The aim of this work is to investigate the relationship between budget constraints and local healthcare expenditure, in light of the process of decentralization ongoing in the country. The analysis is conducted with particular reference to the experience of the Lazio region. This document aims at highlighting those elements of the relationship between federalism and healthcare, which tend to weaken regional financial autonomy. The theme of the relationship between regions and finance, not much investigated so far, is analyzed giving particular attention to the limits of the current financing model of regional healthcare systems.
The Kenya government has over the years reiterated its commitment towards the provision of quality primary health care (PHC) to her populace.The various macroeconomic performance experienced in the late 1980s and early 1990s, however affected the government's ability to sustain the continued provision of PHC.This is not only demonstrated by the high out-of-pocket spending but also low budgetary allocation currently estimated at less than ten (10) percent.The funding levels have negatively affected the ability of the poor to access primary health care while the quality of health care provided has equally been a concern as witnessed by high incidences of lack of essential drugs and other medical supplies, low morale amongst the health personnel involved in the provision of primary health care, lack of medical equipments in most facilities and skewness in the deployment of staff countrywide.The objective of the study was therefore to examine the various alternative financing mechanisms to mitigate against the trends, Since various financing mechanisms have been suggested for consideration.In the study it was found that providers of these services prefer financing mechanisms that pool funds together to ensure that the poor and other vulnerable are cushioned against the catastrophic health expenditure.Other mechanisms favored included establishment of specific taxes to finance health care, and where possible consider issuance of health infrastructure bonds to facilitate construction of modern health facilities across the country within the decentralized framework of counties.Although these mechanisms sound promising, their success will depend not only on political and leadership commitment but also on the ability to identify the poor and where possible provide the necessary safety nets such as waivers and exemptions.It will also be necessary to establish the necessary legal framework that will spearhead the collection and management of the funds collected.
This analysis of the Latvian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. After regaining independence in 1991, Latvia experimented with a social health insurance type system. However, to overcome decentralization and fragmentation of the system, the National Health Service (NHS) was established in 2011 with universal population coverage. More recently, reforms in 2017 proposed the introduction of a Compulsory Health Insurance System, with the objective of increasing revenues for health, which links access to different health care services to the payment of social health insurance contributions. In June 2019 the implementation of this proposal was postponed to 2021. Latvia has recovered from the severe economic recession of 2008, which resulted in the adoption of austerity measures that significantly affected the health care system. The recovery has created fiscal space to focus on policy challenges neglected in the past, especially regarding health. Despite recent increases in spending, the health system remains underfunded and resources have to be allocated wisely. Latvia's health outcomes should be considered within this context of limited health system resources. While life expectancy at birth in Latvia has increased since 2000, reaching 74.9 years in 2017, it remains among the lowest in the EU. Recent reforms have focused on improving access to services in rural/remote areas, increasing funding for health care services, and tougher regulation of tobacco and alcohol. However, a number of longstanding unresolved problems still need to be addressed, including financial sustainability and low public funding, high levels of unmet need, high rates of preventable and treatable mortality, and challenges in both communicable and noncommunicable diseases.
Alexandr Katsaga, Maksut Kulzhanov, Marina Karanikolos, Bernd Rechel
Since becoming independent, Kazakhstan has undertaken major efforts in reforming its post-Soviet health system. Two comprehensive reform programmes were developed in the 2000s: the National Programme for Health Care Reform and Development 2005-2010 and the State Health Care Development Programme for 2011-2015 Salamatty Kazakhstan. Changes in health service provision included a reduction of the hospital sector and an increased emphasis on primary health care. However, inpatient facilities continue to consume the bulk of health financing. Partly resulting from changing perspectives on decentralization, levels of pooling kept changing. After a spell of devolving health financing to the rayon level in 2000-2003, beginning in 2004 a new health financing system was set up that included pooling of funds at the oblast level, establishing the oblast health department as the single-payer of health services. Since 2010, resources for hospital services under the State Guaranteed Benefits Package have been pooled at the national level within the framework of implementing the Concept on the Unified National Health Care System. Kazakhstan has also embarked on promoting evidence-based medicine and developing and introducing new clinical practice guidelines, as well as facility-level quality improvements. However, key aspects of health system performance are still in dire need of improvement. One of the key challenges is regional inequities in health financing, health care utilization and health outcomes, although some improvements have been achieved in recent years. Despite recent investments and reforms, however, population health has not yet improved substantially.
