privileges furthered by decentralization in the richer municipalities, and the fall in services in the poorer ones related to interinstitutional conflicts at the central level
World Bank publications have a large influence on the decisions of governments. This article analyzes the publication "Financing Health Services in Developing Countries: An Agenda for Reform" part of the World Bank Policy Studies series. This study assesses only peripheral reasons for the lack of public and private financial investments in health services. It does not include the result of economic recession, budget cutbacks, and poverty on financing systems. There has been excessive expenditure on luxury in health institutions which takes considerable finances from disease prevention and health promotion services. There is low demand for private services because of the high cost, but public health services sometimes lack tools and money necessary for adequate care. The study does not address the relationship between needs and demand and the supply of health services. It outlines "4 Policy Reforms" in which the aims are to increase to cost of curative services and to use the additional money for prevention. The World Bank favors using private sector services but does not seem to view decentralization of health care as important. Social security systems have been in place in Latin America for 63 years. These systems are funded by wage earners and do not cover lower income rural citizens. Chile was the 1st country to adopt compulsory insurance in 1924 for catastrophes and diseases. The Chilean National Health Service combines institutional and community resources to provide quality health care. Social insurance and other prepayment systems are the rational approaches for financing health care in the Americas. These systems should be based on contributions by the State, employers, and urban and rural workers. There is a need for fund redistribution from institutional curative care to community preventative care. Health care costs should reflect income proportionally. The World Bank contributes vital analysis to the problem of health service financing. Hopefully American governments will recognize the need for health care reform.
To better understand and implement the extensive World Bank study on the financing of health, this limited article was enjoined to discuss salient features of the study and their potential for implementation. With technology for diagnosis and treatment driving health costs up, we are left with still affordable and all around more effective programs on protection and prevention that would be more cost- and health effective in a world where financial health resources are static or being cut back. Health programs and hospitals are generally inefficient with an underutilization of peripheral services. A redesign of integration systems is discussed. 4 policy reforms do, in effect, constitute a positive and feasible agenda. All of these policies will require great political commitment for their unpopularity. 1st, charging users of health services except those truly unable to pay is deemed more just. 2nd, provisions of insurance or other risk coverage (e.g. social security) need expansion. 3rd, effective use of nongovernment resources, the most vague policy reform, is discussed in terms of its implementation. 4th, decentralization of government health services is a prerequisite for achieving significant reform in financing the services. The main point of the World Bank study is active community participation which stops the paternalistic government-mendicant demanding populace pathology that is common today. A special study is suggested which would involve the World Bank and other internal organizations in analyzing the financial and technical support furnished to strengthen, endorse, and empower the reform policies.
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.
Brotowasisto, Oscar Gish, Ridwan Malik, Paramita Sudharto
This paper describes health care financing and expenditures in Indonesia, a developing country spending around $US 9.40 per capita annually for health care (2.6% of GOP). Per capita health care spending has held constant in real terms over the last five years. The public sector accounts for 36.8% of all health care expenditure, or 43.1% if health care spending by state enterprises is included. About 13% of the population, almost all of them government employees and their families, are covered by some form of health insurance. In 1984, 62% of the population was spending privately – at then current exchange rates – an average of $US 2.70 per capita annually for health care, another 30% averaged $US 8.35 each, and the upper 9% $US 31.90. The Government is reviewing various ‘social financing’ mechanisms with a view to expanding health insurance coverage both for those in formal wage employment and the bulk of the population which remains either on the land or is part of the ‘informal’ sector. Steps are also being taken to increase the efficient use of resources by, among other things, making greater use of evaluation techniques and economic methodologies. Such efforts are coupled with more decentralized authority being given to the provinces and districts. Particularly important to future health efforts is the further expansion of community-based activities, especially in the form of the Posyandu (integrated health post).
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.
Gail Henderson, Yuanli Liu, Xiaoming Guan, Zongxiu Liu
Chinese hospitals in the 1980s are in the midst of a technological revolution. Based upon data from several regions in China, this paper describes the political, organizational, economic, and philosophical changes which have accompanied the shift in focus from primary care medicine to high technology tertiary care. The increased authority of physicians, greater contact with the West, and increased funding for medical equipment are key factors in these changes. Although the Chinese state continues to control the administration and financing of most hospitals, the decentralizing reforms of Deng Xiaoping have undermined its ability to effectively plan for, and assess new technology. At present, limited resources prevent most regions from excessive technology acquisition, but the state must rebuild its planning capacity in order to foster rational allocation of scarce medical resources.
A Health Sector Financing and Expenditure (HSFE) survey was conducted in Swaziland against a background of growing concern about resource constraints on policy implementation. It sought to provide basic financial information which could be used when discussing policy options for addressing these constraints. Under a wide definition of the health sector, expenditure in 1984/85 was found to be equivalent to 9.8% of GDP and E73 ($US35) per capita. Recurrent expenditure dominated sectoral expenditure, at 86.7% of the total; 57% of recurrent expenditure was for primary health care (PHC) activities, but only 17.9% for the core preventive programmes which the policy emphasizes. Moreover, the Ministry of Health's own expenditure was biased in favour of curative care. Out-of-pocket payments largely supported general PHC activities and the core programmes were predominantly funded by foreign aid. Policy calls for increased PHC funding, therefore, are justified on the grounds of existing inappropriate allocations. If this is to be achieved there must be improved efficiency of resource use within services and improved coordination with other sources of finance in the sector. It is especially important to address efficiency issues within the Ministry. Particular attention should be paid to strengthening the role and effectiveness of decentralized management structures in resource allocation. The Ministry should also address concerns about the quality of care provided by its services, especially the poor availability of drugs. Increased PHC funding may, further, be made possible through the recruitment of additional finance. More discussion of alternative financing arrangements is necessary, but their efficacy may be dependent on improving the quality of care provided within public facilities.
Abstract Rural development activities are frequently more important than isolated health care interventions in maximizing improvements in rural health status. In addition, integrated socio-economic development of rural areas ensures availability of local resources to finance health schemes, encourages community involvement in development and reforms and strengthens management capacity for health programme implementation and development. Public health services provide in turn an entry point for directly productive development activities. In designing, implementing and operating health components of rural development projects in developing countries, the most serious obstacles are almost invariably the following: (i) how to strengthen the managerial capacity of the health administration from the national to the local level and how to execute integrated programmes through decentralized and uncoordinated agencies; (ii) how to ensure adequate recurrent cost financing and contribution of beneficiaries to operating cost; and (iii) how to achieve active involvement of rural communities in decision-making and services delivery when projects are large and planned and executed by government authorities. In discussing these issues the paper will cite the World Bank’s experiences in a number of African, Asian and Latin American countries.
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.