Trisya Rakmawati, Reece Hinchcliff, Jerico Franciscus Pardosi
The local-level impacts of decentralizing national health systems are significant yet infrequently examined. This review aims to assess whether localized health services delivery in Indonesia, which commenced a health system decentralization process in 2001, achieved its objectives or could be enhanced. A systematic review was undertaken to collate published evidence regarding this topic and synthesize key findings holistically using the six building blocks framework of the World Health Organization (WHO) to categorize health system performance. Four research databases were searched in 2016 for relevant evidence published between 2001 and 2015. The inclusion criteria were relevance to the topic of decentralization impacts at the district level, original research, and published in English. Included articles were appraised for quality using a standardized tool, with key findings synthesized using the WHO building blocks. Twenty-nine articles met the inclusion criteria and categorized under the WHO building blocks categories. The findings highlight problematic impacts of decentralization related to three building blocks: service delivery, health financing, and workforce. In the 15 years of post-decentralization in Indonesia, the service delivery, health workforce, and health financing blocks should be prioritized for further research and policy evaluation to improve the overall health system performance at the district level.
BACKGROUND: Universal health coverage (UHC) assures all types of health service and protects all citizens financially in any conditions due to illness. Globally, the UN sustainable development goal (SDG) provides high priority for UHC as a health related goal. The National health system of Nepal has prioritized in similar way. The aim of this study is to explore the challenges and opportunities on the road to UHC in Nepal. METHOD: We used varieties of search terminologies with popular search engines like PubMed, Google, Google Scholar, etc. to identify studies regarding Nepal's progress towards UHC. Reports of original studies, policies, guidelines and government manuals were taken from the web pages of Ministry of Health and its department/division. Searches were designed to identify the status of service coverage on UHC, financial protection on health particularly, health insurance coverage with its legal status. Other associated factors related to UHC were also explored and presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. RESULTS: We found 14 studies that were related to legal assurance, risk pulling and financing of health service, 11 studies associated to UHC service coverage status and, 7 articles linked to government stewardship, health system and governance on health care. Constitutional provision, global support, progress on the health insurance act, decentralization of health service to the grass root level, positive trends of increasing service coverage are seen as opportunities. However, existing volunteer types of health insurance, misleading role of trade unions and high proportion of population outside the country are main challenges. The political commitment under the changing political context, a sense of national priority and international support were identified as the facilitating factors towards UHC. CONCLUSION: To achieve UHC, service and population coverage of health services has to be expanded along with financial protection for marginalized communities. Government stewardship, support of stakeholders and fair contribution and distribution of resources by appropriate health financing modality can speed up the path of UHC in Nepal.
The 2012 national health policy is the \n overarching health policy framework in Zambia. The policy \n takes a human rights approach to health care provision, \n where all citizens are entitled to basic health care \n (Ministry of Health 2012). The policy is actualized through \n successive five-year national health strategic plans. \n Operationally, Zambia’s health system is centralized, with \n delegated responsibilities from the center to lower levels \n of the health care delivery system. The Ministry of Health \n plays a dual role of policy formulation and strategic \n planning and delivery of health services, with provincial \n and district health offices being upwardly accountable to \n the Ministry of Health headquarters. Going forward, Zambia \n is in the process of launching two major reforms which will \n further affect the organization of the health sector. These \n are (a) implementation of the National Decentralization \n Policy, and (b) introduction of a National Health Insurance \n (NHI) scheme. The PHC function (including transfer of PHC \n staff to local government authorities) is among the front \n runner for decentralization. If national decentralization is \n fully implemented, it will affect the way health services \n are organized, delivered, and financed in the country. Thus, \n adequate preparations in the health sector are required to \n minimize challenges. Secondly, Zambia enacted the NHI Act in \n April 2018 which provides the legal mandate to establish the \n NHI management authority, and the NHI scheme. At the time of \n this study, it was envisaged that implementation of the NHI \n scheme will be done in a phased manner with a view of \n covering the entire population in the medium to long term. \n However, depending on the final design and implementation \n process, the NHI will have a substantial effect on the \n financing and delivery of health programs and services in \n Zambia. One of the immediate challenges will be providing \n insurance cover to the informal sector and indigent people \n in rural areas.
