Blockchain Papers

Calum Thomson, Russell Beale

No abstract is available for this record.

Federico Toth

The purpose of this chapter is to reflect on the main trajectories of change that have characterized the health systems of OECD countries in the last three decades, from the fall of the Berlin Wall to the present day. For this purpose, it is possible to identify five major "reform themes" which traveled transversally through countries generating processes of emulation and policy transfer. The five major reform themes are as follows: (1) stimulation of greater competition; (2) promotion of integration (both in terms of financing and provision); (3) decentralization; (4) strengthening the rights of the patient; (5) extension of insurance coverage. For most of these five themes it is possible to identify a reform that has acted as a forerunner, which other countries have subsequently been inspired by and followed.

Eline Aas, Tor Iversen, Oddvar Kaarbøe

Abstract The Norwegian health care system is semi-decentralized. Primary care and long-term care (LTC) are the responsibilities of the municipalities. Specialist care is the responsibility of the central government and is organised through four Regional Health Authorities (RHA). Resource use, health outcomes and severity are the three main pillars for priority setting, regularly applied in reimbursement decisions for pharmaceuticals. The sustainability of health care is challenged in Norway. The main factors are a growing elderly population with high need of complex, coordinated services, an increasing demand for newly approved drugs and advanced technology and a potential shortage of health care personnel. We present recent trials and policy reforms in Norway aimed at improving care pathways combined with cost containment. Reforms in the pharmaceutical market, both with regard to market access and reimbursement (cost-effectiveness), and regulation of prices, have resulted in cost containment. The primary care sector awaits reform initiatives to recruit and retain physicians as general practitioners. No reform in the hospital sector has had cost containment as a main focus. The sector is characterized with low productivity growth, and expenditures that have increased more than the GDP growth. Waiting times are long, and coordination between sub-sectors of health care has been poor, although the Coordination reform of 2012 has alleviated some of the challenges related to intersectoral coordination. Still, the divided responsibility for health care between the central government and the municipalities creates tensions between national ambitions and local decisions in the financing and provision of health services.

Catherine L. Mavroudis, Jason Tong, Rachel R. Kelz

The cost of surgical care is a substantial part of the rising costs of healthcare in the United States: an operation performed in this country costs 1 to 1.5 times more than that in other countries. The total cost of surgical care in the United States constitutes approximately half of inpatient costs, though only a third of inpatient volume.1–3 This multifactorial problem may be in part due to the pseudo-competitive market for healthcare delivery in the United States, in which the supply and demand curves are distorted by regionalization and payer mix. In response to these pressures, health system formation has increased dramatically in the past decade4 with an unclear impact on surgical value. To date, the true effect of health system formation remains undetermined. Proponents have suggested that health systems are able to spread evidence-based protocols and quality improvement initiatives across all hospitals within a given system. This would further improve both outcomes and efficiency through financial and intellectual economies of scale, and thereby improve value.5 Opponents have raised concerns that system expansion poses risks to patient safety due to inadequately supported changes in infrastructure, staffing, and patient population.6 In practice, not all health systems provide an equal opportunity to improve the value of surgical care. At one extreme, a large, geographically disparate system with hospitals scattered across the country may be able to realize the financial benefits of large-scale supply-chain sourcing, but is unlikely to be able to concentrate complex surgical volume in order for patients to realize potential clinical benefits of operating at scale. On the other hand, a smaller network of hospitals within a single region may be well-suited towards building a hub-and-spoke operative referral network, with resources concentrated on bringing patients to the best surgical infrastructure in one central hospital. Unfortunately, it is also more likely to have the advantage in contract negotiations with payers, thus driving up the cost of care and potentially limiting access for patients due to payer mix. Until we have a clear understanding of what it means to be a health system, we will not be able to evaluate the value of health system formation in surgery. To demonstrate the wide variation in system structure, we present the following case series of health systems in the United States. Using the American Hospital Association (AHA) annual survey dataset,7 we identified 413 systems that contained at least one surgical hospital, defined for this purpose as a hospital with at least 3 operating rooms. We generated multiple random two-percent samples. In studying both hospital and system characteristics, we found few similarities across systems, resulting in significant differences across samples. Two such samples can be seen in Table 1. In the first, we see that system size ranged from two to 27 hospitals. Six out of 7 health systems were in one state, while one 27-hospital system was spread across 14 states. Five systems contained hospitals of at least two different bed-size categories (eg, small and medium), while two contained only small hospitals. Three systems had at least one hospital that was a designated trauma center; five had at least one academic medical center. Four health systems were defined as “independent” system clusters by the AHA, which are “largely horizontal affiliations of autonomous hospitals,” while three were “centralized,” with centrally organized hospital services, physician arrangements, and insurance products.7 The second sample highlights the individuality of each system. These random samples of health systems demonstrate wide variation across the characteristics studied, with more observed differences than discernable similarities. TABLE 1 - A Case Series of Health System Characteristics Among 2 Random Samples of Health Systems in the United States Sample 1 System ID A B C D E F G H No. of hospitals 4 6 27 6 2 2 2 7 No. of states in system 1 1 14 1 1 1 1 1 Bed size category Small (<100 beds) 1 0 25 5 0 2 2 5 Medium (100–299 beds) 2 3 2 1 1 0 0 2 Large (≥300 beds) 1 3 0 0 1 0 0 0 No. of trauma center hospitals 0 2 0 0 1 0 0 4 No. of academic medical center hospitals 3 4 2 0 2 0 0 2 System cluster Ind. Cent. Ind. Ind. Cent. Unk. Ind. Cent. Sample 2 System ID I C J K L M N O No. of hospitals 104 27 2 6 2 73 2 32 No. of states in system 16 14 2 1 1 18 1 4 Bed size category Small (<100 beds) 56 25 2 4 1 29 2 26 Medium (100–299 beds) 25 2 0 1 1 22 0 5 Large (≥300 beds) 23 0 0 1 0 22 0 1 No. of trauma center hospitals 45 0 0 0 1 32 2 14 No. of academic medical center hospitals 40 2 0 0 0 35 1 3 System cluster Dec. Ind. Unk. Ind. Ind. Dec. Ind. Dec. (1) System Clusters: Ind., Independent, Cent., Centralized, Dec., Decentralized, Unk. = Unknown/Missing.(2) Due to random chance, system C was included in both samples. Our findings suggest that system designation does not confer information about hospital structure or the role of each hospital within the system. The heterogeneity of health system structure implies substantial differences in the organization of healthcare delivery across systems. The structure of health systems must be better characterized before their value—or lack thereof—can be determined. In order to do this, as a health services research community, we must develop a cohesive scientific taxonomy analogous to that which exists for cell biology—understanding each organelle, its role within the cell, and that cell's role in maintaining the vitality of a larger organism. The interactions between patients, hospitals, and health systems are no less complex, and the ramifications for the future of our health system are significant. Delineating the characteristics of health systems that confer optimal conditions for high-value care will enable the construction of health systems that maximize the value of healthcare for the patient, payer, and provider. Systems must be accountable to their outcomes to deliver on the promise of improved healthcare delivery, as they enjoy financial privileges associated with the business relationships between entities. Although our examples are focused on surgery and in-hospital care, these principles can be applied across the breadth of medicine. By doing so, we may be able to see substantial gains in the value of care delivery across the United States.

