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.
This paper examines how organization and financing of maternal health services influence health-seeking behavior in Bosomtwe district, Ghana. It contributes in furthering the discussions on maternal health-seeking behavior and health outcomes from a health system perspective in sub-Saharan Africa. From a health system standpoint, the paper first presents the resources, organization and financing of maternal health service in Ghana, and later uses case study examples to explain how Ghana's health system has shaped maternal health-seeking behavior of women in the district. The paper employs a qualitative case study technique to build a complex and holistic picture, and report detailed views of the women in their natural setting. A purposeful sampling technique is applied to select 16 women in the district for this study. Through face-to-face interviews and group discussions with the selected women, comprehensive and in-depth information on health- seeking behavior and health outcomes are elicited for the analysis. The study highlights that characteristics embedded in decentralization and provision of free maternal health care influence health-seeking behavior. Particularly, the use of antenatal care has increased after the delivery exemption policy in Ghana. Interestingly, the study also reveals certain social structures, which influence women's attitude towards their decisions and choices of health facilities.
Evidence-informed decision making (EIDM) can optimize health services and systems. EIDM involves defining problems, identifying measures to tackle them, assessing the quality of global and local evidence and translating it for the main stakeholders in line with social values and laws. Brazil encourages the use of EIDM in health policy in Piripiri, a municipality of 61,840 inhabitants in the country's poorest region, and launched Brazil's first Evidence Use in Health Care (NEv) center in 2010. The development and preliminary results of the NEv center are reported and its vision, composition, mandate, and activities are presented. The NEv center experience has the support of the Evidence-Informed Policy Network, the Latin American and Caribbean Center of Information on Health Sciences and federal and municipal governments. The decentralization of financing and the provision of healthcare services, the expansion of EIDM in management, and the local political context illustrate the progress of the experiment. Its activities include the production and dissemination of deliberative briefs and dialogues with opinion shapers, workers and health service users. Monitoring and evaluation are underway and the results will help to broaden the scale of activities in Brazil and abroad.
Sander Greenland and Charles Poole1 accept that P values are here to stay but recognize that some of their most common interpretations have problems. The casual view of the P value as posterior probability of the truth of the null hypothesis is false and not even close to valid under any reasonable model, yet this misunderstanding persists even in high-stakes settings (as discussed, for example, by Greenland in 2011).2 The formal view of the P value as a probability conditional on the null is mathematically correct but typically irrelevant to research goals (hence, the popularity of alternativeâif wrongâinterpretations). A Bayesian interpretation based on a spike-and-slab model makes little sense in applied contexts in epidemiology, political science, and other fields in which true effects are typically nonzero and bounded (thus violating both the âspikeâ and the âslabâ parts of the model). I find Greenland and Pooleâs1 perspective to be valuable: it is important to go beyond criticism and to understand what information is actually contained in a P value. These authors discuss some connections between P values and Bayesian posterior probabilities. I am not so optimistic about the practical value of these connections. Conditional on the continuing omnipresence of P values in applications, however, these are important results that should be generally understood. Greenland and Poole1 make two points. First, they describe how P values approximate posterior probabilities under prior distributions that contain little information relative to the data: This misuse [of P values] may be lessened by recognizing correct Bayesian interpretations. For example, under weak priors, 95% confidence intervals approximate 95% posterior probability intervals, one-sided P values approximate directional posterior probabilities, and point estimates approximate posterior medians. I used to think this way, too (see many examples in our books), but in recent years have moved to the position that I do not trust such direct posterior probabilities. Unfortunately, I think we cannot avoid informative priors if we wish to make reasonable unconditional probability statements. To put it another way, I agree with the mathematical truth of the quotation above, but I think it can mislead in practice because of serious problems with apparently noninformative or weak priors. Second, the main proposal made by Greenland and Poole is to interpret P values as bounds on posterior probabilities: [U]nder certain conditions, a one-sided P value for a prior median provides an approximate lower bound on the posterior probability that the point estimate is on the wrong side of that median. This is fine, but when sample sizes are moderate or small (as is common in epidemiology and social science), posterior probabilities will depend strongly on the prior distribution. Although I do not see much direct value in a lower bound, I am intrigued by Greenland and Pooleâs1 point that âif one uses an informative prior to derive the posterior probability of the point estimate being in the wrong direction, P0/2 provides a reference point indicating how much the prior information influenced that posterior probability.