Decentralization has been promoted as a strategy to bring decision-making closer to local levels where people know better their needs. In the health sector, however, the evidence for its effectiveness has been mixed. This PhD thesis analyzed the effectiveness of decentralization in improving the health sector by focusing on the Philippines where health services were decentralized through devolution to local governments in 1992. \n \nDrawing from the “decision space” approach and using mixed methods, this thesis determined the conditions that enable decentralization to be effective by analyzing the perspectives of decision-makers in the Philippine health system. Decision-making was explored in the functions of: planning; financing and budget allocation; program implementation and service delivery; management of facilities, equipment, and supplies; health workforce management; and data monitoring and utilization. The interplay between decision space and capacity and accountability in optimizing decision-making for these functions was further analyzed. The thesis then developed a systematic review protocol to assess the global evidence on decentralization’s effectiveness. \n \nThis thesis concludes that changing the structure of governance through decentralization will not enhance service delivery unless certain conditions are met. It is recommended that decentralized countries like the Philippines emphasize capacity building of local decision-makers to perform their functions better, enforce accountability mechanisms to promote good decision-making at local levels, and deploy a combination of decentralized and centralized functions that will be optimal for the health system.
Joshua Ssebunnya, S. Kangere, James Mugisha, Sumaiyah Docrat · 7 authors
BACKGROUND: In spite of the pronounced adverse economic consequences of mental, neurological, and substance use disorders on households in most low- and middle-income countries, service coverage and financial protection for these families is very limited. The aim of this study was to generate potential strategies for sustainably financing mental health care in Uganda in an effort to move towards increased financial protection and service coverage for these families. METHODS: The process of identifying potential strategies for sustainably financing mental health care in Uganda was guided by an analytical framework developed by the Emerging Mental health systems in low and middle income countries (EMERALD project). Data were collected through a situational analysis (public health burden assessment, health system assessment, macro fiscal assessment) and eight key informant interviews with selected stakeholders from sectors including health, finance and civil society. The situational analysis provided contextualization for the strategies, and was complimented by views from key informant interviews. RESULTS: Findings indicate that the following strategies have the greatest potential for moving towards more equitable and sustainable mental health financing in the Uganda context: implementing National Health Insurance Scheme; shifting to Results Based Financing; decentralizing mental health services that can be provided at community level; and continued advocacy with decision makers with evidence through research. CONCLUSION: Although several options were identified for sustainably financing mental health care in Uganda, the National Health Insurance Scheme seemed the most viable option. However, for the scheme to be effective, there is need for scale up to community health facilities and implementation in a manner that explicitly includes community level facilities.
BACKGROUND: Decentralization is promoted as a strategy to improve health system performance by bringing decision-making closer to service delivery. Some studies have investigated if decentralization actually improves the health system. However, few have explored the conditions that enable it to be effective. To determine these conditions, we have analyzed the perspectives of decision-makers in the Philippines where devolution, one form of decentralization, was introduced 25 years ago. METHODS: Drawing from the "decision space" approach, we interviewed 27 decision-makers with an average of 23.6 years of working across different levels of the Philippine government health sector and representing various local settings. Qualitative analysis followed the "Framework Method." Conditions that either enable or hinder the effectiveness of decentralization were identified by exploring decision-making in five health sector functions. RESULTS: These conditions include: for planning, having a multi-stakeholder approach and monitoring implementation; for financing and budget allocation, capacities to raise revenues at local levels and pooling of funds at central level; for resource management, having a central level capable of augmenting resource needs at local levels and a good working relationship between the local health officer and the elected local official; for program implementation and service delivery, promoting innovation at local levels while maintaining fidelity to national objectives; and for monitoring and data management, a central level capable of ensuring that data collection from local levels is performed in a timely and accurate manner. CONCLUSIONS: The Philippine experience suggests that decentralization is a long and complex journey and not an automatic solution for enhancing service delivery. The role of the central decision-maker (e.g. Ministry of Health) remains important to assist local levels unable to perform their functions well. It is policy-relevant to analyze the conditions that make decentralization work and the optimal combination of decentralized and centralized functions that enhance the health system.
