Matthew S. Murphy, Alberto FernƔpndez, Antonio Daponte
the death of General Francisco Franco on 20th November 1975 and the subsequent transition to democracy was a seminal moment in Spanish history, laying the groundwork for important administrative and institutional changes. one of the most important changes during this time period was the establishment of a right to health care in the Constitution of 1978. previously, the Spanish health system had granted access based on employment status, with financing via payroll taxes managed by the Social Security Administration. With the passage of the Constitution of 1978 and subsequently the General Health Law of 1986, Spain developed a national health system which guaranteed universal access to the population and was financed through general taxation. At the same time, the country began to move away from a strongly centralized administration through a devolution process which granted administrative responsibility for governing areas such as education and health to the 17 autonomous communities of Spain. the process began with Cataluna in 1981, followed several years later by Andalucia and was completed in 2002.Both of these elements are essential to understanding the role and organization of the country's public health workforce. the universal nature of the Spanish health care system is regarded as the most significant guarantor of the country's health and wellbeing. At the same time, the central government has a very limited role in the management and organization of the health system. in fact, during the process of devolution, the field of public health was the first administrative element that was turned over to the autonomous communities. As it involved limited financial resources and infrastructure at the time, it was viewed as easily transferable. However, the government has struggled since then to organize and coordinate public health initiatives between the different autonomous communities. the principal coordination mechanism for health- related issues is a body called the Consejo Interterritorial de Salud where the 17 health ministers from the different communities as well as national professional groups meet with the national Minister of Health. Here, they plan the response to disease outbreaks or discuss the effects of new legislation on regional health systems. one of their major initiatives now is standardizing national preventive programs such as population screening procedures and the paediatric vaccine calendar in response to important intercommunal variations in initiatives and resources. ultimately, the Consejo has little legal authority and acts more as a facilitator for collaboration than a regulatory agency.As a result of the decentralization of the administration of health services and the early devolution of the responsibility to ensure public health reaches the autonomous communities, it is difficult to discuss a national public health workforce. there are no national databases or registries of the public health workforce in Spain. each community has developed its workforce based on its history, political philosophy and perceived health needs. Additionally, there is no national accrediting body for public health professionals in Spain, something that is essential for professional regulation and political importance in the workplace. However, there are important professional associations at the national and regional level that fall under the umbrella group SeSpAS, or the Spanish Society of public Health and Health Administration. these associations include groups such as the Spanish Network of primary Healthcare, the Spanish Association of epidemiology and the Spanish Society of environmental Health among others.the national government does play a central role in insuring compliance with european legislation and regulations, particularly in areas of occupational health, environmental health and food safety. As a result, the public health workforce is organized around these areas and usually includes a diverse set of professional profiles. ā¦
Across the Asian region, models of health administration vary from centralized management arrangements to more open decentralized systems. Utilizing a historical perspective, this review compares and contrasts health systems transition in seven countries (the Democratic Peopleās Republic of Korea, Myanmar, Timor Leste, Bhutan, Mongolia, Cambodia and the Philippines) against the background of macro-political and economic reform, and then considers the implications of these findings for approaches to health policy analysis. Four management areas are presented to demonstrate variation in health system design over the last 40 years: centralization and decentralization, human resource management, health financing and constituency emergence. Historical records illustrate that these functions have evolved through political reform eras of centralist, early reform, established reform and pluralist models of administration, with the main driver of system change being periodic historical shifts in the design of the macro-political and socio-economic order. The cross referencing of management variables with these stages of transition illustrates the degree to which health policy parameters are reset by periodic historical shifts in the political and social order. The findings in these case studies call for a more nuanced classificatory system for health systems and policy analysis that unites a technical perspective with a wider social and political field of vision, and, in doing so, builds a more comprehensive picture of the way in which health systems function in the real world.
In 1991, Indonesia began a process of decentralization in the health sector which had implications for the country's public hospitals. The public hospitals were given greater authority to manage their own personnel, finance and procurement, with which they were allowed to operate commercial sections in addition to offering public services. These public services are subsidized by the government, although patients still pay certain proportion of fees. The main objectives of health sector decentralization are to increase the ability of public hospitals to cover their costs and to reduce government subsidies. This study investigates the consequences of decentralization on cost recovery rate of public hospitals at district level. We examine five service units (inpatient, outpatient, operating room, laboratory and radiology) in three public hospitals. We find that after 20 years of decentralization, district hospitals still depend on government subsidies, demonstrated by the fact that the cost recovery rate of most service units is less than one. The commercial sections fail to play their role as revenue generator as they are still subsidized by the government. We also find that the bulk of costs are made up of staff salaries and incentives in all units except radiology. As this study constitutes exploratory research, further investigation is needed to find out the reasons behind these results.