â This connection could be useful to researchers working in an environment in which P values are central to communication of statistical results. In presenting my view of the limitations of Greenland and Pooleâs1 points, I am leaning heavily on their own work, in particular on their emphasis that, in real problems, prior information is always available and is often strong enough to have an appreciable impact on inferences. Before explaining my position, I will briefly summarize how I view classical P values and my experiences. For more background, I recommend the discussion by Krantz3 of null hypothesis testing in psychology research. WHAT IS A P VALUE IN PRACTICE? The P value is a measure of discrepancy of the fit of a model or ânull hypothesisâ H to data y. Mathematically, it is defined as Pr(T(yrep)>T(y)|H), where yrep represents a hypothetical replication under the null hypothesis and T is a test statistic (ie, a summary of the data, perhaps tailored to be sensitive to departures of interest from the model). In a model with free parameters (a âcomposite null hypothesisâ), the P value can depend on these parameters, and there are various ways to get around this, by plugging in point estimates, averaging over a posterior distribution, or adjusting for the estimation process. I do not go into these complexities further, bringing them up here only to make the point that the construction of P values is not always a simple or direct process. (Even something as simple as the classical chi-square test has complexities to be discovered; see the article by Perkins et al4). In theory, the P value is a continuous measure of evidence, but in practice it is typically trichotomized approximately into strong evidence, weak evidence, and no evidence (these can also be labeled highly significant, marginally significant, and not statistically significant at conventional levels), with cutoffs roughly at P = 0.01 and 0.10. One big practical problem with P values is that they cannot easily be compared. The difference between a highly significant P value and a clearly nonsignificant P value is itself not necessarily statistically significant. (Here, I am using âsignificantâ to refer to the 5% level that is standard in statistical practice in much of biostatistics, epidemiology, social science, and many other areas of application.) Consider a simple example of two independent experiments with estimates (standard error) of 25 (10) and 10 (10). The first experiment is highly statistically significant (two and a half standard errors away from zero, corresponding to a normal-theory P value of about 0.01) while the second is not significant at all. Most disturbingly here, the difference is 15 (14), which is not close to significant. The naive (and common) approach of summarizing an experiment by a P value and then contrasting results based on significance levels, fails here, in implicitly giving the imprimatur of statistical significance on a comparison that could easily be explained by chance alone. As discussed by Gelman and Stern,5 this is not simply the well-known problem of arbitrary thresholds, the idea that a sharp cutoff at a 5% level, for example, misleadingly separates the P = 0.051 cases from P = 0.049. This is a more serious problem: even an apparently huge difference between clearly significant and clearly nonsignificant is not itself statistically significant. In short, the P value is itself a statistic and can be a noisy measure of evidence. This is a problem not just with P values but with any mathematically equivalent procedure, such as summarizing results by whether the 95% confidence interval includes zero. GOOD, MEDIOCRE, AND BAD P VALUES For all their problems, P values sometimes âworkâ to convey an important aspect of the relation of data to model. Other times, a P value sends a reasonable message but does not add anything beyond a simple confidence interval. In yet other situations, a P value can actively mislead. Before going on, I will give examples of each of these three scenarios. A P Value that Worked Several years ago, I was contacted by a person who suspected fraud in a local election.6 Partial counts had been released throughout the voting process and he thought the proportions for the various candidates looked suspiciously stable, as if they had been rigged to aim for a particular result. Excited to possibly be at the center of an explosive news story, I took a look at the data right away. After some preliminary graphsâwhich indeed showed stability of the vote proportions as they evolved during election dayâI set up a hypothesis test comparing the variation in the data to what would be expected from independent binomial sampling. When applied to the entire data set (27 candidates running for six offices), the result was not statistically significant: there was no less (and, in fact, no more) variance than would be expected by chance alone. In addition, an analysis of the 27 separate chi-square statistics revealed no particular patterns. I was left to conclude that the election results were consistent with random voting (even though, in reality, voting was certainly not randomâfor example, married couples are likely to vote at the same time, and the sorts of people who vote in the middle of the day will differ from those who cast their ballots in the early morning or evening). I regretfully told my correspondent that he had no case. In this example, we cannot interpret a nonsignificant result as a claim that the null hypothesis was true or even as a claimed probability of its truth. Rather, nonsignificance revealed the data to be compatible with the null hypothesis; thus, my correspondent could not argue that the data indicated fraud. A P Value that Was Reasonable but Unnecessary It is common for a research project to culminate in the estimation of one or two parameters, with publication turning on a P value being less than a conventional level of significance. For