To what extent do the World Health Organization, the World Trade Organization, and the World Bank remain central today and how much influence do they still wield in shaping the global agenda? While several studies have traced the development of various intergovernmental organizations (IGOs), charting their growth and influence in international affairs, and assessing their prospects, few if any have compared IGOs across various fields. This paper aims to fill this gap by taking a closer look at three different policy fields to better understand the current architecture of global governance, the centrality of IGOs, the role of new and other actors, as well as the strengths and weaknesses of this "new" architecture. The authors find that, first, the emergence of new private players has significantly eroded the centrality of IGOs such that the course of global governance in health, trade, and development finance has changed irreversibly. Second, regional arrangements have overtaken global ones and nonstate actors have assumed more prominent roles. Third, this multiplicity of powerful players has led to some positive outcomes but also greater inefficiencies and redundancies. Fourth, developed countries have been pivotal in eroding the centrality of IGOs, but developing countries are taking on a greater role in global governance. Fifth, the new architecture can be described as one of diversification in global health governance, fragmentation in global trade, and variation in multilateral development finance. Global governance in the 21st century is thus characterized by a proliferation of actors and a decentralization of authority, an erosion of IGO centrality accompanied by a greater role for nonstate actors, developing countries, and by increased regionalism. Depending on the sector of governance, its inherent aims, and the nature of the actors involved, the new architecture may be one of variation, fragmentation, or diversification. While this new architecture is complex and might possibly lead to inefficiencies and redundancies, it allows a greater number of actors to participate, making it more representative of the current world order and making it possible to mobilize more resources to promote development.
Introduction According to Canavan et al. [1], results-based financing (RBF) is a method of financing focused on the assumption that linking motivations to the performance would help to improve accessibility, quality and equity in the provision of health services. Blanchett quoted by Canavan et al., [1] argues that its impact would vary
Because of the decentralization of the management of public health and the absence of a reform of its financing, the municipalities started to significantly increase the volume of its own funds invested in this area. In this context, this study aimed to analyze the participation of federal entities - Federal, State and Municipalities - the financing of the Unified Health System (SUS) in the municipalities with 50,000 to 100,000 inhabitants, the Metropolitan Health Region of Campinas, from 2012 to 2014. An integrative literature review and survey data were carried out on the municipalities on the Public Budget using the Health System information. Seven articles were selected and analyzed in full. In relation to the data collected, it was found out that municipalities, state and Union fulfilled what determines the Law n° 141/2012; the three federal entities increased health expenses from one year to another; there was an increase of municipal resources at the local health expenditure and a decrease of Union involvement, and the participation of the State wasnât significant enough. Thus, health financing, by the Union needs to be corrected and should state resources participate in a more significant way, being extremely necessary discussion of new sources of resources to allow more public investment increase in health.
Although there is a burgeoning empirical literature on the rapid growth of health expenditures, there has been little systematic examination of the influence of central government financing behavior. In addition, studies examining the effect of political variables are relatively few and, as they seem to suffer from the omitted variable bias problem, generate improper inferences on health financing dynamics. Moving from this literature, and drawing on recent developments in the coalition governance, as well as researching on fiscal decentralization, in this paper the authors aim to gain insight into the Italian health care financing scenario taking into account the behaviors of government intervention in the sector. Specifically, they analyze regional political fragmentation and competition for effective political power between majority and opposition coalitions and the authors test if the fragmentation of both coalitions is the key variables that determine their effective political power. The authors test their hypothesis in the Italian framework with a new dataset. Data include financial, demographic and political variables. The empirical analysis is conducted with a panel of 15 Italian regions from year 2000 to 2010.
Evidence-informed decision making (EIDM) can optimize health services and systems. EIDM involves defining problems, identifying measures to tackle them, assessing the quality of global and local evidence and translating it for the main stakeholders in line with social values and laws. Brazil encourages the use of EIDM in health policy in Piripiri, a municipality of 61,840 inhabitants in the country's poorest region, and launched Brazil's first Evidence Use in Health Care (NEv) center in 2010. The development and preliminary results of the NEv center are reported and its vision, composition, mandate, and activities are presented. The NEv center experience has the support of the Evidence-Informed Policy Network, the Latin American and Caribbean Center of Information on Health Sciences and federal and municipal governments. The decentralization of financing and the provision of healthcare services, the expansion of EIDM in management, and the local political context illustrate the progress of the experiment. Its activities include the production and dissemination of deliberative briefs and dialogues with opinion shapers, workers and health service users. Monitoring and evaluation are underway and the results will help to broaden the scale of activities in Brazil and abroad.