This paper examines the infrastructureādecentralization nexus in the production of health services with a particular emphasis on the issue of health infrastructure. The first part of the paper presents evidence on health services and infrastructure spending in health for various countries or groups of countries showing the importance of infrastructure spending in the provision of health services. The second part of the paper examines why and how health services are joint production with collective and private characteristics. These characteristics affect the decentralization of such services and thus the decentralization of health infrastructure; it also raises the issue of who should finance what in health care. The third part examines case studies and policy choices in USA, Canada and Switzerland related to various aspects of health care and health infrastructure financing.
The purpose of this paper is to examine the effect of financial incentives on the level of inappropriateness in health care. The case of the Italian NHS seems to be especially interesting when considering the effects of financial incentives on providers behaviors, as decentralization processes have progressively increased the variability among Regional Health Authorities in both the financing and the delivery of health care. In particular, we investigate the effect of DRG tariff differentials on hospital risk-adjusted cesarean rates for first-time mothers during the period 2009ā2011. Our main finding is that Italian hospitals respond to financial incentives in obstetrics and that the strategic behavioral response varies by hospital type.
Issue Serbia started the process of decentralization soon after the first phases of reforms were completed, as the integral part of the European integration process. The Law on Health Care has enabled decentralization in the primary health care sector, in order to strength the democratic governance and to improve administrative and service delivery effectiveness. Through the project with the Norwegian Association of Local and Regional Authorities (KS), the Serbian Standing Conference of Towns and Municipalities in cooperation with public health experts, assisted capacity building of local authorities. The aim of establishing Decentralized Service Improvement Networks is to advance the role of local authorities in public health and primary health care institutions, and to foster horizontal coordination between other social policy areas. Description of the problem Local governments were not aware of opportunities they have as founders of primary health care institutions- to monitor the effects of the undertaken measures in the field of financing, preventive actions and public health protection. Results DSIN for primary health care was established for the six chosen municipalities, comprising of at least 3 representatives of each local government. The cycle of 6 meetings started with a managerial meeting (mayor, heads of the services) in order to agree on a coordinated approach in the municipality and pointing out the challenges for such approach, applying SWOT analysis. DSIN have improved access to relevant statistical and administrative data, set the list of indicators to be monitored at the local level, developed and piloted the methodology for periodical survey of users satisfaction with primary health care and actively analysed and shared experiences (local and international). Furthermore, this network sucessfuly cooperated with the relevant institutions from education, social protection, NGOs, and users of services. Based on the review of all collected relevant data, every municipality have chosen to improve one priority public health service. Lesson The practice of DSIN is based on critical analysis of own performance in the context of performance of other similar institutions, on the basis of opinions of clients of the service and with wide utilization of best practices tested already in other local governments. Key messages Professional network at the local level motivates municipal authorities to perform better, to adopt innovative approaches and to learn from other experiences and good practices. The network enables local governments to learn from each other and to discuss and agree how to best use emerging good and European practice to improve the target services in their municipalities.
This article is a reflection about whether new public management (NPM) styles of reforms seen in other developing countries are also seen in Nepal, and to substantiate these facts with the available evidence and findings. The author saw the emergence of NPM ideas in Western industrialized countries like the United Kingdom and New Zealand. Now it exists in several developing countries of Africa and Asia; but it is very hard to generalize the degree and scope of NPM elements' existence. In Southeast Asia, there is still a mix of the old bureaucratic system with new NPM-oriented reform initiatives. Series of administrative reforms, donor conditionality, and the reestablishment of democracy in the country after 1991 have influenced an orientation toward an efficient, people-oriented, mixed-economy model with increasing partnership of private agencies and nongovernmental organizations in Nepal. The political movement of the last 15 years in the country has strongly called for a new, efficient, and performance-oriented administration and management culture in the country. There are several initiatives already introduced (public-private partnership, decentralization, good governance, accountability/public auditing, performance-based outcome/results-oriented financing and reporting systems). However, to take this momentum up, it still requires strong willingness of political leaders and senior administrators. At the moment, peace and stability of turmoil, political stability, state-of-the-art management skills, and supportive organizational culture are the fundamental requirements for increasing the realization of, and sustaining the NPM-oriented reforms in Nepal.
Cristian VlÄdescu, Vasile AstÄrÄstoae, Silvia Gabriela ScĆ®ntee
The solutions recommended by the Presidential Commission for the improvement of hospital services were: restructuring and reorganization of hospital services; hospital management decentralization and establishment of county hospital agencies to ensure the coordination of hospital services at county level; diversification and use of new hospital services financing methods based on performance and quality of services provided to the patients; development of new management models for ensuring the continuity of care under therapeutic efficacy and economic efficiency. The Commissionās recommendations as regards the sorting out of the problems in the primary health care were: development of primary care multidisciplinary teams; improvement of resource allocation at primary care level, simultaneously with raising efficiency of their use and integration of health services; significant increase of the resources dedicated to primary health care development, in areas like human resources, physical infrastructure, information and communication systems, and medical equipment. The solutions proposed by the Commission for improving the human resources are: drafting a coherent sectorial policy for training, development and allocation of human resources in health; increasing the availability of human resources in the health sector in Romania; stimulate the professional career development in health sector. The successful implementation of the proposed measures is conditioned by the clarification of some aspects and the decision made upon some essential elements that might influence the health system performance. These are: defining the type of health system that is desired for Romania ā from the public/private mix perspective, introduction of market mechanisms that determine the increase of the public sector efficiency and making accountable all those involved in decision making, including the patients.