Alexandra Pintea, Razvan Dorel Pauna, Paul Lazar

This empirical study addresses the role of economic and institutional determinants on population health, estimated by life expectancy and accessibility to good quality medical services. Several national health systems are described descriptively and analytically. The practical application considers 30 European countries for which data on all necessary variables are available. The data are provided by international institutions such as the World Bank, Insurance Europe, Global Health Security and national institutions from the sampled countries. The results of the OLS cross-country regressions clearly demonstrate the positive role of health financing and the decentralization of the national health system. Instead, the role of private health insurance remains debatable, as does its complementarity or substitutability in relation to public funding. Based on the main results, recommendations are formulated regarding possible adjustments for an increased efficiency of the medical system and possible future research directions, especially regarding the role of the financing structure and the type of decentralization of the medical services.

Marcelo Orías, Guillermo Javier Rosa Díez

Introduction Argentina is the third most populated country in South America with an estimated population of 44,494,502. Despite having an area of 2,780,400 km2 (eighth largest in the world), 90% of the population resides in urban areas, with the majority concentrated in and around Buenos Aires. Life expectancy is 79.7 years in women and 73.6 years in men, with cardiovascular disease as the leading cause of mortality. Argentina spends approximately 10% of its gross domestic product on health care (1). There are 3.94 physicians and 4.5 hospital beds per 1000 inhabitants in Argentina (2). The physician-patient ratio is similar to that of Australia, Italy, Spain, and Switzerland, and is double than Brazil and almost four times than Chile and Peru. Argentina has a multitiered, decentralized health care system that is plagued by fragmented management and financing. There are national, provincial, and municipal government–sponsored health care insurances, which together with union-sponsored insurances, provide health care coverage to nearly 22 million people. An additional approximately 10% of the population has private health insurance, leaving nearly 36% of the population without health care coverage or the financial means to pay for private insurance. These individuals are cared for at cost-free public hospitals and community facilities (1,2). The first hemodialysis (HD) treatment in Argentina dates back to 1955. Five years later in 1960, the Argentine Society of Nephrology was founded (3). Epidemiology The incidence and prevalence of CKD and ESKD have been growing steadily, most likely because of increasing rates of diabetes and obesity as well as an aging population. Indeed, CKD is now the seventh leading cause of mortality in Argentina, and CKD-related deaths have increased by 15% between 2007 and 2017 (4). The National Transplantation Institute (INCUCAI) supports a National Dialysis and Transplant Registry (5,6). Patient reporting is obligatory; therefore, national data are valid and representative. Reporting is the responsibility of the dialysis center director, and it is provided online. Patient identity is preserved by data security systems. The annual incidence of ESKD is 160 patients per million population, with diabetes and hypertension as the most common etiologies (Table 1). At the end of 2018, there were 29,929 patients with ESKD on chronic dialysis, representing a prevalence rate of 673 patients per million population (Figure 1) (5,6). Of these, approximately 93.5% are on in-center HD, 6.5% on peritoneal dialysis (PD), and none are on home HD. Of the patients on HD, 70% receive dialysis via an arteriovenous fistula, 15% receive dialysis via an arteriovenous graft, and 15% receive dialysis via central venous catheters. First year and annual mortality rates on dialysis are 18% and 16.4%, respectively (Table 1), with cardiovascular cause being the most common (6). Annual mortality rate has been above 16% for the last 4 years (Figure 2). RRT in Argentina has incidence and prevalence rates above the mean for Latin America, most likely because dialysis and transplant are readily available in the country (Table 2). Nevertheless, PD is relatively less used compared with the rest of Latin America (7–9). Table 1. - Characteristics of patients on dialysis in Argentina Characteristic Value Country population 44,494,502 Patients on hemodialysis 29,929 Patients on peritoneal dialysis 1945 Patients with functioning kidney transplant 11,486 Prevalence of hepatitis B, % 0.2 Prevalence of hepatitis C, % 1 Prevalence of HIV, % 0.8 Prevalence of diabetes, % 28 Membrane dialyzer (reuse), synthetic/substituted cellulose/cellulose, % 83/14/4 Type of vascular access, native AVF/prosthetic AVF/catheter 70/15/15 Prevalence of patients with ESA, % 87 No. of hemodialysis centers 597 Hospital-based dialysis units, % 25 Nonprofit dialysis units, % 11 No. of peritoneal dialysis centers 79 Dialysis covered by insurance, % 100 Out-of-pocket expenses, % 0 Dialysis unit staffing, nurses/technicians, % 95/5 Payment per hemodialysis session, USD 55 Patient-nurse ratio in hemodialysis units, adult/pediatric 4–5/2–3 Average length of dialysis session, h 4 Minimum patient evaluation by physician per mo 4 No. of transplant centers 55 Adjusted annual mortality dialysis rate, % 16.48 Etiology of ESKD, % Diabetes 36.5 Nephroangiosclerosis 20 Unknown cause 17 GN 9 Myeloma and amyloidosis 1 Obstructive uropathy 6 Polycystic kidney disease, adult type 5 Epidemic uremic hemolytic syndrome 0.5 Other 5 Cause of death, % Cardiovascular 50 Infection 25 Neoplasia 6 Other 19 Source: Argentinean Registry of Dialysis and Transplantation (5,6). AVF, arteriovenous fistula; ESA, erythropoiesis-stimulating agents; USD, United States dollars. Figure 1.: Annual prevalence of dialysis patients ( 5 , 6 ).Figure 2.: Annual dialysis mortality rate . Rate is expressed in deaths per 100 patients at risk with 95% confidence interval bars. Source: Argentinean Registry of Dialysis and Transplantation (5,6). Table 2. - Comparison of RRT between Argentina and Latin America Argentina Latin America Prevalence of patients with ESKD under RRT (dialysis and transplant) a 976 805 Dialysis incidence rate a 160 154 Kidney transplant rate a 30 21 Patients on peritoneal