Although decentralization is based on the simple idea that smaller organizations, properly structured and steered, are inherently more agile and accountable than larger organizations, in the health system this idea requires much more exploration (Saltman et al. 2007). Health systems are large and composed of several subsystems, including health care providers, health financing, and public administration. All of them have their own organizational patterns and values. Furthermore, inside each of them are further divisions, sometimes with almost opposite approaches: health promotion, disease prevention, clinical medicine, or palliative care. All of these subsystems and divisions could recognize decentralization as an opportunity or a threat.
Hans Okkels Birk, Karsten Vrangbæk, Andreas Rudkjøbing, Allan Krasnik · 7 authors
Denmark has a tradition of a decentralized health system. However, during recent years, reforms and policy initiatives have gradually centralized the health system in different ways. The structural reform of 2007 merged the old counties into fewer bigger regions, and the old municipalities likewise. The hospital structure is undergoing similar reforms, with fewer, bigger and more specialized hospitals. Furthermore, a more centralized approach to planning and regulation has been taking place over recent years. This is evident in the new national planning of medical specialties as well as the establishment of a nationwide accreditation system, the Danish Healthcare Quality Programme, which sets national standards for health system providers in Denmark. Efforts have also been made to ensure coherent patient pathways - at the moment for cancer and heart disease - that are similar nationwide. These efforts also aim at improving intersectoral cooperation. Financially, recent years have seen the introduction of a higher degree of activity-based financing in the public health sector, combined with the traditional global budgeting.A number of challenges remain in the Danish health care system. The consequences of the recent reforms and centralization initiatives are yet to be fully evaluated. Before this happens, a full overview of what future reforms should target is not possible. Denmark continues to lag behind the other Nordic countries in regards to some health indicators, such as life expectancy. A number of risk factors may be the cause of this: alcohol intake and obesity continue to be problems, whereas smoking habits are improving. The level of socioeconomic inequalities in health also continues to be a challenge. The organization of the Danish health care system will have to take a number of challenges into account in the future. These include changes in disease patterns, with an ageing population with chronic and long-term diseases; ensuring sufficient staffing; and deciding how to improve public health initiatives that target prevention of diseases and favour health improvements.
2010 represented the moment when the reform was applied in the health field by decentralizing the management ofthe health units with beds (hospitals). This analysis points out the way hospital financing was carried out after that and the main problems the health care system of Romania has to deal with. In the end there are presented a few personal considerations on the main challenges for the future.
Jan Klavus, Ilkka Vohlonen, Juha Kinnunen, Veli Koistinen · 5 authors
The Finnish health care system is financed in a highly decentralized manner. In the tax-financed Beveridge model each municipality is responseble for financing and organizing health care services for its residents. This paper examined the annual incidence and treatment costs of three cost-intensive DRG-groups, and all DRG-groups together. The objective was to estimate municipal level predictions on the incidence of new illness cases and their associated costs, and to analyze whether there was greater uncertainty in anticipated specialized health care costs in municipalities with smaller populations. The dataset comprised of longitudinal hospital utilization and discharge data from Hospital Discharge Registers. The expected annual variation of illness cases and costs was assessed with respect to 95% confidence intervals estimated for each morbidity group and municipality. The results indicated that the costs of the selected morbidity groups fluctuated in a completely uncontrollable manner in municipalities with small populations. As the median size of Finnish municipalities is less than 6000, the inability to anticipate periodic health care costs constitutes an extensive financial problem and calls for the establishment of larger regional units and funding pools.