Arianna De Nicola, Simone Gitto, Paolo Mancuso, Vivian Valdmanis
Over the past twenty years, important changes in the Italian health system have led to different approaches in organizing, delivering and financing health services throughout the country's regions. In this paper, we assess the impacts that such changes have had on health efficiency. The analysis performed here is in two stages. In the first stage, healthcare efficiency is measured via bootstrapped Data Envelopment Analysis. In the second stage, the impacts of organizational and environmental variables on efficiency are investigated. Our results highlight that the organizational model adopted by the Lombardia region allows for the best results in healthcare efficiency in Italy. A process of administrative decentralization from the regional governments to local health units appears to be a source of inefficiency. Finally, patient mobility has a significant impact on healthcare efficiency.
Efficiency Analysis Using DEA
Health Systems, Economic Evaluations, Quality of Life
The aim of this chapter is to critically describe the evolution of the Spanish National Health System (NHS) in the last 25 years and its current situation. We will also revise the main reforms which are currently under debate. During these years, even with its ups and downs, the NHS has become a cornerstone of the Spanish welfare state. Mostly financed through taxes and with the predominance of public provision, the system has been able to incorporate the latest medical advances, offering quality health services almost universally. At the same time, in an ad hoc and rather hasty manner, the system has gone through a decentralization process that started with the devolution of health competences to the so-called historical regions, and was finally extended in 2002 to the 17 Spanish Autonomous Communities (ACs). These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
This paper selects potential proxy variables of public preference, analyzes the impact mechanism between public preference and social security expenditure, and focus on the relationship among fiscal decentralization, public preference and social security expenditure by using provincial panel data (1998-2006). The result shows that fiscal decentralization measured by different indicators is significantly correlative with fiscal social security expenditure and exists spatial heterogeneity. The decentralization of fiscal revenues and degree of fiscal self-financing are significantly negative with social security expenditure, while the decentralization of fiscal expenditure is significantly positive with social security expenditure. The potential proxy variables of public preference are less significantly with local governmentsā² social security expenditure behavior, which suggests the fact that the vertical social security expenditure mechanism is yet responded affectively to social pension voices.
In the Nordic countries, health care is an integral part of what is often termed the Scandinavian (or Nordic) model of the welfare state (Esping-Andersen 1990). Thus, health care is generally seen as a public responsibility, with universal access, negligible user fees, and a strong focus on equity (Martinussen & Magnussen 2009). In this chapter we discuss the Nordic model of health care primarily by focusing on one country, Norway.We also highlight similarities and differences between Norway and the other Nordic countries. While Norway is a small country in terms of population, it covers a large area and thus geographical equity is an important issue. This is reflected throughout the system; in structural issues, in choice of (political and administrative) governance models, and in choice of financing system. Although Norway, as are the other Nordic countries, is characterized by a tradition of locally elected governments (municipalities and counties), health policy and healthcare reforms in the past 15 years serve as illustrations of the potential conflicts between public articipation, local governance, and a stated goal of national equity. These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
Hana Brixi, Yan Mu, Beatrice Targa, David Hipgrave
China's current health system reform (HSR) is striving to resolve deep inequities in health outcomes. Achieving this goal is difficult not only because of continuously increasing income disparities in China but also because of weaknesses in healthcare financing and delivery at the local level. We explore to what extent sub-national governments, which are largely responsible for health financing in China, are addressing health inequities. We describe the recent trend in health inequalities in China, and analyse government expenditure on health in the context of China's decentralization and intergovernmental model to assess whether national, provincial and sub-provincial public resource allocations and local government accountability relationships are aligned with this goal. Our analysis reveals that government expenditure on health at sub-national levels, which accounts for ā¼90% of total government expenditure on health, is increasingly regressive across provinces, and across prefectures within provinces. Increasing inequity in public expenditure at sub-national levels indicates that resources and responsibilities at sub-national levels in China are not well aligned with national priorities. China's HSR would benefit from complementary measures to improve the governance and financing of public service delivery. We discuss the existing weaknesses in local governance and suggest possible approaches to better align the responsibilities and capacity of sub-national governments with national policies, standards, laws and regulations, therefore ensuring local-level implementation and enforcement. Drawing on China's institutional framework and ongoing reform pilots, we present possible approaches to: (1) consolidate key health financing responsibilities at the provincial level and strengthen the accountability of provincial governments, (2) define targets for expenditure on primary health care, outputs and outcomes for each province and (3) use independent sources to monitor and evaluate policy implementation and service delivery and to strengthen sub-national government performance management.