This article analyzes the process through which WHO was established on the basis of the experience of the League of Nations Health Organization (LNHO). The article particularly focuses on the LNHO technocrats. Through their prewar experiences, technocrats realized that international health governance could promote international cooperation, while it could be utilized by various national representatives as one of their diplomatic strategies. Technocrats tried to alleviate this vulnerability by balancing big powers with smaller powers, national representatives with specialists, and centralization with decentralization. Their efforts and the development of international security in which economic and social cooperation were evaluated as a means towards international security resulted in the international health governance's autonomous establishment under the UN system, which can be termed as the origin of âhuman security.â The development of social cooperation in the postwar period can be considered to be an extension of their efforts in the League of Nations.
Abstract Globally, post-Alma Ata health care system reforms have included reorganization of government health agencies, establishment of rationalized, evidence-based systems of care, implementation of user charges for public services, and experiments with third party financing. Drawing on materials collected in the context of long-term ethnographic research in Mongolia, this chapter reveals that there is a mismatch between the economic rationality that underlies current health reform programs and the realities of the lived experiences of illness in poor communities. Coupled with decentralization and poor regulatory oversight, current health reform efforts can result in fragmentation of the health system, increasing opportunity costs for health care seeking by poor households, reduced access to essential drugs, and an overall increased risk for health-cost related impoverishment. The chapter concludes by arguing that ethnographic information on health care seeking in poor communities can inform health reform efforts through explaining how features of health reform produce health inequities.
Seen from France, this report underlines how far we still have to go in our country to reduce social inequalities in health. France is not one of the partner countries of the Commission1 and the conceptions of health determinants which are developed in the report appear far removed from the paradigm which predominates in our country. We can no longer say that France is at the âpre-contemplativeâ stage:2 data exist, the phenomenon of social inequalities in health is known and well documented for numerous states of health. But these efforts, which issue largely from the world of research, have not resulted in a system of routine statistical surveillance. Furthermore, at this âcontemplativeâ stage, there is no explicit public policy and no objective written down in law. In the law on public health policy of 2004, objective 34 touches on this question, but restricts it to the state of health of the most precarious populations. As stated in the report, reduction of social inequalities in health is above all a political problem, but it is essential to provide evidence. In this respect, the report lends support to those who, in France, think that it is important to continue to increase our knowledge of the subject, but that the most pressing question is how we can move on to the active stage. It is strange to see how our country, always ready to give others lessons on human rights, tolerates a problem as well documented as social inequalities in health. Although the right to optimal health is laid down in a number of texts, this question of social justice and ethics does not mobilize opinion. This is so in France, but also throughout the world. The question thus remains to find out on what basis opinion and the decision makers can be mobilized. Though today it is unfortunately a fragile argument, it seems to us that the ethical imperative put forward in the report must remain central. The fact that the reduction of social inequalities can be a source of economic gain, as shown in a Canadian report,1 is an argument to be developed in order to remove economic objections, but it cannot be the central argument for mobilization. This report may well enjoy less popularity in France than a previous WHO report.3 In its World Health Report 2000, the World Health Organisation had no hesitation in describing the French health system as one of the best in the world. In that report, the conception of health determinants was in line with the prevailing conception in France. The health system was described as being the essential factor of the good health of a country. âIf Sweden enjoys better health than Ugandaâlife expectancy is almost exactly twice as longâit is in large part because it spends exactly 35 times as much per capita in its health systems.â3 On the basis of this analysis, since 1945 France has enjoyed a system of social protection which proclaims, among its objectives, the improvement of the population's level of health. Within this system of social protection, the general health insurance system, completed by specific schemes for the poorest among the population, should allow widespread access to health care. The number of French people who have the benefit of insurance against ill health has constantly increased over the years and now almost the entire population is covered. In 2002, according to the Health and Social Protection survey, 91% of residents in France also had complementary coverage.4 At the same time, the mortality statistics remind us that in this country social inequalities in health are particularly marked in comparison with our European neighbours. This apparent paradox calls into question such a conception of health. The 2008 report puts the determinants back into perspective in a most useful