Moritz Piatti-Fünfkirchen, Magnus Lindelöw, Katelyn Jison Yoo
Progress toward universal health care (UHC) in Africa will require sustained increases in public spending on health and reduced reliance on out-of-pocket financing. This article reviews trends and patterns of government spending in the East and Southern Africa regions and points out methodological challenges with interpreting data from the World Health Organization's (WHO) Global Health Expenditure Database (GHED) and other sources. Government expenditure for health has increased for most countries, albeit at a slower rate than gross domestic product (GDP). In most countries there has been a prioritization away from health in government budgets, putting the onus on the private sector and donors to fill the gap. Donor support is important in the region but reliance on external spending is not consistent with countries' stated ambitions of universal health coverage. A number of methodological challenges with estimating health expenditures are identified. Capturing health expenditures adequately across agencies and levels of decentralization can be challenging, and off-budget funds and arrears are evasive. Measurement error can be significant because actual expenditure information can be hard to come by and is often dated and unreliable. Furthermore, how external financing is captured will affect government health expenditure estimates. These factors have contributed to differences in expenditure estimates between the WHO GHED and country-specific public expenditure reviews and complicate interpretation. The article concludes that it is critical to strengthen national data capacity and international efforts to promote quality and consistency of data. The GHED is an invaluable resource for monitoring and benchmarking health expenditures. It is best used in combination with deep dive country expenditure assessments.
BACKGROUND & OBJECTIVES: Numerous studies have highlighted the regressive and immiserating impact of out-of-pocket (OOP) health spending in India. However, most of these studies have explored this issue at the national or up to the State level, with an associated risk of overlooking intra-State diversities in the health system and health-seeking behaviour and their implication on the financial burden of healthcare. This study was aimed to address this issue by analyzing district level diversities in inequity, financial burden and impoverishing impact of OOP health spending. METHODS: A household survey of 62,335 individuals from 12,134 households, covering eight districts across three States, namely Gujarat, Haryana and Rajasthan was conducted during 2014-2015. Other than general household characteristics, the survey collected information on household OOP [sum total of expenditure on doctor consultation, drugs, diagnostic tests etc. on inpatient depatment (IPD), outpatient depatment (OPD) or chronic ailments] and household monthly consumption expenditure [sum total of monthly expenditure on food, clothing, education, healthcare (OOP) and others]. Gini index of consumption expenditure, concentration index and Kakwani index (KI) of progressivity of OOP, catastrophic burden (at 20% threshold) and poverty impact (using district-level poverty thresholds) were computed, for these eight districts using the survey data. The concentration curve (of OOP expenditure) and Lorenz curve (of consumption expenditure) for the eight districts were also drawn. RESULTS: The distribution of OOP was found to be regressive in all the districts, with significant inter-district variations in equity parameters within a State (KI ranges from -0.062 to -0.353). Chhota Udepur, the only tribal district within the sample was found to have the most regressive distribution (KI of -0.353) of OOP. Furthermore, the economic burden of OOP was more pronounced among the rural sample (CB of 19.2% and IM of 8.9%) compared to the urban sample (CB of 9.4% and IM of 3.7%). INTERPRETATION & CONCLUSIONS: The results indicate that greater decentralized planning taking into account district-level health financing patterns could be an effective way to tackle inequity and financial vulnerability emerging out of OOP expenses on healthcare.
Based on the principles of universality and equality and the guideline of integrality, the Brazilian Public Healthcare System, called Unified Health System (SUS), was constituted as a regionalized and hierarchical services network. There is the recognizing of interdependence between municipalities and between levels of government to guarantee the provision of services. The Union and the states share with the municipalities the responsibility for guaranteeing the constitutional right of access to health goods and services in the country, increasing the requirement for actions cooperation and coordination between the three levels of government. To respond to these questions, intergovernmental relations have undergone progressive transformations since the creation of the system. Recently, in a context of reducing federal social spending, the demand for lesser Union regulation has increased, with changes in federal funds allocation. In the light of the institutional trajectory of the last three decades, as well as the literature on decentralization in health and federalism and social policies, the text has the aim of analyzing the change occurred in 2017 in the form of federal transfers in the SUS. Considering these contributions, the study stresses that the results of decentralization may be negative for efficiency in management and for equity in access to health services. It also emphasizes the relevance of coordination arrangements and mechanisms to improve the health policy outcome and effectiveness in system management. Analyzing the worsening of the financing of the SUS, with a probable reduction of the participation of the Union in the allocation of health resources due to the freezing of its minimum application by EC 95, the study points to the risk of transferring greater responsibilities to states and municipalities, already undermined by underfunding in the health area. Consequently, this changing can cause a reduction in the coordination capacity of the system, a loss of effectiveness, an increase in competition and fragmentation, and an increase in the inequality of access to health goods and services in the country.