Mohammad Kurniawan, Deni Harbianto, Digna Niken Purwaningrum, Tiara Marthias
Despite Indonesiaās health status improvement over the last decade, special efforts to achieve the MDGs goals are still warranted, especially in maternal, neonatal, and child health (MNCH). However, the current centrally driven MNCH policies do not address the geographical disparities and the different constraints faced by Indonesian provinces and districts. Moreover, the MNCH slow progress may have been hindered by various funding constraints, for example small local budget allocation specifically for MNCH, lack of evidence-based budget planning leading to unsound health planning and implementation. Therefore, this study aims to assess the current health financing mechanism used in one of Indonesian Province of Papua, that has low MNCH outcome. This was an observational study using mixed-methods. Study subjects were from the Provincial and four selected District Health Offices in Papua Province of Indonesia. overnment official documents analysis and direct observations on the study subjects were done to assess the financing and budgeting for MNCH in Papua. The study shows a low commitment from the local government in MNCH priority areas. The main reason was that the largest share of MNCH funding still comes from Central Government (ABPN), whereas the proportion funded from local sources is relativity low. Furthermore, there is a very limited use of evidence-based financing and budgeting, mainly due to limited capability of the human resources for health as well as the largely undocumented epidemiological and health system data. This limited human resource capability also largely affected by the low commitment of the local government. Despite the relatively large amount of MNCH funding in Papua, human resource limitation poses a serious problem in scaling up for priority interventions. Low local government commitment is still the main obstacle in health budgeting policy. These problems may also applicable to other districts of Indonesia and as unanticipated effects from ill-designed health decentralization.
The ļ¬rst conversation excerpted above took place in an era when for-fee provisioning of health care services was ļ¬rst being established as a central feature of Russiaās broader, post-Soviet health care reforms. The second statement took place over a decade and a half later in the United States, just months after the Congress passed and President Obama signed historic legislation mandating comprehensive health care reform aimed at increasing coverage and aļ¬ordability. Despite their separation in time and space, these excerpts reveal a common cultural contradiction that plays out in contexts of market-oriented health care. These two health professionals simultaneously conļ¬rmed and rejected an approach to the exchange of health care as analogous to the exchange of any other consumer service, an approach captured in the aphorism āyou get what you pay for.ā When the Russian clinic chief backtracked to assert, āI canāt do bad work,ā she implicitly contested the widespread assumptions in health policy circles that physiciansā āinterestā in the outcomes of their work is derived solely from how well they are paid.1 For Valentina Pavlovna and many Russian doctors, at stake in the issue of whether women who paid actually obtained a superior quality of care was nothing less than their sense of professional pride and dedication. She had spent her entire career in the Soviet socialist model of free and universal health care, which charged physicians with the obligation of providing competent care to all patients for free as a matter of professional integrity. Yet she was reincarnating her clinic based on the popular notion that physiciansā expertise and dedication was only available if bought.2 Still, when asked directly about whether she endorsed inequalities of care based on ability to pay, she found herself unable to condone this practice as ethically acceptable. The US dental studentās statement is telling in that he phrased his perspective through caveats ā āIām not saying Iām like that, or anybody else in here is ā¦ but [the get-what-you-pay-for mentality is] kinda ingrained in people when they purchase anything.ā Implicitly, he denied that, as a health care professional, he would provide compromised care to the poor ā an admission that would seem to violate professional integrity if not also formal ethics. Yet at the same time, he suggested it would be reasonable for health care users to expect to receive worse quality care if they obtained those services for free or through reduced fees. Health policy planners and analysts would do well to contemplate this ambivalence characterizing the relationship between usersā fees, professionalsā integrity, and the presumed unequal quality of medical care. This ambivalence, I will show, stems from mixed cultural messages and uncertain criteria about entitlement, or about what diļ¬erent groups of physicians and patients are seen to deserve. Tacit understandings about entitlement are linked with actorsā expectations of their own and othersā obligation and responsibility; these understandings in turn shape the kinds of claims perceived as legitimate, and the resulting silences that characterize certain kinds of need; they also work as logics shaping the ways providers conceptualize their career choices and daily work practice. Indeed, cultural visions regarding various groupsā legitimate scope of entitlements and their related responsibilities stand in relation to each other in a systematic way and shape daily practice. Anthropologists refer to this interrelated set of concepts and practices as moral economies, or āconsensual assumptions about reciprocal obligationsā (Minkler and Cole 1997: 40), understanding āeconomiesā here to involve the circulation of goods, both material (such as money and beneļ¬ts) and non-material (such as dignity, integrity, entitlement, and social standing) ā and noting how these various types of goods are often intertwined. We analyze the ways in which moral economies serve as the implicit conceptual backdrop against which certain cultural practices are reproduced without question as āthe right thing to do,ā while other practices may be protested against as representing betrayals of justice or the violation of fairness (Thompson 1971). My goal in this chapter is to introduce