way. On a world-wide scale, access to drinking water, to a diet which prevents malnutrition, protection against the vagaries of the climate are the major decisive factors in social inequalities in health. In line with this analysis, the report emphasizes actions which target determinants outside the health system and the need for a coherent policy in order to achieve health equity. A large number of spheres are involved, some of which seem a priori far removed from health: these are not only education, but also access to employment, working conditions, the age of retirement, the housing policy and lastly policies of redistribution, through taxation and direct financial aid. These are all relevant to social inequalities in health in France. The impact of investments concerning children at the very start of life and young people, in particular relating to education and training, is strongly pertinent to social inequalities in health, especially because of the links between education, qualification and health later in life. The role of unemployment and working conditions1 and of housing and transports are emphasized. In agreement with studies which have shown the protective influence of social networks and social support, and the role that a sense of control over one's life can play, citizens are encouraged to participate actively in decisions related to healthâand this theme is a far-reaching one. Behaviour change is not mediated only by individual approaches to health education. The prices of food products, the industrial processing of foods, institutional catering, advertising, legislative measures and regulations are all paths to be explored. We must thus be delighted that the report stresses the intersectoral aspect of the fight against social inequalities in health, as this is a key issue. For example, the report points out the contradictions which were observed in certain Northern European countries when the common agricultural policy of the European Union came to thwart the efforts of the health authorities, themselves supported by the government.5 It thus will help to promote an intersectoral approach to health, at a national and at a European level, a choice which involves fundamental policy choices. For example, the increase in precarious employment, obligatorily part-time work, poorly paid jobs and their detrimental effects clearly shows that what is at stake here is the choice between a potential political determination and the predominantly economic (and short term) approach which is that of the liberal ideology. Just as for the issue of climate change, the fight against social inequalities in health is clearly revealed here as a global combat implying a choice of development strategy. Measurement and surveillance are one dimension of the solution. With the partial exception of death certificates and of a longitudinal survey of mortality based on the Permanent Demographic Sample, in France social characteristics are ignored by nearly all routine statistics, whether hospital information systems, health insurance data or registers of specific diseases. The data produced by research studies, generally based on one-off surveys or at best surveys repeated every few years, do not allow us to grasp changes in inequalities over time. The proposals for a minimum statistic system and a system which covers social determinants are important and should be developed in France. The information systems of healthcare institutions, starting with those of hospitals, are silent as to the social situation of those who use them, and this evidently restricts their ability to adapt their services to the needs of these persons. Naturally, the report does not elude the question of healthcare and advocates universal access to quality care. At a time when health expenditure is strictly limited, it is important to examine the question of patientsâ share in these expenses and its effects on care consumption and health in the light of health inequalities. The Rand Corporation study,6 carried out in the 1970s in a sample of American families, followed for 3â5 years and randomly assigned to health insurance plans which differed by levels of reimbursement and the share to be paid by the household, is still topical. The conclusions of this randomized study showed that the amount of care consumed decreased markedly as soon as >25% of the cost was borne by the patient. No difference in state of health was observed in the population as a whole. But the impact of the cost to be borne made itself felt as soon as the poor population was concerned. It is interesting to point out that the share borne by the patient in France has been around 25% during the last 20 years, a proportion which has tended to increase. But the tendency in France is to increase the participation of households in health expenses, including (particularly) persons who are in a precarious situation because of their state of health, with in due course an impact on social inequalities in health. The report stresses the need for health systems to be proactive. Taking the need for proactivity into account is particularly pertinent in France, where the system is still widely based on a logic of offer. Issues related to secondary access to care are somewhat briefly dealt with in the report, which is strongly centred on primary access. But to ensure that this first phase is well organized is not sufficient if the system is ineffective in other respects, or if its malfunctions concern mainly the most disadvantaged patients.7 The report suggests that the role of the healthcare system goes beyond the treatment of diseases. Physicians and the other health professionals are leaders of opinion, who influence conceptions and representations of health. Finally, this is where analysis of health determinants is put together and where the directions taken by public health and research are given value. This last remark