dialysis, % 6.5 11.5 Nephrologist a 30 18 aRates are expressed per million population. Source: Latin American Registry of Dialysis and Transplantation (7). Structural Organization and Logistics of Dialysis Argentina has dialysis units in both hospital and private settings. There are a total number of 597 dialysis centers in the country. Eleven percent (68 centers) of these centers are government owned, 377 (63%) are independent dialysis centers, and the rest (152 centers; 26%) are owned by foreign dialysis companies. One hundred eighty-seven dialysis units are in the province of Buenos Aires, and the rest are located throughout the rest of the country. Dialysis is covered by patients’ union health system or health insurance; ultimately, the government pays if the patient does not have insurance. Government coverage is universal if a patient does not have union or health insurance. This includes illegal immigrants, noncitizens, and refugees. Payment for HD and PD is capitated at approximately United States $700 per month or United States $55 per HD session. Physicians across the country are paid by monthly salaries, and some also have private practice. PD solutions are not manufactured in the country and are, therefore, imported. Bundle HD and PD payment includes vascular access, erythropoietin, appropriate vaccination, and transfer to and from the dialysis unit. Monthly reimbursement is irrespective of procedure number. Average HD sessions last for 240 minutes, with 95% of patients receiving three or more dialysis sessions per week (5,6). Online hemodiafiltration has been recorded since 2015. Approximately 20% of HD centers have this technology. Although 70% of patients on incident dialysis start with a temporary catheter as their vascular access, at 6 months into treatment most have permanent vascular access. Seventy percent of prevalent patients have an arteriovenous fistula. Nephrologists insert all temporary catheter access. Permanent HD catheters are placed by nephrologists also but mostly by vascular surgeons. Arteriovenous fistulas are 100% done by vascular surgery. Interventional nephrologists do not perform arteriovenous fistulas. Almost 87% of the patients are on erythropoietin or similar agents, and synthetic HD membranes are most commonly used. (Table 1) (5,6). The advent of technologic advancement, biosecurity implementation, and specific treatment has decreased the prevalence of hepatitis B, hepatitis C, and HIV in the dialysis population (0.2%, 1%, and 0.8%, respectively). Isolation of patients with hepatitis B is mandatory. No formal end-of-life care support programs are available in Argentina. Staffing of Dialysis Units Argentina is third among Latin American countries considering nephrology physicians per million inhabitants (Table 2) (7,8). There is one nephrologist for every 40 patients, and a nephrologist must be present in the dialysis unit at all times. There are approximately 80 renal fellows in training per year. Most patients are seen daily or at least four times a month. In continuous ambulatory peritoneal dialysis, they are seen once a month. Historically, non-nurse technicians accounted for the majority of dialysis personnel, but this has progressively decreased to approximately 5%. Nurses now provide the lion’s share of dialysis care. The main driving force for this change occurred 10 years ago when regulations were changed to increase the number of dialysis nurses taking care of these patients. The nurse to patient ratio is four to five adult patients per nurse in HD units and two to three children per nurse in pediatric units. In PD, the ratio is 20 adult and 15 pediatric patients per nurse (5,6). No formal dialysis nurse certification is in place in the country. Transplantation in Argentina The International Registry of Organ Donation and Transplantation reports that in 2019 there were approximately 1674 kidney transplants (1325 from deceased donors and 349 from living donors) in Argentina. There were 69 simultaneous kidney-pancreas transplants, 19 kidney-liver transplants, and 5 kidney-heart transplants. More men (62%) were transplanted than women. The availability of kidney transplants differs regionally around Argentina, with approximately 6546 patients with ESKD currently on the transplant list waiting for a new kidney. Average waiting time on the transplant list is over 4 years. Swap living kidney transplants have occurred, but there are very few cases (5). Transplantation is regulated by the INCUCAI (5,6). Since 2004, the INCUCAI has supported a National Dialysis and Transplant Registry. Patient reporting is obligatory, and therefore, national data are valid and representative. The INCUCAI in conjunction with the Argentine Society of Nephrology analyzes and reports the data of the National Dialysis and Transplant Registry (5,6). The INCUCAI, the Argentine Society of Nephrology, and the Argentine Transplant Society promote organ donation campaigns regularly. A recent law has declared the general population as presumed donors, and this has increased donation by 20%–25%. There are barriers to donation, but none are due to social or cultural barriers. Some of these barriers include logistics of organ harvesting and transportation in a large country, insufficient organ harvesting teams in some regions, etc. Future Directions and Challenges RRTs are accessible and available in Argentina, and utilization rates are acceptable compared with other countries in the region. It will be challenging to improve what is currently available with limited economic resources. An advanced kidney care program is not available nationwide and needs to be designed and implemented to guarantee early and programmed dialysis initiation and preemptive transplant when possible. PD is underused in Argentina for many reasons: peritoneal solutions are not manufactured in the country and are expensive, and most nephrologists have not been trained in PD because HD has been the predominant form of dialysis historically. Because many patients still begin dialysis without previous planification, the preferred dialysis modality used in urgent situations is HD through temporary catheter access. Training and economic incentives will help develop PD further. Home HD will most likely be set aside for some time. This technology is not available yet, and no reimbursement plans are underway for this dialysis modality. Disclosures G.J. Rosa Diez is employed by Fressenius. The remaining author has nothing to disclose. Funding None.