example, in our study of the effects of redistricting in state legislatures (Gelman and King),7 the key parameters were interactions in regression models for partisan bias and electoral responsiveness. Although we did not actually report P values, we could have: what made our article complete was that our findings of interest were more than two standard errors from zero, thus reaching the P < 0.05 level. Had our significance level been much greater (eg, estimates that were four or more standard errors from zero), we would doubtless have broken up our analysis (eg, studying Democrats and Republicans separately) to broaden the set of claims that we could confidently assert. Conversely, had our regressions not reached statistical significance at the conventional level, we would have performed some sort of pooling or constraining of our model to arrive at some weaker assertion that reached the 5% level. (Just to be clear: we are not saying that we would have performed data dredging, fishing for significance; rather, we accept that sample size dictates how much we can learn with confidence; when data are weaker, it can be possible to find reliable patterns by averaging.) In any case, my point is that in this example it would have been just fine to summarize our results in this example via P values even though we did not happen to use that formulation. A Misleading P Value Finally, in many scenarios P values can distract or even mislead, either a nonsignificant result wrongly interpreted as a confidence statement in support of the null hypothesis or a significant P value that is taken as proof of an effect. A notorious example of the latter is the recent article by Bem,8 which reported statistically significant results from several experiments on extrasensory perception (ESP). At brief glance, it seems impressive to see multiple independent findings that are statistically significant (and combining the P values using classical rules would yield an even stronger result), but with enough effort it is possible to find statistical significance anywhere (see the report by Simmons et al9). The focus on P values seems to have both weakened that study (by encouraging the researcher to present only some of his data so as to draw attention away from nonsignificant results) and to have led reviewers to inappropriately view a low P value (indicating a misfit of the null hypothesis to data) as strong evidence in favor of a specific alternative hypothesis (ESP) rather than other, perhaps more scientifically plausible, alternatives such as measurement error and selection bias. PRIORS, POSTERIORS, AND P VALUES Now that I have established my credentials as a pragmatist who finds P values useful in some settings but not others, I want to discuss Greenland and Pooleâs proposal to either interpret one-sided P values as probability statements under uniform priors (an idea they trace back to Gossett)10 or else to use one-sided P values as bounds on posterior probabilities (a result they trace back to Casella and Berger).11 The general problem I have with noninformatively derived Bayesian probabilities is that they tend to be too strong. At first, this may sound paradoxical, that a noninformative or weakly informative prior yields posteriors that are too forcefulâand let me deepen the paradox by stating that a stronger, more informative prior will tend to yield weaker, more plausible posterior statements. How can it be that adding prior information weakens the posterior? It has to do with the sort of probability statements we are often interested in making. Here is an example from Gelman and Weakliem.12 A sociologist examining a publicly available survey discovered a pattern relating attractiveness of parents to the sexes of their children. He found that 56% of the children of the most attractive parents were girls, when compared with 48% of the children of the other parents, and the difference was statistically significant at P < 0.02. The assessments of attractiveness had been performed many years before these people had children, so the researcher felt he had support for a claim of an underlying biological connection between attractiveness and sex ratio. The original analysis by Kanazawa13 had multiple-comparisons issues, and after performing a regression analysis rather than selecting the most significant comparison, we get a P value closer to 0.2 rather than the stated 0.02. For the purposes of our present discussion, though, in which we are evaluating the connection between P values and posterior probabilities, it will not matter much which number we use. We shall go with P = 0.2 because it seems like a more reasonable analysis given the data. Let Ξ be the true (population) difference in sex ratios of attractive and less attractive parents. Then the data under discussion (with a two-sided P value of 0.2), combined with a uniform prior on Ξ, yield a 90% posterior probability that Ξ is positive. Do I believe this? No. Do I even consider this a reasonable data summary? No again. We can derive these âNoâ responses in three different ways: first, by looking directly at the evidence; second, by considering the prior; and third, by considering the implications for statistical practice if this sort of probability statement were computed routinely. First, a claimed 90% probability that Ξ > 0 seems too strong. Given that the P value (adjusted for multiple comparisons) was only 0.2âthat is, a result that strong would occur a full 20% of the time just by chance alone, even with no true differenceâit seems absurd to assign a 90% belief to the conclusion. I am not prepared to offer 9-to-1 odds on the basis of a pattern someone happened to see that could plausibly have occurred by chance alone, nor for that matter would I offer 99-to-1 odds based on the original claim of the 2% significance level. Second, the prior uniform distribution on Ξ seems much too weak. There is a large literature on sex