underlines the importance of giving professionals training on social determinants of health. Their commitment is undoubtedly essential to negotiate the turn towards less biological or medicinal concepts of health. The way in which behaviours are conceptualized in fact determines the way in which they will be taken into account by public health. In agreement with what we have said above, the presentation in the report of the aims of research in public health is particularly pertinent: research on the causes of social inequalities in health, on interventions aiming to reduce them, analysis of public policies and lastly statistical measurement and surveillance. In view of the issues at stake and of the nature of the determinants, research on health should be more interdisciplinary and should integrate social determinants. Redressing the balance towards these objectives should enhance their value, unlike a primarily biological or disease-oriented approach. The complexity of the interventions and so of the methods used to evaluate them justifies not only the interdisciplinary approach, but also a reflection on the notion of proof. Going beyond randomized trials, the question is how to make use of qualitative as well as quantitative data. Evaluation of interventions and strategies to reduce social inequalities in health raises a difficult problem, particularly when these are interventions of a structural type or which aim at long-term modifications. Assessing a research programme carried out in the Netherlands on social inequalities in health, it was found that the interventions subsidized by the programme had been specific, targeted interventions that were easy to evaluate. The projects evaluated were all of this type, to the exclusion of any wide ranging, far-reaching public policy.8 The causes of inequalities are multiple, and several levels of explanation coexist, proximal and fundamental causes. We pay tribute to the very ambitious nature of this report, which runs counter to the policies of international bodies (WTO) and so underlines the most fundamental causes of health inequalities. The main messages of the report are all the more essential as the financial and economic crisis may worsen inequalities by affecting the weakest first. Can health be the theme to mobilize us towards humane objectives, not only economic ones? The report stresses that the sector of health and healthcare professionals, including the minister or ministers responsible, could take position as defenders of wide societal objectives giving health and health equality their rightful place as a marker of progress. This supposes that professionals and politicians become aware of the importance of social determinants of health. This task is a particularly important one in France, and it is without doubt one of our primary challenges.
I wanted to like this book, and tried hard, but ultimately failed. I have recently written several papers on inappropriate corporate influences on the funding and conduct of epidemiological research, and have discussed several examples of hazards where the epidemiologic findings were strongly, and unethically, opposed by industry and by academic epidemiologists funded by industry.1â3 This book provides âthe other side of the coinâ and discusses in depth four examples (environmental causes of breast cancer, electromagnetic fields and cancer, residential radon exposure and lung cancer and passive smoking) where, in the author's opinion, the health risks were low or non-existent, but were hyped by researchers and policy makers thus resulting in unnecessary research, inappropriate funding decisions and unjustified public concern. Such things certainly happen, and we need books like this which attempt to discuss them objectively, and which point out that academic researchers may also be affected by a range of influences including career and funding opportunities, even if they only accept peer-reviewed government funding and do not accept corporate funding. Thus, they may have incentives to overstate the evidence, just as industry and industry-funded epidemiologists may have incentives to negate or understate the evidence of health risks from environmental exposures. The book states its case well, is clearly written and discusses complicated issues in a relatively simple and readable way. It makes the case that âeach side tends to cite the evidence that supports its point of view in order to influence public policyâ (p. 6) and that âthe tendency to overstate the evidence, for whatever purpose, actually strengthens the opposing party's hand. It sanctions the partisan use of science that should be rejected, no matter who is engaging in it.â (p. 7) The book also makes the important points that: (i) we have to some extent reached the limits of ârisk factorâ epidemiology and have identified the strong risks (e.g. active smoking and lung cancer) and are now trying to assess weak risks (e.g. passive smoking and lung cancer), which are much more difficult to assess and much more prone to be overwhelmed by bias; (ii) for many of these risks (e.g. residential radon exposure and lung cancer) it is not possible to directly estimate the risks from low exposures, and it is necessary to make theoretical assumptions to interpolate from the findings of studies of highly exposed occupational populations (e.g. miners exposed to radon); and (iii) many of these risks are very small and have received perhaps excessive funding and scientific attention in comparison with other public health risks. So far so good. I agree with all of the above statements, and started reading the book in a positive frame of mind, with the expectation that it was an important book that would be an essential antidote to the writings of myself and others who have tended to emphasize the hazards of corporate influences. However, I became more frustrated and less impressed as I worked my way through