Collins Chansa, Mulenga Mukanu, Chitalu Miriam Chama‐Chiliba, Mpuma Kamanga · 7 authors

Zambia has been using output-based approaches for over two decades to finance whole or part of the public health system. Between 1996 and 2006, performance-based contracting (PBC) was implemented countrywide with the Central Board of Health (CBoH) as the provider of health services. This study reviews the association between PBC and equity of access to maternal health services in Zambia between 1996 and 2006. A comprehensive document review was undertaken to evaluate the implementation process, followed by a trend analysis of health expenditure at district level, and a segmented regression analysis of data on antenatal care (ANC) and deliveries at health facilities that was obtained from five demographic and health survey datasets (1992, 1996, 2002, 2007 and 2014). The results show that PBC was anchored by high-level political support, an overarching policy and legal framework, and collective planning and implementation with all key stakeholders. Decentralization of health service provision was also an enabling factor. ANC coverage increased in both the lower and upper wealth quintiles during the PBC era, followed by a declining trend after the PBC era in both quintiles. Further, the percentage of women delivering at health facilities increased during the PBC era, particularly in rural areas and among the poor. The positive trend continued after the PBC era with similar patterns in both lower and upper wealth quintiles. Despite these gains, per capita health expenditure at district level declined during the PBC era, with the situation worsening after the PBC era. The study concludes that a nationwide PBC approach can contribute to improved equity of access to maternal health services and that PBC is a cost-efficient and sustainable policy reform. The study calls for policymakers to comprehensively evaluate the impact of health system reforms before terminating them.

Ilmo Keskimäki, Liina‐Kaisa Tynkkynen, Eeva Reissell, Meri Koivusalo · 8 authors

This analysis of the Finnish health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Finland is a welfare state witha high standard of social and living conditions and a low poverty rate. Its health system has a highly decentralized administration, multiple funding sources, and three provision channels for statutory services in first-contact care: the municipal system, the national health insurance system, and occupational health care. The core health system is organized by the municipalities (i.e. local authorities) which are responsible for financing primary and specialized care. Health financing arrangements are fragmented, with municipalities, the health insurance system, employers and households all contributing substantial shares. The health system performs relatively well, as health services are fairly effective, but accessibility may be an issue due to long waiting times and relatively high levels of cost sharing. For over a decade, there has been broad agreement on the need to reform the Finnish health system, but reaching a feasible policy consensus has been challenging.