ratios, with factors such as ethnicity, maternal age, and season of birth corresponding to difference in probability of girl birth of <0.5 percentage points. It is a priori implausible that sex-ratio differences corresponding to attractiveness are larger than for these other factors. Assigning an informative prior centered on zero shrinks the posterior toward zero, and the resulting posterior probability that Ξ > 0 moves to a more plausible value in the range of 60%, corresponding to the idea that the result is suggestive but not close to convincing. Third, consider what would happen if we routinely interpreted one-sided P values as posterior probabilities. In that case, an experimental result that is 1 standard error from zeroâthat is, exactly what one might expect from chance aloneâwould imply an 83% posterior probability that the true effect in the population has the same direction as the observed pattern in the data at hand. It does not make sense to me to claim 83% certaintyâ5-to-1 oddsâbased on data that not only could occur by chance alone but in fact represent an expected level of discrepancy. This system-level analysis accords with my criticism of the flat prior: as Greenland and Poole1 note in their article, the effects being studied in epidemiology are typically range from â1 to 1 on the logit scale; hence, analyses assuming broader priors will systematically overstate the probabilities of very large effects and will overstate the probability that an estimate from a small sample will agree in sign with the corresponding population quantity. Rather than relying on noninformative priors, I prefer the suggestion of Greenland and Poole1 to bound posterior probabilities using real prior information. I would prefer to perform my Bayesian inferences directly without using P values as in intermediate step, but given the ubiquity of P values in much applied work, I can see that it can be helpful for researchers to understand their connection to posterior probabilities under informative priors. SUMMARY Like many Bayesians, I have often represented classical confidence intervals as posterior probability intervals and interpreted one-sided P values as the posterior probability of a positive effect. These are valid conditional on the assumed noninformative prior but typically do not make sense as unconditional probability statements. As Sander Greenland has discussed in much of his work over the years, epidemiologists and applied scientists in general have knowledge of the sizes of plausible effects and biases. I believe that a direct interpretation of P values as posterior probabilities can be a useful startâif we recognize that such summaries systematically overestimate the strength of claims from any particular dataset. In this way, I am in agreement with Greenland and Pooleâs interpretation of the one-sided P value as a lower bound of a posterior probability, although I am less convinced of the practical utility of this bound, given that the closeness of the bound depends on a combination of sample size and prior distribution. The default conclusion from a noninformative prior analysis will almost invariably put too much probability on extreme values. A vague prior distribution assigns much of its probability on values that are never going to be plausible, and this disturbs the posterior probabilities more than we tend to expectâsomething that we probably do not think about enough in our routine applications of standard statistical methods. Greenland and Poole1 perform a valuable service by opening up these calculations and placing them in an applied context.
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 âŒ90% 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 Indonesiaâs 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.
Eliana JimenezâSoto, Katarzyna Alderman, David Hipgrave, Sonja Firth · 5 authors
In the pursuit to take forward the Global Strategy for Womenâs and Childrenâs Health and accelerate progress toward Millennium Development Goals 4 and 5 in Asia and the Pacific, there is ample evidence on what should be done and why investments in Reproductive, Maternal, Neonatal and Child Health (RMNCH) are, or should be, national priorities. However, there is scant evidence on best practice approaches to prioritizing the investment in RMNCH, and implementation of health system strategies to improve the health of women and children, which remains a challenge for many countries in the region.In decentralized systems, which make up the vast majority in the region, prioritization usually takes place at different levels. Decision-making on the content of the benefits package, that is, which health interventions may be financed with public monies are usually taken by national authorities (macro-level or national priority setting). The difficult task of deciding how to deliver the benefits package, that is, the actual mix of providers (public and private), programs, resources, and strategies, usually rests on the shoulders of state, provincial and even district authorities (meso-level or subnational priority setting). Evidence-based recommendations were recently made for low and middle income countries (LMICs) to improve the process of prioritizing health interventions at national level (Glassman et al., 2012). However, scarce evidence exists to guide subnational authorities in their prioritization exercises.The primary aim of this exercise is therefore to provide evidence-based recommendations to inform decisions by subnational authorities on how to prioritize service delivery investments in RMNCH in Asia and the Pacific. For this purpose we undertook a review of the available evidence on priority setting for health in both the published and the grey literature during the last 10 years. Although our primary focus was on priority setting at the subnational level, we also examined the more extensive literature on macro-level priority setting to identify lessons learned.