the book, particularly when coming to discussions of issues that I had been involved in (e.g. electromagnetic fields and cancer). This probably reflects my own influences and prejudices. However, it became increasingly difficult, as I worked my way through the book, to avoid the conclusion that the discussions of these issues were, for want of a better word, âbiasedâ, as well as being rather âgrumpyâ and unpleasant in parts. It seems that no one can get it right. No single study is good enough or big enough, but meta-analyses should be discouraged because they combine studies from different exposure settings and with different methodologies. Researchers are criticized for arguing that âone must rely upon the evaluation of the data as a whole using expert judgement and the meta-analyses as a guideâ (p. 101), because this simply reflects their vested interests to continue researching a topic when an individual study is inconclusive. The findings of individual studies are dismissed because they are ânot statistically significantâ, even if they are consistent with previous findings. Significant associations are dismissed because they involved multiple comparisons, even if the specific associations were the a priori reason for the study and had been found previously [e.g. âthe reported association [of EMFs with childhood] leukaemia was one of a very large number of comparisons made by the researchers and hence could well have arisen by chanceâ (p. 100)]. Studies that show interesting dose-response associations verging on statistical significance, such as the National Cancer Institute childhood leukaemia study,4 are not only dismissed, but also researchers are condemned for not accepting the findings as proof of lack of risk (âit is hard to escape the impression that the reluctance of the NIEHS working group to close the door on the possibility of EMF as a cause of leukaemia had more to do with its membersâ stake in this area of research than with scientific rigorâ (p. 101). While every academic researcher who wants to study these issues apparently has a vested interest, even if their university salary is already funded, critics of the research are apparently unbiased, reasonable and objective, even if their criticisms are directly or indirectly funded by industry. Researchers into radon and lung cancer are biased because they do not repeatedly emphasize that tobacco smoking is the major cause of lung cancer, and that most cases of radon-induced lung cancer involve joint effects with smoking (the corollary that some cases of lung cancer in smokers are due to joint effects with radon exposure is never mentioned, nor is it mentioned that the same arguments could be applied to many other important lung carcinogens such as asbestos). The book gives particular emphasis to issues of biological plausibility, even though there are many historical examples of associations that were not biologically plausible when they were first discovered by epidemiologists, and the aetiological mechanisms involved were only subsequently discovered in laboratory-based studies. This is why, for example, all of the 30â40 known occupational causes of cancer (as classified by the International Agency for Research on Cancer) were first discovered in epidemiological studies, not in the laboratory. If it had been plausible that these substances caused cancer, then they would not have been used in the workplace. So epidemiology will always be in front of mechanistic research with regards to discovering new environmental and occupational causes of disease. The book also fails to mention that there are many historical examples of risks (dioxin and cancer is one example) where the evidence was initially weak and inconsistent but has strengthened over time (leading to the classification of dioxin as a carcinogen by the International Agency for Research on Cancer in 1997). So what are we supposed to do about ubiquitous environmental exposures that may carry weak risks, but which may account for a substantial number of cases of disease on a population level? Kabat's solution is nihilistic, namely that we simply should not study such exposures, or at least not attempt to quantify their effects: âit is entirely plausible that in some cases exposure to ETS may account for a few cases of lung cancer in nonsmokers, but ⊠it is not possible to quantify the excess risk with any certaintyâ (p. 150). The argument is essentially that the risks are too small to quantify accurately, and therefore should not be studied, or at least should not be estimated quantitatively. We are never told how we should decide if a risk is too âsmallâ to be concerned about if we do not first attempt to estimate its magnitude. And how are we supposed to tell the public that the risks are small (and their concerns are unimportant) without attempting to estimate them? And who decides what is a âsmallâ risk? The book finishes, literally on the last page, by advocating a âbroader/integrative vision of epidemiologyâone that can accommodate social, economic, and ecological/environmental realities ⊠as well as rapidly evolving knowledge of the mechanisms of disease at the molecular levelâ (p. 186).5â8 Such developments are to be encouraged, but they are intended to be inclusive, not exclusive, and we will have to continue to grapple with problems of studying weak risks from ubiquitous environmental exposures, even if they receive less attention than they have in the past. It is important to consider the influences on such research, including influences on academic researchers with regards to career opportunities and funding, even though these will continue to be relatively minor compared with the massive and pervasive influences of corporate funding of research and of critics of research.1â3 This book could have made a major contribution in this regard, but its lack of balance means that it fails to make such a contribution.