Adelyne Maria Mendes Pereira, Luciana Dias de Lima, Cristiani Vieira Machado
This article discusses the processes of de centralization and regionalization of health policy in Brazil and Spain between 1980 and 2015. The study was developed with contributions of the historical institutionalism and of the historical com parative method, by means of three dimensions of analysis: State context; trajectory and institution ality of the decentralization and regionalization of health; and constraints. The study showed that,in both countries, the more general context of re-democratization and decentralization of the State conditioned the reforms of health systems and their political-administrative organization. In addition, historical, institutional and political factors have had a specific impact in each case, influencing the regional organization of services, the balance of power and the division of responsibilities between the governmental spheres in the management, financing and coordination of health policy. The study suggests that the way these factors interrelated over time is important for understanding the decentralization and regionalization of health systems in different contexts.
José Carvalho de Noronha, Gustavo Souto de Noronha, Telma Ruth Pereira, Ana Maria Costa
This article reflects on the future of the Brazilian Unified Health System (SUS, acronym in Portuguese), based on the foresight exercises conducted by the Brasil Saúde Amanhã initiative of the Oswaldo Cruz Foundation. The text briefly reviews some paths followed by the SUS as referred to in the Federal Constitution of 1988. It highlights the movement towards the decentralization of care and the constraint of health financial resources that reduced policies of increasing public expenditures. It examines the public and private arrangements for financing and provision of services that have resulted in sectoral privatization, mainly from economic policies articulated with concession of fiscal benefits. It analyzes the changes in the public sector financing through successive constitutional amendments that resulted in the weakening of established social protection policies, particularly of the health sector. For the future, the text considers population aging and analyzes trends in the epidemiological profile, with consequent changes in the health care paradigm. The article concludes by pointing out the consequences of fiscal strangling in the organization of the healthcare system and the need to reverse legal provisions that hamper the fulfillment of the constitutional mandate for equity and universality.
Background: Governments engage in setting health sector priorities among competing interests to maximize health system goals within the available resources. This is important as misalignment between health priorities and budget allocations can lead to low budget allocations and underspending in the health sector.\nGoal: The goals of the study are twofold. First, measure the extent of alignment between a stated government priority and actual government expenditure. Second, if there is misalignment, explain the underlying bottlenecks including institutions, structures, and capacities.\nMethod: The study focuses on one stated health sector priority shared between Kenya and Mozambique, which is improving geographical equity of governmental resources for health. An explanatory mixed methods design is used, in which quantitative analysis is followed by a qualitative assessment. In quantitative analysis, Gini index is used to summarize the differences in per capita health expenditures across regions. In addition, health expenditure is decomposed as a product of total budget, health budget priority, and health budget execution to identify whether resource allocation or resource utilization lead to geographical inequity. The qualitative assessment consisted of 23 semi-structured key informant interviews, 10 for Kenya, 11 for Mozambique, to explain the quantitative results.\nResults: In both Kenya and Mozambique there is geographical inequity in government health spending, which is inconsistent with the stated government priority (Gini greater than zero). The decomposition of health expenditure suggests that, in Kenya, the misalignment is driven by both resource allocation and utilization processes; in Mozambique, it is driven largely by the resource allocation process. \nThe qualitative analysis reveals several bottlenecks that are common between the two countries. At the institutional level, there is institutional separation between planning and budgeting, decision-making is ad hoc, and difficult decisions on hard choices and tradeoffs are left to the end of the budget process. At the structural level, rapid and unplanned decentralization in Kenya and the deconcentration model in Mozambique have led to inadequate structures to align planning and budgeting. At the capacity level, there are too many administrative demands on planning and budgeting staff, who also lack technical expertise and adequate data to make evidence-based decisions.