José Jesús Martín Martín, María del Puerto López del Amo González
The Spanish National Health System (SNHS) has sustainability problems resulting from weaknesses in institutional design and governance compounded by the economic crisis it faces. The global economic crisis has had a particularly virulent impact in Spain, characterized by high levels of unemployment and public and private debt. Fiscal adjustment policies implemented may significantly compromise the SNHS. Along with general funding problems, the strong territorial decentralization of health jurisdictions in the Autonomous Communities has not been backed up by efficient State-level health coordination. The SNHS suffers from problems in its rules of governance, its autonomous financing system, human resource policies and diversity of direct and indirect management models in different Autonomous Communities. A reform strategy in Spanish healthcare governancemust be articulated within the context of a broader review of public policies to stabilize the lines of defense of the welfare state. Within the scope of the health sector, the financing system must be improved and institutional changes to increase efficiency must be implemented.
Health care is widely considered to be an important determinant of health. The health care systems of Western Europe have recently experienced significant reforms, under pressure from economic globalization. Similarly, in Eastern Europe, health care reforms have been undertaken in response to the demands of the new market economy. Both of these changes may influence equality in health outcomes. This article aims to identify the mechanisms through which health care may affect inequalities. The authors conducted a literature review of the effects on health inequalities of European health care reforms. Particular reference was paid to interventions in the fields of financing and pooling, allocation, purchasing, and provision of services. The majority of studies were from Western Europe, and the outcomes most often examined were access to services or income distribution. Overall, the quality of research was poor, confirming the need to develop an appropriate impact assessment methodology. Few studies were related to pooling, allocation, or purchasing. For financing and purchasing, the studies showed that publicly funded universal health care reduces the impact of ill health on income distribution, while insurance systems can increase inequalities in access to care. Out-of-pocket payments increase inequalities in access to care and contribute to impoverishment. Decentralizing health services can lead to geographic inequalities in health care access. Nationalized, publicly funded health care systems are most effective at reducing inequalities in access and reducing the effects on health of income distribution.
There is an avalanche of interest in health systems with countries, donors, international experts and academic institutions all rushing to promote, fund or build capacity to address this wave of interest. As Anne Mills documents in an article in this volume, there is also a growing literature on how to think about health systems, how to use research on health systems to improve their performance, and pleas for greater investment in knowledge about health systems. We are probably riding on the crest of this new wave and it will be important to make use of it to further our knowledge about how to achieve health system effectiveness. With continuing global economic uncertainty, this wave may pass if we do not take advantage of it now. It is useful to reflect on why there is such interest in this theme now. There are probably many converging causes but the most important, to my mind, is a replay of an old debate between vertical programmes and horizontal, integrated approaches that has experienced swings of interest at least since the Alma Ata Conference in 1978 emphasized the integrated primary health care approach. During the last decade or more, there has been a major focus on vertical disease-specific programmes supported by greatly increased funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Alliance for Vaccines and Immunisation (GAVI), US President’s Emergency Plan for AIDS Relief (PEPFAR), Bill and Melinda Gates Foundation, among other donors. The major claim of these programmes was that by focusing on clear disease-specific objectives they would be more effective in shorter time periods and they could be held more accountable to donors (since the results could be more measurable) than the difficult and diverse efforts to improve the many elements of a health system through the horizontal integrated approach. While there were evident successes in these programmes, there was also a growing recognition that health system constraints—especially in human resources and logistics systems—were becoming major obstacles to achieving even their limited objectives of increased coverage of HIV/AIDS, tuberculosis, malaria and immunizations. With the added emphasis on the Millennium Development Goals (MDGs) and the slow progress toward their achievement in many countries, the international community and national governments have turned increasingly toward attempting to reduce the health system constraints—an approach that is closer to the integrated horizontal approach. Both GAVI and the Global Fund have added a separate fund for health systems interventions. In 2008, the G8 called for greater attention to health system strengthening as compatible with the prior focus on vertical programmes (Reich et al. 2008). In 2009, the World Bank convened a seminar on health system strengthening attended by representatives from the World Health Organization (WHO), GAVI and Global Fund. A task force on Healthy Women and Healthy Children calling for a health system funding platform was initiated at the UN General Assembly. In 2010, the WHO and others sponsored the First Global Symposium on Health Systems Research in Montreux, Switzerland. While many observers are trying to argue that the two approaches are now more compatible, at least in rhetorical terms it seems that the pendulum is shifting toward greater attention to health system strengthening. So how do we, the readers of Health Policy and Planning, take advantage of this interest? Health Policy and Planning is dedicated to the publication of high quality research that, as the name implies, improves decisions on policy and planning. This poses for us a central question: how can we do research that will improve health systems? The answer is complex for it requires attention to the kind of knowledge that is both researchable and leads to practical, implementable recommendations. The place to start is with a framework of analysis that is both analytical, in that it