Hassan Leli, Osman Addulahi, Benjamin Tsofa

<ns4:p> <ns4:bold>Background:</ns4:bold> Health sector decentralization, defined as the transfer of decision making over health sector resources from a central to a peripheral entity; has been and continues to be a widely adopted health system reforms in many low and middle-income countries (LMICs). However, its reported effects have been varied. Nevertheless, decentralization reforms aimed at providing public hospital management autonomy are increasing in prevalence in many LMICs. The range and form of this autonomy because of these reforms has often produced mixed effects. We set out to understand the range of financial management autonomy that has been granted to public hospitals in decentralized health systems in LMICs, and what forms of accountability arrangements have been used to facilitate this autonomy. </ns4:p> <ns4:p> <ns4:bold>Methods:</ns4:bold> We systematically searched PubMed, Google Scholar, Web of Science and CINAHL databases for published articles on this subject. We only included articles that reported empirical findings on hospital level financing and financial management in the context of decentralization in LMICs and/or those that included findings on hospital level finance management accountability arrangements. After a systematic search we found four articles that met our inclusion criteria. We undertook a thematic synthesis of the data and narrative reporting of our findings. </ns4:p> <ns4:p> <ns4:bold>Results:</ns4:bold> From the review – we find that decentralization reforms did not result in improved funding flows, finance management autonomy or accountability mechanisms and for public hospitals. These outcomes were irrespective of the mode and form of decentralization reform adopted. </ns4:p> <ns4:p> <ns4:bold>Conclusion:</ns4:bold> From our review, it is evident that though health sector decentralization reforms have been widely promoted and adopted in the past few decades across LMICs, there is minimal evidence that these reforms have improved funding flows to public hospitals, improved financial management autonomy or accountability mechanisms; so as to enhance the performance of these hospitals at sub-national level. </ns4:p>

Sergiu Chirilă, Beatrice Severin

Abstract Primary health care (PHC) represents one of the most important parts of any health system, and consists of first-contact medical services (preventive, curative and rehabilitation) for the patients. Our study analyses the family physicians' opinions related to a series of measures that could improve Romania's healthcare system through an online survey. We identified three components, first one related to control over spendings, increase of medicine market efficiency and transparency in using public funds, second one related to standardization of care processes, accreditation, implementation of guidelines and control over utilization of specialty services and component number three related to type of insurance houses, with competition among them, better decentralization and integrated provision of medical services. The conclusions of the survey emphasize the fac that primary care health is affected by sub optimal financing, with a need of better support for its development through investments in health promotion, services integragion and human resources as means of increasing general health status of the population.

Peter Nan-shong Lee

The focus of this chapter concerns the changing balance among three major funding sources to medical care. It examines the trend of growth and decline of franchise funding relative to the two public funding sources (government subsidies and public insurances) during the period of economic reform. An analysis is devoted to the issue of shrinkage of government subsidies that was inadvertently caused by decentralization of managerial powers from the central to the provincial and local level, coupled with the pro-growth policy advocated by the government prior to the early 2000s. The study treats the decline and restoration of public expenditures (government’s subsidies and public insurances) as a long-term process, dictated by the progress of institutional and policy restructuring. In addition, it tries to make a preliminary assessment on the extent medical care is politicized in the process of policymaking.

Diane M. Dewar

From a societal point of view, it is difficult to determine whether a centralized or decentralized health system is superior. A normative statement of that kind entails substantial value judgments and trade-offs. No two health care systems are identical, although many share characteristics that allow us to develop typologies which are useful in analysis of any particular system. Third parties make the health care system much more complex because the source of third-party financing and the method of reimbursement must be worked into the model. The Socialized Health Insurance Program (SI) in Germany is based on government mandated financing by employers and employees. The essential features of the Canadian health care system are national insurance, free choice of health care provider, private production of medical services, and regulated global budgets and fees for health care providers. The United States health care system is the expensive in the world but under-performs relative to many peer countries on most dimensions of performance.

Muneeb Usman

Health care organizations function in multidimensional environments and their organizational cultures are complex and demanding. The expectations from health care services are high and as a result patients want the most effective and latest possible treatments, while the politicians demand responsible services. As far as healthcare professionals are concerned they require motivating and challenging work environments. All these goals and objectives can be at the root of wicked problems in healthcare management. Thus, this research paper aims to assess the impact of reforms like decentralization, health care financing and the use of information communication technology (ICT) on Patients satisfaction in public hospitals of KPK (Pakistan). The aim of these reforms was to solve the problems encountered in health care systems and to improve healthcare systems. Findings show that there is positive relationship between reforms and increase in Patient’s satisfaction Keywords: Reforms, Decentralization, Health care Financing, ICT'S in the Health Care, Quality of service, Patient Satisfaction

Bolaji S Aregbeshola

A major challenge to achieve health coverage in Nigeria is expansion of health access to the poor, vulnerable and informal sectors, which constitute over 70% of the population of more than 186 million. Evidence from other countries suggests that it is difficult for contributory insurance schemes to achieve universal health coverage in such conditions, especially with such a large informal sector. In fact, Nigeria's national social health insurance program has provided coverage to less than 5% of the population since its implementation in 2005, private voluntary health insurance has shown poor potential to extend coverage, and community-based health insurance has failed to expand access to poor, vulnerable and informal sector populations as well. Decentralization of health insurance to the states has limited potential to expand health insurance coverage for the poor, vulnerable and those in the informal sector. Furthermore, social health insurance in many developed countries has taken many years to achieve universal health coverage. This paper suggests that policy makers should consider adopting a tax-based, noncontributory, universal health-financing system as the primary funding mechanism to accelerate progress toward universal health coverage. Social health insurance and its decentralization to states for formal sector workers should serve as a supplement, while private voluntary health insurance should cover better-off groups. Simultaneously, it is critical to tackle issues of poor governance structures, mismanagement of funds, corruption, and lack of transparency and accountability within regulatory and implementing agencies, to ensure that monies allocated for expanded health insurance coverage are well managed. Although the proposed universal health coverage reform may take some years to achieve, it is more feasible to collect taxes, improve tax administration and expand the tax base than to enforce payment of contributions from nonsalaried workers and those who cannot afford to pay for health insurance or for services out of pocket.