Mehdi Jafarı, Amin Habibirad, Arefeh Pourtaleb, Mohammad Hossein Salarianzadeh
BACKGROUND: Since the early 1990s, Iran has initiated structural and decentralization reforms in the hospital system. This policy led to the formation of a Board of Trustees (BOTs) for the governing of public educational hospitals and making important modifications in hospitals' financing. This study was conducted to identify the barriers in implementing this policy. METHODS: All the Iranian Medical Sciences Universities and hospitals involved in the policy implementation were included in this qualitative study. The data were analyzed by using content analysis. RESULTS: In total, 403 problems were divided into 9 classes including problems related to implementing regulation, financial problems in policy implementation, problems related to faculty members, ambiguity in executive regulation, problems related to the BOTs, authority level, hospital structure, the quality and quantity of hospital human resources, and fee for services. CONCLUSION: It appears that "implementing regulation" and "financial problems" embrace over 50% of the barriers. Apparently, the new approach to hospitals' autonomy has not achieved the desired goals. Considering the contextual factor, the evidence and identification of the clear role of various stakeholders should be essential determinants. Partial implementation of this policy without paying attention to the other aspects would end in failure. The results showed insufficient budget to be the most influential factor that posed a dilemma in implementing the BOTs' policy. However, BOTs in Iranian health system need to strive toward a higher level of performance that will improve effectiveness and efficiency now more than ever.
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
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.
Brian M. Till, Alexander W. Peters, Salim Afshar, John G. Meara
Blockchain technology and cryptocurrencies could remake global health financing and usher in an era global health equity and universal health coverage. We outline and provide examples for at least four important ways in which this potential disruption of traditional global health funding mechanisms could occur: universal access to financing through direct transactions without third parties; novel new multilateral financing mechanisms; increased security and reduced fraud and corruption; and the opportunity for open markets for healthcare data that drive discovery and innovation. We see these issues as a paramount to the delivery of healthcare worldwide and relevant for payers and providers of healthcare at state, national and global levels; for government and non-governmental organisations; and for global aid organisations, including the WHO, International Monetary Fund and World Bank Group.
IntroductionHealth is the foundation of an engaged and happy life, and modern humans have been the fortunate beneficiaries of great advances in medical technology (Collins, 2015). With each new technology, more clues become available to decipher the problems that plague our well-being. The advent of individualized information from cheaper genome sequencing, the Internet of
Marcelo Battesini, Carla Lourenço Tavares de Andrade, Marismary Horsth De Seta
Health Surveillance carries out a set of actions to prevent health risks related to the consumption of products and the provision of services under the Unified Health System (SUS). The implementation of Health Surveillance actions relies heavily on the federal funding policy, which induces its decentralization. This text aims to analyze the federal funding of Health Surveillance to States and Municipalities from the scheduled onlendings in the period 2005-2012. Among the main results are the increase of per capita values, steady at around the mean value of R$ 1.25/inhabitant/year; the increased number of municipalities that agreed to carry out strategic actions; and a stable trend in the proportions of each federated entity at around 50% to Municipalities, 25% to state federated entities and 20% to the Central Public Health Laboratories (LACENs). Results show that the adoption of unified nationwide per capita values caused distortions that indicate inequity among state territories, pointing to the need to clarify the concept of equity in financing under the National Health Surveillance System and to broaden the discussion on the currently used allocation criteria.
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.
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.
Hilaire Zon, Milena Pavlova, Koiné Maxime Drabo, Wim Groot
'Four' types of decentralization are distinguished in health care: deconcentration when the shift in authority is to regional or district offices; devolution when the shift is to state, provincial or municipal governments; delegation when semi-autonomous agencies are granted new powers; and privatization when ownership is granted to private entities. This article systematically reviews the experiences of local governments of Sub-Saharan African countries with the provision of health services during and after decentralization reforms. The article highlights the achievements, challenges and issues associated with decentralization. The review shows that most countries have mainly focused on the process by enacting numerous policies, regulations and standards with mixed outcomes for health services delivery. Decentralization in general, and resource transfer from the central to local governments in particular, are a highly political issue that influences the health reform strategy on decentralization. The literature shows the complexity of implementing decentralization schemes which strongly impact the health service organization and delivery. The theory of decision space applied in a comparative analysis found that some functions, particularly financing, remain under the control of the central state. Despite the numerous challenges, this review identifies some good practices in resources transfer, key determinants being the type of decentralization and the government's will to make legislative and administrative changes required for the effectiveness of decentralization. The literature search, even though systematic, resulted in a limited number of relevant publications with evidence on the link between decentralization and health services delivery. This is a largely unexplored research area, especially the use of financial resources by local governments, the factors that drive local decision-making processes and the effects of decentralization on health care sector performance.