provides empirically based categories about health systems, and purposive, in that it is oriented toward how to improve the system. Many of the frameworks that are available provide a recognizable set of functional issues whose boundaries help focus attention on specific interactions that can be studied, such as financing, service delivery, human resources, governance (Mills et al. 2001). The WHO Building Blocks framework is a very popular approach that is guiding much of the discussion and research in health systems (WHO 2007). Another approach developed by Harvard School of Public Health faculty is oriented toward using analytical categories in a purposive manner that starts with an ethically derived vision of what we would like to achieve, and works back toward finding the reasons why we have not achieved those objectives. It then focuses our attention on what we can change using evidence on the effectiveness of changing different ‘control knobs’ or policy levers, including financing, payments, organization, regulation and persuasion (Roberts et al. 2004). There is a great deal of overlap in these models and they are compatible in many ways that can guide research toward practical recommendations for policy. A second question is about levels of analysis. Should we attempt to research whole national systems, with typologies of systems and comparisons of the achievements of the different models? We often hear this orientation used in policy arguments such as the recent arguments over whether the USA should adopt the Canadian single payer model. However, this approach suffers from methodological challenges such as the ‘small number’ problem (which limits the ability to use sophisticated quantitative analysis due to the few comparable national systems) and the many different characteristics and historical trajectories that confound the analysis. Few countries—Chile, China, Colombia, Ghana, Taiwan, Turkey and Eastern European countries—have even attempted broad multifaceted health system reforms and they have tended to develop their own reform models rather than copying others. Nevertheless, there are many country studies of health reforms that provide evidence and much can be gained by detailed evaluation of the effectiveness of these models that can inform policy choice in different contexts. An alternative means of assessing health systems is to focus on sub-systems or analysis of specific policy changes, focusing on different social health insurance approaches, pay for performance, contracting, decentralization or other reforms, and assessing their performance in terms of achieving health system objectives like the MDGs, reduction in catastrophic expenditures caused by paying for illness, or broader responsiveness and accountability to citizens. The advantage of this approach is that, if the research is well designed, the causality of the impact of the changes on health system objectives can be more clearly demonstrated, and it allows a more focused attention to policy changes that different countries can adopt in an incremental way. This approach can address both systems issues and vertical programme needs. For instance, the work that I am involved in on decentralization—looking at the relationship between choice, capacity and accountability at different levels of a health system—can be used to make policy recommendations on general health system reform as well as specific reforms of logistic systems, vertical immunization or family planning programme effectiveness (Bossert et al. 2007). The challenge in this approach is to account for the general national context factors—political, economic, social and cultural—which may influence the performance of these initiatives. What works in Chile may not work in China due to many different characteristics of the country contexts. This is a major lacuna in the current research in health systems often covered over by focusing only on the differences in average income levels, assuming for instance that health system changes in low-income countries are all relatively similar. However, governance issues, cultural and ethical differences, past histories with different health systems, all play a role in constraining the lessons learned from one country to another. The recent concern with political economy and political institutionalism may inform future work in this area (Fox and Reich, forthcoming). In addition, focus on one subsystem or one policy lever is likely to miss the interactions among different subsystems changes that synergistically influence outcomes. For instance, changes in decentralization may be enhanced by changes in social insurance programmes, or the creation of a new cadre of health workers. Focusing on one in order to evaluate its separate impact will miss the role of the combined changes on achieving objectives. However, if we are aware of these limitations, it might be possible to move collectively toward setting a research agenda in which multidisciplinary researchers assess the different subsystems in ways that inform each other. Those of us who focus on organizational issues like decentralization and human resources need to be aware of and incorporate in our studies, the work of experts in economics, ethics, politics and other behavioural sciences, as well as epidemiologists and biostatisticians who help us understand the underlying population and social processes underpinning those systems. There is also an imbalance of research on functional areas of analysis with a much greater body of knowledge on financing and payment issues than on organizational issues and governance and regulation. In recent years, there has been greater interest in governance, politics and human resources issues, but these areas are so complex that they require much greater attention and more funded research than is currently in the pipeline. This poses an additional requirement for multidisciplinary studies that address these under-researched areas to bring the level of knowledge up to that of the more economic themes. This is a huge task of course and current funders have little patience for large research projects in health systems. Indeed there is considerable pressure for evaluating the performance of programmes and projects that have been funded in a very short and unrealistic time frame. It suggests that we need to be nimble and develop cadres of multidisciplinary experts to be able to quickly do the solid research necessary but within limited funds and short time horizons to provide well-documented policy recommendations. If we do not, we are likely to have missed the opportunities of this wave of interest as funding for health systems declines due to alternative priorities, donor fatigue or general global economic restrictions. None declared.