Alberto Infante Campos

The Spanish National Health System (SNHS) was legally defined in 1986. There are many well documented studies on how its basic traits (universality, accessibility, decentralization, integrated public health networks, public and private provision, financed by taxes, social premiums and copayments, etc.) have evolved since then. This paper explains how the SNHS facilities and functions are deeply decentralized and how the recent economic crisis has changed this picture, with central health planning basically located into the Ministry of Finance and mainly guided by deficit control considerations.

abc, Gbeneol J. Tombari

Rwanda is a good example of how a country can overcome challenges and obstacles to improve the socioeconomic well-being of citizens. With no reliable healthcare system in 1994, after the genocide against the Tutsi, the country has come a long way in building a decent healthcare system for its people. The purpose of this research is to analyze the changing PPP mixed in health care sector in Rwanda. The study was carried out to reflect/reveal or bring to light the perennial problems of the healthcare mixes within a period of six months. This work looked at the public-private sector mixes in healthcare system using Rwanda as a case study. In Rwanda, the ministry of health began health sector reforms in accordance with the Lusaka declaration in 1995. These reforms included decentralization of the health system, development of the primary healthcare system, and community participation in managing health service financing. Rwanda is one of the few African countries with 90% coverage in all Districts for immunization and access to critical health services including TB treatment and access to ARVs for HIV patients. Within a very short period of 23 years, Rwanda has built a working health system in which even the poor and disadvantaged have access to quality medical care through the Community Based Health Insurance.

Francis Amagoh

This chapter examines the evolution of health care system in Kazakhstan since its independence. The Soviet health system, which emphasized centralized planning with the principle of free universal health coverage for all, has been adopted by Kazakhstan. To bring major improvements in the health system, the reform measures have altered the institutional and procedural aspects of health care delivery as well as the behavioral aspects of health care providers. In analyzing the health reform programs, four elements in the reform have been examined, namely, decentralization, efficiency and quality, expenditure and financing, and competition. The health financing system consolidates funds at the oblast level, where oblast health departments serve as the single health purchaser or single payer for all state health funds. The National Program of Health Care Reform and Development incorporates a new health financing policy, which aims to improve the linkage between different levels of care, reinvest resources saved through rationalization and decrease regional differences in health financing.