the framework of moral economies to the study of health care policy planning and analysis in Russia and the United States. More speciļ¬cally, I suggest that eļ¬orts to improve access to care by addressing physician workforce issues have not adequately conceptualized the ways health providersā experiences, aspirations, and strategies are embedded in moral economies that deļ¬ne (if ambivalently and with contradictions) professional and patient entitlement and obligation. Examining the moral economies of health care and professional work through which providers in Russia and the United States make sense of their career decisions and daily practice will bring new and important insights into the challenges of increasing access to underserved populations. Both Russia and the United States have great needs to extend access and improve the quality of health care. The particular characteristics of these two countriesā health care systems and system needs are dramatically diļ¬erent: whereas Russiaās problems of access stem from gaps in what is supposedly a universal model of free health care, the USAās system of work-based insurance structurally ensures that tens of millions of citizens will face barriers to access because of lack of health care coverage.3 Russian health care reforms have focused on introducing new ļ¬nancing mechanisms while facilitating the emergence of private and semi-privatized services; in the USA, contrastingly, new health care reforms aim to extend insurance coverage and enhance the capacity of community-based, publicly funded clinics for rural and urban residents excluded by the market-based, private health care system. While these diļ¬erences are immensely important, it is also notable that, in both contexts, workforce issues entail a key part of eļ¬orts to address existing needs. In particular, health planners in both countries recognize that access and quality of care are intensely aļ¬ected by the situations and actions of physicians. Yet in neither context do planners recognize how physiciansā entanglement in access and quality of care issues is related to the moral economy of health care. This essay highlights the ways Russian and US physiciansā career decisions and daily practices regarding patient access to their services are aļ¬ected by culturally shaped notions of professional entitlement and patient worth, as well as the perceived symbolic worthiness of particular sectors of health care vis-Ć -vis the system as a whole. All of these are dimensions of the moral economy of health care. The section that follows examines the ways Russian health policy planners and analysts have deļ¬ned (and ignored) problems of access as they set about reforming their contemporary health care system. Mainstream discourses emphasize that barriers to access stem from doctorsā demands for illegal payments from patients; and reforms focus on raising physiciansā salaries. I then draw on my ļ¬eldwork, and more recent doctorsā blog-postings, to argue that low salaries alone do not explain physiciansā willingness to demand payments from patients ā physicians draw on cultural and symbolic understandings of how medical work is and should be valued; they make social assessments of what kinds of persons they are treating, what kinds of care these patients deserve, and what these patients should oļ¬er in return for medical treatment. Such culturally embedded calculations, which often remain tacit or discussed through providersā jokes, stories, and the like, play a signiļ¬cant role in shaping the tenor and character of professional work. In other words, improvements in access and quality do not result mechanistically from increased funding and higher salaries ā because material issues alone do not capture the notions of entitlement and responsibility through which physicians make sense of their daily work practices. We need to see material remuneration as part of the broader symbolic messages that the state and patients communicate regarding the value of medical work and diļ¬erent forms of expertise; in turn, the actions of physicians can be seen as commentaries on the varying social worth of diļ¬erent patient groups, the perceived legitimacy of certain kinds of diseases, and their sense of what experts owe to patients, the state, and themselves. I then turn to the US context, where health care reforms aim to promote physiciansā and dentistsā willingness to work in primary care and with underserved populations. Obamaās reforms increase the funding for, and work opportunities in, primary care as a way of recruiting new graduates, while medical and dental schools undertake programs to cultivate studentsā commitments to ācommunitiesā and āserviceā. Yet public health clinics not only pay less, they also represent lower symbolic value relative to private practice. Market-based health care orients itself to the interests of consumers ā those who pay for care ā whereas recipients of public welfare services are deemed āfailed consumersā, expected to be grateful for charity and not entitled to make demands. My ļ¬eldwork with dental students reveals how the disparate social worth of private and public clinics, their populations, and the meanings of work in each sphere get conveyed to new practitioners in training. Although committed faculty struggle to insist that under-served populations deserve high quality care, the structural organization of health care often confounds this message. Increased funding and pedagogical attention to the plight of the underserved importantly acknowledge the countryās gaping inequities, but these reform eļ¬orts do not substantially subvert the moral economy of market-based medicine; such radical change would require the cultural acceptance of dramatically new calculations of clinician entitlement and the social worth of public health ā a vision of clinicians as indebted to society for their training and opportunities, and a notion that all patients, regardless of social background, are entitled to high-quality services and dignity. The issue of health care access ā ensuring that all patients who need medical care can receive it ā is complexly intertwined with the transitions from a Soviet health care model to a post-Soviet one, whose ļ¬nancing procedures and legal guarantees are still being worked out some two decades after the collapse of the socialist system. Health care reforms are currently an