Health Systems, Economic Evaluations, Quality of Life
George Schieber, Cheryl Cashin, Karima Saleh, Rouselle Lavado
Identifies the strengths and weaknesses of Ghanaâs health system in three broad areas: (1) governance, management, and organization; (2) delivery system, pharmaceuticals, and public health; and (3) financing. Ghanaâs well-developed, highly decentralized, and evolving health system operates on an integrated three-level (national, regional, and district) scheme and incorporates a community-level health delivery system.Improving health outcomes, financial protection, and consumer responsiveness in an equitable, efficient, and sustainable manner requires a well-functioning delivery system of human and physical infrastructure that includes reasonably priced, available, and effective pharmaceuticals and well-functioning public health programs that target the major disease burdens and are tightly coordinated with the National Health Insurance Scheme (NHIS) basic benefits package. Ghana has come a long way toward developing a modern health care delivery system, improving the availability of effective drugs, and operating effective public health programs but continues to grapple with interrelated management, delivery system, and financing issues.
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
INTRODUCTION: In recent years, the country of Mongolia (population 2.8 million) has experienced rapid social changes associated with economic growth, persisting socio-economic inequities and internal migration. In order to improve health access for the urban poor, the Ministry of Health developed a "Reaching Every District" strategy (RED strategy) to deliver an integrated package of key health and social services. The aim of this article is to present findings of an assessment of the implementation of the RED strategy, and, on the basis of this assessment, articulate lessons learned for equitable urban health planning. METHODS: Principal methods for data collection and analysis included literature review, barrier analysis of health access and in-depth interviews and group discussions with health managers and providers. FINDINGS: The main barriers to health access for the urban poor relate to interacting effects of poverty, unhealthy daily living environments, social vulnerability and isolation. Implementation of the RED strategy has resulted in increased health access for the urban poor, as demonstrated by health staff having reached new clients with immunization, family planning and ante-natal care services, and increased civil registrations which enable social service provision. Organizational effects have included improved partnerships for health and increased motivation of the health workforce. Important lessons learned from the early implementation of the RED strategy include the need to form strong partnerships among stakeholders at each level of the health system and in the community, as well as the need to develop a specific financing strategy to address the needs of the very poor. The diverse social context for health in an urban poor setting calls for a decentralized planning and partnership strategy, but with central level commitment towards policy guidance and financing of pro-poor urban health strategies. CONCLUSIONS: Lessons from Mongolia mirror other international studies which point to the need to measure and take action on the social determinants of health at the local area level in order to adequately reduce persistent inequities in health care access for the urban poor.
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.
Background: Health financing provided by the government greatly helps the implementation of health system in the decentralized era. General Allocation Fund and Local Revenue and Expenditure Budget are apparently inadequate to finance health service. Some efforts have been made to finance health service such as Community Health Insurance (Jamkesmas), Childbirth Insurance (Jampersal), and Health Operational Fund (Bantuan Operasional Kesehatan/BOK). These are meant to achieve Millennium Development Goals in 2015. The practice of coordination from planning to implementation and stakeholdersâ commitment can affect the process of maternal and child health service. Coordination is definitely needed to run the program policy and prevent the overlapping financing in order that the objective of the program can be achieved. Objective: To evaluate coordination of planning, implementation and stakeholdersâ commitment in relation to maternal and child health (MCH) service in Lombok Tengah District. Method: This was a descriptive-analytical study with a qualitative approach and a case-study design. Samples were taken purposively. The data were obtained through in-depth interview, observation and documentation analysis. Result: The planning coordination of MCH health financing had not been optimal, even despite the involvement of cross sector and program. However, the organizations of health professionals were not involved in program planning. The coordination of health financing implementation had not been optimal as well. Even though there was no overlapping financing from some different sources, in the policy implementation there was