Alan Maynard, Stuart H. Altman, Sally C. Stearns

Like many countries, the health care industries of England 1 and the United States consume large amounts of resources and struggle to achieve equity and efficiency. They attempt to reach these goals in quite different ways, exhibiting common challenges familiar to reformers throughout the world. Recent activities in England and the United States suggest that significant changes being discussed in the United States or implemented in the United Kingdom could upset previously accepted policies and threaten some or many of the gains made to provide more equal and timely accessible care to all individuals. Policy makers in both countries wrestle with similar problems of redistribution and system design. Although in the United States, the issues of equity and expenditure controls do not have the same importance as in England, both countries seek the “Holy Grail” of limiting spending both by government and the private sector by redesigning institutions that manifest inefficiency and contribute to inflationary pressures. Yet competing value systems permeate the political debate about how to accomplish these aims. These value systems underlie political preferences for regulation and markets. Although a minority in the United States advocates for universal care funded by a single payer, private employer-based insurance remains the bedrock mechanism. Unlike the United Kingdom and most Organisation for Economic Cooperation and Development (OECD) countries, the United States has never shown a political willingness to have government responsible for financial protection for all inhabitants against the cost of medical care. The United States has, however, accepted this responsibility for major components of society, namely, the aged, disabled, and low-income families and children (e.g., via Medicare, Medicaid, and the State Children's Health Insurance Program). This commitment was expanded with the Affordable Care Act (ACA) in 2010, commonly known as Obamacare. The outcomes of the two health care systems reflect a preference for collectivism in funding and access in the United Kingdom and for pluralism in funding (less third-party coverage) and a greater role for privately delivered care in the United States. But the battle continues in both countries as important groups advocate for the reversal of these preferences. Policy makers continually try to change their health care systems. Some of these changes seek to develop greater efficiency in how care is delivered as a means of controlling the burdens imposed on society by ever-increasing public and private expenditure. Both countries face common problems that have been well identified for decades but have proven difficult to resolve. Reformers face three common problems. First, unwarranted variations in clinical practice (Wennberg, 2008, Wennberg, 2012) are produced by price variations in insurance systems and volume variations elsewhere (Institute of Medicine, 2013). Second, both systems have been slow to develop measures of the value of health care outcomes, that is, improvements in the length and quality of life. Third, both health care systems have perverse incentives that inhibit efficiency-inducing change; for example, they use hospital pricing or tariff systems that incentivise activity with little regard to patient value. Inadequate evaluation and political resistance to change continue to produce inefficiency. The end result is unnecessary spending and unethical deprivation of beneficial care for some populations. The English single payer system is characterised by frugality and cycles of famine and plenty, with attendant bouts of supply side reform (Street & Maynard, 2007). Constrained funding in the 1980s led to the Thatcher reforms and the creation of the “quasimarket” of purchaser and providers contracting for public and private care. These structural reforms received increased funding in the early 1990s. By the end of the 1990s, financial parsimony was creating renewed performance problems, for example, increased waiting times for elective surgery. As a consequence, the Blair government financed a large increase in funding. Since 2010, the Coalition and now Conservative government has exerted extreme expenditure controls, and current plans will result in real per capita funding falling by 2018. Since the Thatcher era, the often violent fluctuations in NHS funding have been accompanied by the “redisorganisation” of structures and processes of care whilst maintaining universal cover age free at the point of use. The purchaser side of the National Health Service (NHS) market has evolved from health authorities to primary care trusts and now to clinical commissioning groups, all with similar functions and uncertain impact. The provider side of the market remains dominated by public institutions as private providers have made only marginal inroads to public funding. The current chronic underfunding of the NHS and social care, manifested currently by increased waiting times for elective procedures, has produced inevitable pursuit of the “Holy Grail” of increased productivity. The Five Year Forward View (NHS, 2014) involved the acceptance of government parsimony and for the 2015–2020 period. Its authors argued that the NHS would require £30 billion to meet demographic and technological demands, of which only £8 billion was to be provided from tax revenues. The additional £22 billion was to be funded from productivity increases. Current NHS spending is £110 billion. Currently, a frenzy of structural reform proposals range from integration of currently fragmented hospital, primary and social care systems to hospital mergers to the abolition of the purchaser-provider “market” with the creation of accountable care organisations. These proposals involve unevidenced merger plans and deskilling of nursing and other workforce changes. The Sustainability and Transformation Plans (https://www.england.nhs.uk/stps/) are radical but unlikely to yield £22 billion of productivity gains in 5 years. There is little available funding to finance the change process, and its duration is likely to take many years to free up resources. Both options assume that healthcare is much more expensive in the United States than in any OECD country because American patients use too much medical care. Yet the evidence does not support this assumption. Americans are less likely to be admitted to a hospital and have a lower length of stay once in a hospital than many OECD countries. Americans also are less likely to see a doctor or use fewer pharmaceuticals than patients in OECD countries. U.S. patients do use more very expensive medical devices such as MRIs or new and expensive drugs, but on net, the pluses and minus may cancel out. What separates United States spending from that in OECD countries are the prices charged for all medical activities. The reasons for the higher prices are complicated and due to a myriad of factors including the higher wages paid to most participants in the healthcare system (not only physicians); the much higher prices Americans pay for drugs and medical devices; and the fact that the complexity of the U.S. system has evolved in a way that requires the use of many more lawyers, consultants, and administrators, all of whom are well paid. The latter consideration is possibly more central because some key providers such as primary care physicians receive relatively low compensation relative to education costs and work conditions. Additional efforts within the United States that are sometimes related to the ACA include a broad interest in insurance redesign, emphasis on value from services provided, and a focus on patient-centred outcomes. Value-based cost-sharing approaches are being implemented in the United States as well as other OECD countries (Thomson, Schang, & Chernew, 2013), though these approaches are more easily implemented for certain services such as pharmaceuticals. The Medicare program is testing a number of value-based payment innovations and incentive payments. The Patient-Centered Outcomes Research Institute is a nongovernmental institute created under ACA that was charged with assessing the effectiveness and appropriateness of medical treatments. However, the Patient-Centered Outcomes Research Institute is not able to mandate coverage or reimbursement for any treatments and infamously is prohibited from considering cost per quality-adjusted life years in its recommendations despite widespread interest in this measure in many other countries. The American and the English health and social care systems differ greatly, but they are surprisingly similar in some dimensions. Key differences pertain to who pays for care and how it is delivered, with the United States having a more decentralized and fragmented system leading to inequalities in the provision of care and its funding. The English system is universal and largely free at the point of consumption system but constrained by limited funding (which also generates inequalities in access to timely care). The supply side problems are more similar for both countries. Increasingly, U.S. reform in terms of payment mechanisms is being emulated by the English. Both systems seek better measurement and management of “value,” that is, the effects of health care on the length and quality of patients' lives. The hospital systems of both countries are attempting to integrate care function and move away from “fee for service” to bundled or incentive payments. The American system is the product of producer incentives producing grossly inflated costs. Concomitantly, a growing proportion of the U.S. population has a limited view about who should be eligible for government-supported health care services and the types of services that should be supported. Despite greater underlying consensus in favour of universal coverage, the English system's crisis is a product of parsimony and fragmentation of funding and provision. Both systems are permeated by organisational inertia and the defence of political values and self-interest. The United States is grappling with more than a sea change given political restructuring and the very uncertain future of most expansions of insurance or medical cost coverage under the ACA. England faces potentially revolutionary structural changes in supply and a real political challenge in its single payment system. Although current trends are not positive, the authors maintain hope that both countries will prevent further deterioration in health care coverage and return towards more progressive policies to protect their inhabitants' access to care when subjected to the misfortunes of medical illness.

Sorin Dan

No abstract is available for this record.

Cristian Vlădescu, Silvia Gabriela Scîntee, Victor Olsavszky, Cristina Hernández‐Quevedo · 5 authors