oļ¬cial state priority, one of the 2006 National Projects that Putin established to reform governance and bring legitimacy to the state in the wake of several decades of massive cynicism towards decaying government services. The 1990s had witnessed an unprecedented public health crisis, characterized by skyrocketing rates of premature male mortality, plummeting fertility, the alarming spread of infectious disease, from tuberculosis to HIV, and more. While these indicators reļ¬ected the simultaneous conļ¬uence of multiple socio-economic disruptions and rapid cultural transformations, the Russian government also attributes part of the health care crisis to the poor funding and poor performance of the health care system itself (Ministerstvo 2009).4 Citing the ongoing declining population numbers and extraordinary high rates of mortality, throughout the 1990s conservative and nationalist critics of market reforms accused the Yeltsin government of causing the āgenocideā of the Russian people, which, they claimed, was ādying outā due in part to widespread unemployment, poverty, and a loss of social stability and values. Following this era, Putin built widespread legitimacy for his administration, in part through funneling portions of state revenues from higher oil prices into tangible beneļ¬ts for citizens, especially through the partial revival of the stateās withered system of social support. In the National Project for health care, these investments included increased funding to improve primary care, raise health care providersā salaries, build new medical clinics, and develop innovative methods and technologies ā all represented as signiļ¬cant initiatives to improve the quality and accessibility of medical care (Antonova 2007: 191). Given the fact that the Soviet health care system had one of the highest ratios of doctors to population in the world and a system of universal coverage, it is somewhat ironic that the country has been and continues to be plagued by serious problems of access at present. My ethnographic research and analysis of health policy debates in the 1990s found that barriers to access were created not only by ļ¬nancial need, but by pervasive cultural dynamics too: providers evaluated patientsā social worth by assessing their apparent education and ācultural levelā, as well as the type of condition patients had. Even at present, patients with HIV and other STIs face shaming and prefer to seek care at specialized AIDS centers rather than mainstream clinics (Bendina 2009). Exclusionary tactics against those deemed to have a ālow level of cultureā are common, with the result that patients who felt berated distrusted the medical professionals and were reluctant to use their services (Rivkin-Fish 2005). Rusinova and Brown (2003) found that access to care depended on the networks and social skills that patients were able to deploy to maneuver around bureaucratic obstacles and pervasive mistrust. Patientsā strategies, and their success in obtaining high quality services, differed according to their social strata and the related social and cultural capital they could mobilize. My research further explored the speciļ¬c ways in which patientsā strategies and networking aļ¬ected providersā sense of personal obligations to provide especially attentive care. Close acquaintance relations facilitated access not merely to medical services, but even more importantly, to trustworthy, satisfying relations with providers. The acquaintance relationship in turn helped physicians, as they were more likely to have their expertise acknowledged and valued when they shared a personal connection with patients (Rivkin-Fish 2005). Certainly, personalized relations compromised the possibility of equity in health care; yet the perceived ethical character of these relationships, and the kinds of (inadequate) solutions they achieved to the problems of mutual distrust and enmity between doctors and patients, have not been addressed in policy debates, which often caricature these relations as simply exploitative and extortionist. Until the late 1990s, many Russian health providers expressed great ambivalence about the introduction of fee-based health care, seeing required monetary payments as unethical and creating compromises in professional integrity. Physicians trained during the Soviet era described entering medicine as a calling, an arena in which scientiļ¬c knowledge could be applied in an apolitical career that provided humanitarian-oriented workers with the satisfaction of saving lives. The ļ¬nancial remuneration was less than in other professional ļ¬elds, but the sense of mission was invaluable. Yet, as Russian society underwent broader shifts driven by the profoundly transformative ubiquity of consumer culture, professionals began to redeļ¬ne cultural expressions of self-respect, and their expectations for a digniļ¬ed middle-class lifestyle transformed: markers of success (or failure) now became read in the clothing one wears, the mode of transportation one takes, the holiday destinations one chooses, the state of disrepair or remodeling of oneās apartment. The signiļ¬cance of oneās professional occupation became increasingly interpreted on the basis of whether it enabled culturally emerging aspirations to consume expensive goods. Male physicians told me their marriages were threatened because they were committed to practicing medicine in public hospitals and not demanding money from the poor; women physicians described being able to continue with their career only because they had ārichā husbands who agreed to support their āuncompensatedā calling. Many worried about how they would fund their childrenās higher education as tuition payments were becoming more common. The economic crisis that medical professionals confronted was thus experienced as at the same time a piercingly unjust material deprivation, a traumatic source of life-altering interpersonal loss, and a cruel attack on the social value of their professional role. The focus of health care reforms as early as 1993 centered on creating new ļ¬nancing models that would decentralize and shift the ļ¬ow of resources away from the state as a monolithic funder. Policy makers roundly celebrated ideas of competition, fee-for-service, and salary diļ¬erentiation for performance as solutions to the problems created by the Soviet system, almost never considering how market mechanisms