cost sharing for referral and drugs. Private sectors were not involved in the implementation of Jampersal. Stakeholdersâ commitment was relatively optimum as reflected from the policy and action in health development acceleration particularly MCH. The process of MCH service at both primary and secondary level could run well. Conclusion: Coordination of MCH financing implementation in Lombok Tengah District through BOK, Jampersal, Jamkesmas, Community Empowerment National Program of Healthy and Smart Generation and Local Revenue and Expenditure Budget had not been optimal; therefore, it needed to be improved to eliminate cost sharing. Professional organizations and private health providers were not yet involved in the program planning and implementation. Keywords: coordination, stakeholdersâ commitment, health financing, maternal and child health, program evaluation
William Newbrander, Chavanne L. Peercy, Megan ShepherdâBanigan, Petra Vergeer
Fragile states need assessment of decentralized management capabilities, not just of the central level, to design capacity-building efforts focused on improving management. Improving the management capacity of health departments at the provincial or district level is just as critical as strengthening the central ministry in fragile states if a health system that effectively addresses the real health needs of the population is to be formed. This paper describes a management capacity assessment tool developed for use in fragile states. It uses a framework that describes six critical management areas: oversight and coordination; human resources; resource management; health financing; community involvement; and health information management. These core areas of health system management are assessed with regard to capacity in three core management functions: the capacity to plan, to implement, and to monitor and evaluate. The tool was applied to assess the management capacity of six counties in Liberia. The results helped differentiate the level of capacity of the different counties and clarify the actions required to strengthen the health system in the periphery. The assessment also allowed the prioritizing of county health offices with regard to the level of capacity building required to improve management. The tool also identified successes that can inform the design of future health programs in other county health offices. The tool can be applied to other challenging country situations to assess management capacity, which will help focus technical assistance to the health sector in fragile states.
INTRODUCTION: In Sub-Saharan Africa (SSA) sound planning is required as interest increases in the decentralization of healthcare financing and the implementation of a sector-wide approach to health care. For this, improved knowledge of national morbidity and mortality is essential. Data from remote areas of SSA are needed to ensure that public health priority-setting and actions reflect the situation in all regions, not just those easily accessed and readily researched. In order to understand the causes, circumstances and changes over time of death in a remote and underserved region, this study sought information on all deaths in a district hospital over a 17 year period. METHODS: The study design was a retrospective review of the hospital records (in registers) of all patients hospitalized in Kolofata District Hospital, a rural public hospital in the Far North Region of Cameroon, 1 January 1993 to 31 December 2009. A line listing was extracted of all 1281 inpatient deaths, and this included dates of admission and death; patient name, address, sex and ethnic group; presenting complaint; duration of symptoms; summary of physical examination; and the diagnosis presumed to be the cause of death. RESULTS: Children under the age of 15 years and males comprised the majority of deaths (63.9% and 56.0%, respectively). Causes of death were related to the seasons. Infectious diseases including acute lower respiratory tract infection, malaria and diarrhoeal diseases were the leading causes of death; AIDS caused most adult deaths. A total of 67% of patients presented within 1 week of symptom onset, and 56.8% of deaths occurred on or before the day after admission. Deaths due to AIDS, malaria and complications of pregnancy increased over time. Among Kolofata District residents, death from vaccine-preventable measles and neonatal tetanus were rare, particularly in the later study years. The proportion of deaths attributed to non-communicable diseases did not increase in the 17 year period. CONCLUSIONS: To reduce mortality in this world region, priority should be given to the prevention and management of lower respiratory tract infections, malaria, diarrhoeal diseases, AIDS, and the complications of pregnancy. The planning of health resources and activities should take into account seasonal variations in the causes of death. Improvements to emergency services and community education that emphasises the need for earlier presentation when ill should reduce deaths that occur soon after hospital admission. Death due to measles and neonatal tetanus has become rare, a reflection of the effectiveness in this area of the national vaccination program.