Introduction of the market, privatization and decentralization have been the dominant corner stones throughout the first two decades of China’s reform line after the introduction of the open door policy in 1978. Many China researchers (e.g. Wang 2008; Wu 2008) thereby judge, that China’s development path was not merely a transition from planned economy to market-oriented economy, but that a “market society” emerged, in which market principles permeate also noneconomic arenas and “threatened to become the dominant mechanism integrating all of society (and even political life)” (Wang 2008: 18). The marketization of the health sector thereby entailed that social security schemes and therewith financing of public health care collapsed almost completely and out-of-pocket payment became the dominant factor defining people’s access to health care. 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 examines health care reform in urban and rural China. Before health care reform, Chinese health service facilities were run entirely by the state and basically they performed a social welfare function. This health care system greatly improved the population health conditions but many problems started to emerge in 1980s when the economic reform started. Since then, the government has been struggling to maintain a balance between meeting people’s health care needs and develop the health care “industry”. Problems and their contribution factors in organization, financing and performance of the health care reform are examined and analyzed. In terms of organization, decentralization of the decision making power in health sector and marketization of the medical establishments constitutes the main organizational changes in the health care reform. This organizational reform of health sector as an imposed institution change, encounters lots of resistance in the process of implementation. A tremendous amount of conflictions arises because of the commercialization of health sector that used to perform social welfare function. In
Healthcare, Law, Governance, and Management Studies
The present study describes and explains the changing role of the state in the Italian healthcare system since the beginning of the 1970s, with a particular focus on developments following 1978 when the healthcare system was transformed from a social insurance system into a national health service. In order to address these changes in a systematic way, we track healthcare system development along three dimensions: regulation, financing, and service provision. With regard to regulation, we observe a relative retreat of the state due to decentralization processes and internal market mechanisms. Quantitative measures for the financing and service provision dimension also indicate a modest relative retreat of the state. Taking regional data into account, we identify a clear North-South-divide in the public/private mix of financing and service provision. Although the focus of the paper is to describe the changing role of the state in the Italian healthcare system, we also offer preliminary explanations. We seek to identify the role of exogenous shocks such as economic crises versus endogenous stressors specific to the healthcare system itself (i.e. inherent inefficiencies) on healthcare system change. Therefore, the paper aims to provide a tentative, yet dynamic account of healthcare system change that is both descriptive and explanatory.