in health care would aļ¬ect access to care for the poor and socially marginalized or providersā own well-being. A brief examination of the actual realities wrought by this new ļ¬nancing model reveals both the ideological character of these reforms, and their narrow, mechanistic understanding of the social dynamics that shape access to care. In the new ļ¬nancing system, employers and municipal governments were required to make contributions to quasi-governmental health insurance funds (OMC). Each of Russiaās eighty-nine regions (except Chechnya) has its own fund, a situation that contributed to decentralized policies and signiļ¬cant variation across the country. The employer payroll tax for medical insurance of workers was set at 3.6 percent, an amount that both insurance fund directors and chief doctors decried as severely low, as reported in Judyth Twiggās survey conducted in 2000 (2002: 2260). Municipal governments made contributions on behalf of the non-working population. They determined their payments on a per capita basis, with the amount decided by each individual region (Twigg 2001: 204). The federal government was also to continue payments to health care, but the amount was small and expected to gradually diminish as an overall percentage of health care ļ¬nancing (Curtis et al. 1995: 760). In the year following Russiaās ļ¬nancial crisis of 1998, the funding for health care as a proportion of GDP dropped by 30 in to in by it had to of GDP (Ministerstvo the per capita paid by regions was the actual throughout the Russian from a low of per capita paid in the of to a high of per capita in (Ministerstvo In the early that, in many the funds were with private insurance is to the of patients and quality (Twigg Even at that time, doctors and other critics the of insurance funds and private insurance which represent an of have been expressed that these were payments for the health care system for personal in In somewhat that insurance to be facilitating the of insurance but the mechanisms and that employers were not the amount they Indeed, to reforms as early as et al.
The issue of small and declining health sector financing by the central and state governments in India is addressed by the launching of National Rural Health Mission in 2005-06. Bottom up planning starting with village as unit used as the main strategy of NRHM to meet the region specific health needs would serve well to promote health sector development. The provision of effective and quality health services with a special focus on the backward districts with weak human development is also slated to be an important objective of NRHM. Analyzing the district level NRHM funds flow and expenditure in Karnataka the present paper argues that the district wise allocations are wrought with poor expenditure planning. Program implementation plans and allocations significantly vary from one another. Such deviations in the earmarking of planned funds defy the very purpose of stringent bottom up planning involving colossal manpower and financial resources to track the grass root felt needs. In addition such aberrations do not help the government in the achievement of professed outcomes. This is a serious lapse in NRHM implementation and can seriously distort the effectiveness of public spending and to be taken care of in future. Utilisation of the allocated resources is poor and there is absolute mismatch between the planned estimates for important components of NRHM like RCH, NRHM additionalities, Disease control program and Immunisation and actual expenditure. Enhancing the government health sector financing in a big way to reach 2-3 percent mark of GDP by 2012 has been an important objective of National Rural Health Mission (NRHM) launched by the Government of India in 2005-06. Both the Central and state governments share the responsibility of enhancing the government spending. As we get closer to 2012, it is necessary to review the success of the NRHM in enhancing the health sector funding by the government, more importantly to know how effectively these funds have got transmitted to the grass root level to be translated to healthcare services. Regarding the aggregate funding of the health sector at the national level to reach 2-3 percent level, it has been observed that while the health sector outlay as a percent of GDP has been increasing ever since the launch of NRHM, it is unlikely that the goal of 2-3 percent of GDP would be reached by 2012. (Berman et al, 2010) At the grassroots level important issues in translating outlays into outcomes relate to whether funding reflects the local needs as identified in the Program Implementation Plan (PIP); whether adequate and timely funding is provided to the health facilities in the districts; whether the backwardness focus that NRHM professes to achieve is attained or not. This gains special importance in the context of NRHM policy pronouncements to provide accessible, affordable, accountable, effective and quality healthcare services, especially to the rural population and vulnerable groups throughout the state with special focus on the backward districts with weak human development and health indicators especially among the poor and marginalized groups like women and the vulnerable sections of the society. (NRHM, Mission document, 2005) The main strategy of the NRHM adopted for the purpose is the decentralized planning in the form of health plans prepared starting with village as a 1 Faculty of Economics, Institute for Social and Economic Change, Nagarabhavi, Bangalore 560072 can be reached at gayithri@isec.ac.in
Abstract The aim of this paper is to better understand the impacts of a decentralized public health delivery system of the Philippines on local government spending. Specifically, it investigates determinants of local government public health expenditures for the year 2007. Within the context of the Philippines' decentralized health system, particular emphasis is given to horizontal fiscal interactions. The research addresses these issues in an empirical spatial econometric framework utilizing public finance local government data. A key finding is the positive fiscal interaction among local governments that is consistent with competition for scarce resources such as doctors, as well as competition among political actors prior to elections. The policy implications of these results are also discussed.