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). âŠ
Since the 1980s, neoliberal policies have prescribed reducing the role of governments, relying on market forces to organize and provide health care and other vital human services. In this context, international trade agreements increasingly serve as mechanisms to enforce the privatization, deregulation, and decentralization of health care and other services, with important implications for democracy as well as for health. Critics contend that social austerity and "free" trade agreements contribute to the rise in global poverty and economic inequality and instability, and therefore to increased preventable illness and death. Under new agreements through the World Trade Organization that cover vital human services such as health care, water, education, and energy, unaccountable, secret trade tribunals could overrule decisions by democratically elected officials on public financing for national health care systems, licensing and training standards for health professionals, patient safety and quality regulations, occupational safety and health, control of hazardous substances such as tobacco and alcohol, the environment, and affordable access to safe water and sanitation. International negotiations in 2003 in Cancun and in Miami suggested that countervailing views are developing momentum. A concerned health care community has begun to call for a moratorium on trade negotiations on health care and water, and to reinvigorate an alternative vision of universal access to vital services.
While Washington has been unable to lead the way in significant health care reform, the health care system has begun to transform itself in terms of curbing skyrocketing health care costs, dealing with the more than forty million Americans who lack health care coverage, and the problems plaguing the Medicare and Medicaid systems. The search has begun for a health care model that ensures quality care to a wide population in a cost-efficient manner. This article explores how the U.S. Health care system currently functions, examines several innovative models, and suggests ways in which a decentralized, community-based approach to health care reform can address our nationâs health care crisis. Specifically, Part I examines the current system of health care financing. Part II discusses current efforts to provide community based care. Part III offers suggestions for a community-based approach to health care reform, including ways to stimulate provider volunteerism, financing mechanisms, and methods to overcome potential legal barriers to local reform efforts.
Open access
Health Systems, Economic Evaluations, Quality of Life
This article discusses some needed changes to the functioning and management of the World Health Organization (WHO). WHO is unable to meet new challenges and needs reform. The Executive Board of WHO initiated an internal review in 1992 that led to a management-related focus, while informal groups within the agency tackled funding constraints. Some governments and nongovernmental groups have proposed reorganization of international health assistance. The authors urge that the public health sector and researchers join the reform effort. WHO was established in 1948 and was the sole global health agency. The demand for greater international health cooperation has increased over time. WHO is an association of sovereign states. WHO demonstrated success in eliminating smallpox, promotion of health policy, collection and dissemination of epidemiologic information, and establishment of standards in health care and medical ethics. WHO staff comprises about 5000 persons. The annual budget is too small at about US$900 million. In 1995 only 56% of receipts were collected. WHO's constitution mandates complete health for all, but there has been a widening gap between rich and poor and those with access to health services and those without. Absolute and relative poverty are the main determinants of premature mortality and ill health. The major challenge for health policy is this disparity; the focus of international collaboration should be on this issue. The machine metaphor of organizational structure no longer works in today's world. The authors propose that WHO limit functions in health development and create a full mandate for dealing with determinants of health. WHO should be participatory, open to constituents, autonomous, and flexible. Member states must be more powerful in policy formulation. Program implementation should occur in independent programs in a decentralized system.
<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.
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.