Anna Sagan, Dimitra Panteli, W Borkowski, M Dmowski · 31 authors
Since the successful transition to a freely elected parliament and a market economy after 1989, Poland is now a stable democracy and is well represented within political and economic organizations in Europe and worldwide. The strongly centralized health system based on the Semashko model was replaced with a decentralized system of mandatory health insurance, complemented with financing from state and territorial self-government budgets. There is a clear separation of health care financing and provision: the National Health Fund (NFZ) the sole payer in the system is in charge of health care financing and contracts with public and non-public health care providers. The Ministry of Health is the key policy-maker and regulator in the system and is supported by a number of advisory bodies, some of them recently established. Health insurance contributions, borne entirely by employees, are collected by intermediary institutions and are pooled by the NFZ and distributed between the 16 regional NFZ branches. In 2009, Poland spent 7.4% of its gross domestic product (GDP) on health. Around 70% of health expenditure came from public sources and over 83.5% of this expenditure can be attributed to the (near) universal health insurance. The relatively high share of private expenditure is mostly represented by out-of-pocket (OOP) payments, mainly in the form of co-payments and informal payments. Voluntary health insurance (VHI) does not play an important role and is largely limited to medical subscription packages offered by employers. Compulsory health insurance covers 98% of the population and guarantees access to a broad range of health services. However, the limited financial resources of the NFZ mean that broad entitlements guaranteed on paper are not always available. Health care financing is overall at most proportional: while financing from health care contributions is proportional and budgetary subsidies to system funding are progressive, high OOP expenditures, particularly in areas such as pharmaceuticals, are highly regressive. The health status of the Polish population has improved substantially, with average life expectancy at birth reaching 80.2 years for women and 71.6 years for men in 2009. However, there is still a vast gap in life expectancy between Poland and the western European Union (EU) countries and between life expectancy overall and the expected number of years without illness or disability. Given its modest financial, human and material health care resources and the corresponding outcomes, the overall financial efficiency of the Polish system is satisfactory. Both allocative and technical efficiency leave room for improvement. Several measures, such as prioritizing primary care and adopting new payment mechanisms such as diagnosis-related groups (DRGs), have been introduced in recent years but need to be expanded to other areas and intensified. Additionally, numerous initiatives to enhance quality control and build the required expertise and evidence base for the system are also in place. These could improve general satisfaction with the system, which is not particularly high. Limited resources, a general aversion to cost-sharing stemming from a long experience with broad public coverage and shortages in health workforce need to be addressed before better outcomes can be achieved by the system. Increased cooperation between various bodies within the health and social care sectors would also contribute in this direction. The HiT profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services, and the role of the main actors in health systems; they describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis.
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This article contributes to the limited empirical literature on the impact of decentralization on economic welfare by investigating the hypothesis that shifts towards more fiscal decentralization in health services would be accompanied by improvements in population health. Building on a conventional public finance model applied to health care, this hypothesis is tested on a panel data of the highly decentralized Canadian provinces during the period 1979 to 1995. The results of the exploratory empirical analysis presented in this article suggest that fiscal decentralization of health services in Canada has had a positive and substantial influence on the effectiveness of public policy in improving a population's health over the period studied.
The aim of this research is to better understand the effects of a decentralized health system of the Philippines on public health care expenditures by investigating determinants of local government public health spending for year 2007. Within the context of the Philippines’ decentralized health system and health externalities that arise at the individual-level and manifest at the regional level, particular emphasis is given to spatial spillovers and fiscal interactions among municipalities. The research addresses these issues in an empirical spatial econometric framework utilizing public finance local government data for the Philippines. Competition for health resources including doctors and drugs, thereby bidding up the costs of health inputs is one of the potential causes for positive fiscal spatial dependence cited in this paper. It is also anticipated that this could be an outcome of yardstick competition, where local agents strategically compete with each other by spending higher in order to be re-elected, 2007 being an election year.
David E. Bloom, Ajay Mahal, Larry Rosenberg, Jaypee Sevilla
Abstract The rapid ageing of India's population, in conjunction with migration out of rural areas and the continued concentration of the working population in the informal sector, has highlighted the need for better economic security arrangements for the elderly. Traditional family ties that have been key to ensuring a modicum of such security are beginning to fray, and increased longevity is making care of the elderly more expensive. As a result, the elderly are at increased risk of being poor or falling into poverty. In parallel with its efforts to address this issue, the Government of India and some of the Indian states have initiated an array of programmes for providing some level of access to health care or health insurance to the great majority of Indians who lack sufficient access. Formal‐sector workers have greater social security than those in the informal sector, but they only represent a small share of the workforce. Women are particularly vulnerable to economic insecurity. India's experience offers some lessons for other countries. Although there is space for private initiatives in the social security arena, it is clear that most such efforts will need to be tax‐financed. The role that private providers can play is substantial, even when most funding comes from public sources, but such activity will face greater challenges as more individuals seek benefits. India has also shown that implementation can often be carried out well by states using central government funds, with a set of advantages and disadvantages that such decentralization brings. Finally, India's experience with implementation can offer guidance on issues such as targeting, the use of information technology in social security systems, and human resource management.