Using cross-country analysis and case studies, this book provides new insights and potential policy responses for the key fiscal policy challenges that both advanced and emerging economies will be facing.
The Italian National Health System (NHS), established in 1978, follows a model similar to the Beveridge model developed by the British NHS (Beveridge 1942; Musgrove 2000). Like the British NHS, healthcare coverage for the Italian population is provided and financed by the government through taxes. Universal coverage provides uniform healthcare access to citizens and is the characteristic usually considered the added value of a welfare system financed by tax revenues. Nonetheless, in Italy the strong policy of decentralization, which has been taking place since the early 1990s, has gradually shifted powers from the state to the 21 Italian regions. Consequently, the state now retains limited supervisory control and continues to have overall responsibility for the NHS in order to ensure uniform and essential levels of health services across the country. In this context, it has become essential, both for the ministry and for regions, to adopt a common performance evaluation system (PES). This article reports the definition, implementation, and first evidences of a pilot PES at a national level. It shows how this PES can be viewed as a strategic tool supporting the Ministry of Health (MoH) in ensuring uniform levels of care for the population and assisting regional managers to evaluate performance in benchmarking. Finally, lessons for other health systems, based on the Italian experience, are provided.
Western countries with strong primary care systems organize their health services around this healthcare modality, which serves as a gateway to the system and is characterized by multidisciplinary teamwork, management transferred to the teams and a broad services portfolio. The contractual relationship between professionals and the public health system is a useful tool to modulate the efficiency of services and their ability to meet the expectations of citizens and professionals. Some countries choose to contract professionals directly, either individually or through a professional organization, an option known as a self-management system. Others opt to contract public or private entities, which in turn recruit health professionals as employees. In the latter countries, the concept of management decentralization and managerial autonomy has arisen. In Spain, only Catalonia has enabled professional entities to be hired to provide public health services, through commercial formulas, i.e. in a competitive market relationship. This relationship allows the use of corporate governance mechanisms that are not subject to public control through state intervention. The other forms of management promoted in Spain to avoid the controls of state intervention - foundations or associations - have been unsuccessful, except in the autonomous region of Valencia and some models in the autonomous region of Madrid.
Open access
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
Under traditional health insurance arrangements, citizens were covered by some insurance scheme.When sick, insurance arrangements allowed citizens to go to a health care provider, pay the price of the care received and be reimbursed later.Alternatively, the care provider would be owned by the insurer (like in integrated national health systems) and the patient paid nothing at the moment of consumption.In such arrangements, providers would freely set their prices or have no price to set at all (in an NHS-like system).Recent developments in health care financing include independent institutions that negotiate the prices with the financing institution.This is true with respect to health maintenance organizations (HMOs), managed care in general, but also in national health systems where decentralization and the split between provision and financing is implemented.In this scenario, negotiation over contractual terms, including prices as one major element, becomes a relevant issue in the analysis of performance of health care systems.Both empirical and theoretical analyses have been produced, and are reviewed below.This chapter reflects our views and preferences.It does not aim to be an encyclopaedic view of the existing literature on bargaining in health care.Instead, we try to highlight the new developments associated with explicit bargaining between third-party payers and providers of health care (a relation which is, in itself, only one of many that exist in the health care sector).Bargaining theory has a long tradition in the economics literature.However, it is only recently that this approach has found space in the analysis of the health care sector.The recognition of the strategic interaction among agents in the health care sector (patients, providers and third-party payers) came with the application of models borrowed from the industrial organization tradition dating from the 1970s.It was in the early 1990s when a step forward was taken with the eruption of the models of bargaining (see for example, Osborne and Rubinstein, 1990, for a nice presentation) In many situations the health care sector has the structure of a bilateral monopoly/oligopoly.In this context, bargaining becomes the natural way to approach the interactions among agents.Most economic analyses of contract design in health care in fact assume that the party that moves first, typically the payer, proposes a take-it-or-leave-it offer to the provider.We take here a broader view, looking at other types of negotiation procedures.We do not discuss issues related to contract design, which are taken up in chapter 22 by Chalkley in this Companion.We focus here on models of explicit bargaining between two parties, which we call the payer and the provider.On theoretical grounds, simple bargaining models can have their results transposed in a straightforward way: higher bargaining power and higher M2835-JONES9781849802673PRINT.
Public health expenditure is an important part of fiscal expenditure.With the establishment of the public finance system,it is important to define the ratio of public health expenditure in the fiscal expenditure reasonably.The paper uses panel data to analyze empirically what factors influence spending behaviors of local governments on health in China.The result indicates that there exists a certain correlation between economic development,population size,urbanization and local public spending on health.There is no necessary relation between population structure,the organization and official amount expan sion and public health expenditure.The fiscal decentralization has only a small negative effect on the public health expendi ture.