In Burkina Faso, as in most developing countries, the operational level of the health system is made up of Health Districts (HDs), the activities of which are typically coordinated by the District Team (DT). Assessing the the core functions of DTs, as described by WHO, shows two important weaknesses. Firstly, instructions from "above" are often implemented rather passively: DTs tend not to display much leadership. Secondly, the current organisation, based on input financing and centralised planning, does not sufficiently promote either the vision or research functions of DTs. In this article, we report our experience in the Orodora HD in Burkina Faso, where the DT's leadership and vision proved to be essential ingredients for effective health action in the district. Our description of six interventions implemented between 2004 and 2008 shows how DT leadership and vision have improved outputs at the HD level. Until 2004, the district applied static health planning. The health system was insufficiently financed and performed poorly. Faced with this situation, the DT decided to set up several priority interventions based on health care access criteria and patient concerns, while respecting and contextualizing national norms and objectives. Six interventions were then implemented. The first was ensure that quality blood (meeting transfusion security norms) was available at the District Hospital (DH), by picking blood up from the regional blood transfusion center weekly. This speeded up care at the DH, reduced the number of cases referred to the regional hospital for transfusion, and reduced neonatal and maternal mortality. The second intervention sought to improve the skills of health workers in managing emergency cases and to improve relationships with the referral hospital through the reintroduction of counter-referral procedures. This led to a decrease in unnecessary referrals and also reduced the mortality rates of serious cases. The third intervention, by implementing a decentralized approach to tuberculosis detection, succeeded in improving access to care and enabled us to quantify the rate of tuberculosis-HIV co-infection in the HD. The fourth intervention improved financial access to emergency obstetric care by providing essential drugs and consumables for emergency obstetric surgery free of charge. The fifth intervention boosted the motivation of health workers by an annual 'competition of excellence', organised for workers and teams in the HD. Finally, our sixth intervention was the introduction of a "culture" of evaluation and transparency, by means of a local health journal, used to interact with stakeholders both at the local level and in the health sector more broadly. We also present our experiences regularly during national health science symposia. Although the DT operates with limited resources, it has over time managed to improve care and services in the HD, through its dynamic management and strategic planning. It has reduced inpatient mortality and improved access to care, particularly for vulnerable groups, in line with the Primary Health Care and Bamako Initiative principles. This case study would have benefited from a stronger methodology. However, it shows that in a context of limited resources it is still possible to strengthen the local health system by improving management practices. To progress towards universal health coverage, all core functions of a DT are worth implementing, including leadership and vision. National and international health strategies should thus include a plan to provide for and train local health system managers who can provide both leadership and strategic vision.
In 1991, the Philippines joined a growing list of countries that reformed health planning through decentralization. Reformers viewed decentralization as a tool that would solve multiple problems, leading to more meaningful democracy and more effective health planning. Today, nearly two decades after the passage of decentralization legislation, questions about the effectiveness of the reforms persist. Inadequate financing, inequity, and a lack of meaningful participation remain challenges, in many ways mirroring broader weaknesses of Philippine democracy. These concerns pose questions regarding the nature of contemporary decentralization, democratization, and health planning and whether these three strategies are indeed mutually enforcing.
Immunization programs are important tools for reducing child mortality, and they need to be in place for each new generation. However, most national immunization programs in developing countries are financially and organizationally weak, in part because they depend heavily on funding from foreign sources. Through its Sustainable Immunization Financing Program, launched in 2007, the Sabin Vaccine Institute is working with fifteen African and Asian countries to establish stable internal funding for their immunization programs. The Sabin program advocates strengthening immunization programs through budget reforms, decentralization, and legislation. Six of the fifteen countries have increased their national immunization budgets, and nine are preparing legislation to finance immunization sustainably. Lessons from this work with immunization programs may be applicable in other countries as well as to other health programs.
Much of current research on issues of equity in low- and middle-income countries focuses on uncovering and describing the extent of inequities in health status and health service provision. In terms of policy responses to inequity, there is a growing body of work on resource reallocation strategies. However, little published work exists on the challenges of implementing new policies intended to improve equity in health status or health service delivery. While the appropriateness of the technical content of policies clearly influences whether or not they promote equity, policy analysis theory suggests that it is important to consider how the processes of policy development and implementation influence policy achievements. Drawing on actor analysis and implementation theory, we seek to understand some of the dynamics surrounding the proposed implementation of one set of South African staff allocation strategies responding to broader equity-oriented policy mandates. These proposals were developed by a team of researchers and mid-level managers in 2003 and called for the reallocation of staff between better- and lesser-resourced districts in the Cape Town Metropolitan region to reduce broader resource allocation inequities. This was felt necessary because up to 70% of public health expenditure was on staff, and new financing for health care was unavailable. We focus on the views and reactions of the two sets of implementing actors most directly influenced by the proposed staff reallocation strategies: district health managers and clinic nurses. One strength of this analysis is that it gives voice to the experience of the district level--the key but much neglected implementation arena in a decentralized health system. The paper's findings unpack differences in these actors' positions on the proposed strategies, and explore the factors influencing their positions. Ultimately, we show how a lack of trust in the relationships between mid-level managers and nurse service providers influenced the potential to implement a specific set of equity-oriented strategies.