This analysis of the Romanian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Romanian health care system is a social health insurance system that has remained highly centralized despite recent efforts to decentralize some regulatory functions. It provides a comprehensive benefits package to the 85% of the population that is covered, with the remaining population having access to a minimum package of benefits. While every insured person has access to the same health care benefits regardless of their socioeconomic situation, there are inequities in access to health care across many dimensions, such as rural versus urban, and health outcomes also differ across these dimensions. The Romanian population has seen increasing life expectancy and declining mortality rates but both remain among the worst in the European Union. Some unfavourable trends have been observed, including increasing numbers of new HIV/AIDS diagnoses and falling immunization rates. Public sources account for over 80% of total health financing. However, that leaves considerable out-of-pocket payments covering almost a fifth of total expenditure. The share of informal payments also seems to be substantial, but precise figures are unknown. In 2014, Romania had the lowest health expenditure as a share of gross domestic product (GDP) among the EU Member States. In line with the government's objective of strengthening the role of primary care, the total number of hospital beds has been decreasing. However, health care provision remains characterized by underprovision of primary and community care and inappropriate use of inpatient and specialized outpatient care, including care in hospital emergency departments. The numbers of physicians and nurses are relatively low in Romania compared to EU averages. This has mainly been attributed to the high rates of workers emigrating abroad over the past decade, exacerbated by Romania's EU accession and the reduction of public sector salaries due to the economic crisis. Reform in the Romanian health system has been both constant and yet frequently ineffective, due in part to the high degree of political instability. Recent reforms have focused mainly on introducing cost-saving measures, for example, by attempting to shift some of the health care costs to drug manufacturers by claw-back and to the population through co-payments, and on improving the monitoring of health care expenditure.

Thomas Braendle, Carsten Colombier

No abstract is available for this record.

Arturo Vargas Bustamante

For more than three decades healthcare decentralization has been promoted in developing countries as a way of improving the financing and delivery of public healthcare. Decision autonomy under healthcare decentralization would determine the role and scope of responsibility of local authorities. Jalal Mohammed, Nicola North, and Toni Ashton analyze decision autonomy within decentralized services in Fiji. They conclude that the narrow decision space allowed to local entities might have limited the benefits of decentralization on users and providers. To discuss the costs and benefits of healthcare decentralization this paper uses the U-form and M-form typology to further illustrate the role of decision autonomy under healthcare decentralization. This paper argues that when evaluating healthcare decentralization, it is important to determine whether the benefits from decentralization are greater than its costs. The U-form and M-form framework is proposed as a useful typology to evaluate different types of institutional arrangements under healthcare decentralization. Under this model, the more decentralized organizational form (M-form) is superior if the benefits from flexibility exceed the costs of duplication and the more centralized organizational form (U-form) is superior if the savings from economies of scale outweigh the costly decision-making process from the center to the regions. Budgetary and financial autonomy and effective mechanisms to maintain local governments accountable for their spending behavior are key decision autonomy variables that could sway the cost-benefit analysis of healthcare decentralization.

FERDINAND GITHETHUKI MUCHOMBA

Devolution, as other types of decentralization, profoundly changes governance relations in the health system. Devolution is meant to affect performance of the health system by transferring responsibilities and authority to locally elected governments. This study aimed to establish the effect of devolved governance on the performance of the health sector in Kenya. The guiding objectives included: To establish the influence of devolved procurement on the performance of the health sector; to determine the effect of devolved leadership on the performance of the health sector; to evaluate the effect of devolved resources on the performance of the health sector; and to establish the effect of devolved policy and regulatory framework on the performance of the health sector in Kenya. The study adopted the descriptive survey research design. The target population was 572 patients and health care providers from Nairobi and Mombasa County. Stratified sampling method was adopted at the rate of 10% to come up with a sample size of 57 respondents. Primary data was collected using questionnaires from all the respondents. Secondary data was sourced from health sector reports in Kenya from the year 2010 to 2014. The collected data was then analyzed through frequencies and percentages to enable the research come up with conclusions and recommendations for the study. The researcher employed the assistance of some computer tools, including the Statistical Programmes for Social Sciences (SPSS) and excel version 16 to analyze the data quantitatively. The analyzed data was presented in the form of graphs tables and charts. The Study established that devolution process has not been fully implemented and its effect has not been fully experienced in the health sector. The sector performance was averagely rated in the study and its contribution to GDP reduced by 0.5 percent by the end of the year 2013. The devolved procurement process, organizational leadership, resources allocation and availability as well as policy and regulatory framework had a significant influence on the performance of the level four hospitals and the overall health sector. It was recommended that the health sector players should improve in financing of critical health investment areas, particularly those relating to improving quality of care.

Evelyn Waweru, Catherine Goodman, Sarah Kedenge, Benjamin Tsofa · 5 authors

In many African countries, user fees have failed to achieve intended access and quality of care improvements. Subsequent user fee reduction or elimination policies have often been poorly planned, without alternative sources of income for facilities. We describe early implementation of an innovative national health financing intervention in Kenya; the health sector services fund (HSSF). In HSSF, central funds are credited directly into a facility's bank account quarterly, and facility funds are managed by health facility management committees (HFMCs) including community representatives. HSSF is therefore a finance mechanism with potential to increase access to funds for peripheral facilities, support user fee reduction and improve equity in access. We conducted a process evaluation of HSSF implementation based on a theory of change underpinning the intervention. Methods included interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. We found impressive achievements: HSSF funds were reaching facilities; funds were being overseen and used in a way that strengthened transparency and community involvement; and health workers' motivation and patient satisfaction improved. Challenges or unintended outcomes included: complex and centralized accounting requirements undermining efficiency; interactions between HSSF and user fees leading to difficulties in accessing crucial user fee funds; and some relationship problems between key players. Although user fees charged had not increased, national reduction policies were still not being adhered to. Finance mechanisms can have a strong positive impact on peripheral facilities, and HFMCs can play a valuable role in managing facilities. Although fiduciary oversight is essential, mechanisms should allow for local decision-making and ensure that unmanageable paperwork is avoided. There are also limits to what can be achieved with relatively small funds in contexts of enormous need. Process evaluations tracking (un)intended consequences of interventions can contribute to regional financing and decentralization debates.