Shoba Raja, Sarah Wood, Victoria de Menil, Saju C Mannarath
BACKGROUND: Limited evidence about mental health finances in low and middle-income countries is a key challenge to mental health care policy initiatives. This study aimed to map mental health finances in Ghana, Uganda, India (Kerala state), Sri Lanka and Lao PDR focusing on how much money is available for mental health, how it is spent, and how this impacts mental health services. METHODS: A researcher in each region reviewed public mental health-related budgets and interviewed key informants on government mental health financing. A total of 43 key informant interviews were conducted. Quantitative data was analyzed in an excel matrix using descriptive statistics. Key informant interviews were coded a priori against research questions. RESULTS: National ring-fenced budgets for mental health as a percentage of national health spending for 2007-08 is 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda. Budgets were not available in Lao PDR. The majority of ring-fenced budgets (76% to 100%) is spent on psychiatric hospitals. Mental health spending could not be tracked beyond the psychiatric hospital level due to limited information at the health centre and community levels. CONCLUSIONS: Mental health budget information should be tracked and made publically accessible. Governments can adapt WHO AIMS indicators for reviewing national mental health finances. Funding allocations work more effectively through decentralization. Mental health financing should reflect new ideas emerging from community based practice in LMICs.
Decentralization involves the dispersion of power, functions and finances from a central authority to regional and local authorities. Decentralization reforms have become widespread in low- and middle-income countries, mainly due to movements towards democratiza-tion, the spread of multi-party electoral systems and transitions towards market economies. In particular, decentraliza-tion of financing systems, particularly for health, is now a common aspect of reform in these countries. The main advantage is the dynamism it can bring into the resource allocation mechanism; it also can facilitate re-allocation of funds through a visible, vibrant and bottom-up approach.
Recent reforms of the National Health Service (NHS) financing system in Italy (D.Lgs. 446/97 and D.Lgs. 56/2000) have potentially given more responsibility for health care to Regions, increasing their power over this function. Starting from this normative process, the aim of the paper is to analyse the Italian health spending in the Ordinary Statute Regions (OSR), by proposing a model to verify empirically whether the financing mechanisms are actually defined at local level or if Regions act as agents of the central government. The empirical results do not support the evolution of fiscal federalism in the health sector, highlighting in fact that health financing decisions are mostly centralized in Italy, even if the institutional context has recently moved towards decentralization of health financing sources, extending the autonomy of sub-national governments.
Government spending on health has grown as a percent of GDP over the last 40 years in industrialized countries. Widespread decentralization of healthcare systems has often accompanied this increase in spending. In this paper, we explore the effect of soft budget constraints on subnational health spending in a sample of OECD countries. We find countries where subnational governments rely primarily on central government financing and enjoy large borrowing autonomy have higher healthcare spending than those with more restrictions on subnational government borrowing.
The HiT profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The Ukrainian health system has preserved the fundamental features of the Soviet Semashko system against a background of other changes, which are developed on market economic principles. The transition from centralized financing to its extreme decentralization is the main difference in the health system in comparison with the classic Soviet model. Health facilities are now functionally subordinate to the Ministry of Health, but managerially and financially answerable to the regional and local self-government, which has constrained the implementation of health policy and fragmented health financing. Health care expenditure in Ukraine is low by regional standards and has not increased significantly as a proportion of gross domestic product (GDP) since the mid 1990s; expenditure cannot match the constitutional guarantees of access to unlimited care. Although prepaid schemes such as sickness funds are growing in importance, out-of-pocket payments account for 37.4% of total health expenditure. The core challenges for Ukrainian health care therefore remain the ineffective protection of the population from the risk of catastrophic health care costs and the structural inefficiency of the health system, which is caused by the inefficient system of health care financing. Health system weaknesses are highlighted by increasing rates of avoidable mortality. Recent political impasse has complicated health system reforms and policy-makers face significant challenges in overcoming popular distrust and fatigue in the face of necessary but as yet unimplemented reforms.