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 Presidentâs 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 constraintsâespecially in human resources and logistics systemsâwere 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 constraintsâan 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 âcontrol knobsâ 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 âsmall numberâ 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 countriesâChile, China, Colombia, Ghana, Taiwan, Turkey and Eastern European countriesâhave 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 decentralizationâlooking at the relationship between choice, capacity and accountability at different levels of a health systemâcan 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 factorsâpolitical, economic, social and culturalâwhich 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.
This paper describes the Brazilian health system, which includes a public sector covering almost 75% of the population and an expanding private sector offering health services to the rest of the population. The public sector is organized around the Sistema Ănico de SaĂșde (SUS) and it is financed with general taxes and social contributions collected by the three levels of government (federal, state and municipal). SUS provides health care through a decentralized network of clinics, hospitals and other establishments, as well as through contracts with private providers. SUS is also responsible for the coordination of the public sector. The private sector includes a system of insurance schemes known as Supplementary Health which is financed by employers and/or households: group medicine (companies and households), medical cooperatives, the so called Self-Administered Plans (companies) and individual insurance plans.The private sector also includes clinics, hospitals and laboratories offering services on out-of-pocket basis mostly used by the high-income population. This paper also describes the resources of the system, the stewardship activities developed by the Ministry of Health and other actors, and the most recent policy innovations implemented in Brazil, including the programs saĂșde da Familia and Mais SaĂșde.
Honoratha Mushi, K. Mullei, J. Macha, Francis Wafula · 7 authors
Health worker training is a key component of the integrated management of childhood illness (IMCI). However, training coverage remains low in many countries. We conducted in-depth case studies in two East African countries to examine the factors underlying low training coverage 10 years after IMCI had been adopted as policy. A document review and in-depth semi-structured interviews with stakeholders at facility, district, regional/provincial and national levels in two districts in Kenya (Homa Bay and Malindi) and Tanzania (Bunda and Tarime) were carried out in 2007-08. Bunda and Malindi achieved higher levels of training coverage (44% and 25%) compared with Tarime and Homa Bay (5% and 13%). Key factors allowing the first two districts to perform better were: strong district leadership and personal commitment to IMCI, which facilitated access to external funding and encouraged local-level policy adaptation; sensitization and training of district health managers; and lower staff turnover. However, IMCI training coverage remained well below target levels across all sites. The main barrier to expanding coverage was the cost of training due to its duration, the number of facilitators and its residential nature. Mechanisms for financing IMCI also restricted district capacity to raise funds. In Tanzania, districts could not spend more than 10% of their budgets on training. In Kenya, limited financial decentralization meant that district managers had to rely on donors for financial support. Critically, the low priority given to IMCI at national and international levels also limited the expansion of training. Levels of domestic and donor support for IMCI have diminished over time in favour of vertical programmes, partly due to the difficulty in monitoring and measuring the impact of an integrated intervention like IMCI. Alternative, lower cost methods of IMCI training need to be promoted, and greater advocacy for IMCI is needed both nationally and internationally.
Kathryn Church, Korrie de Koning, Adriane Martin Hilber, Hermen Ormel · 5 authors
Current attempts to address the high burden of sexual health morbidity and mortality in developing countries remain limited in scale due to a range of health system constraints. We conducted a literature review of the policy and programmatic issues that influence the integration of sexual health into primary care services in developing countries. Forty-seven reports were identified from a search of both peer-reviewed and gray literature. Key issues identified were intersectoral and intergovernmental coordination; management and organizational issues including decentralization, health sector reform, logistics, and referral systems; human resources, including training and support required to increase service scope; relationships between the public and private sectors; and scaling-up and financing issues.
Historically, health care in Zimbabwe was provided primarily to cater to colonial administrators and the expatriate, with separate care or second-provision made for Africans. There was no need for legislation to guarantee its provision to the settler community. To address the inequities in health that had existed prior to 1980, at independence, Zimbabwe adopted the concept of Equity in Health and Primary Health Care. Initially, this resulted in the narrowing of the gap between health provision in rural areas and urban areas. Over the years, however, there have been clear indications of growing inequities in health provision and health care as a result of mainly Economic Structural Adjustment Policies (ESAP), 1991â1995, and health policy changes. Infant and child mortality have been worsened by the impact of HIV/AIDS and reduced access to affordable essential health care. For example, life expectancy at birth was 56 in the 1980s, increased to 60 in 1990 and is now about 43. Morbidity (diseases) and mortality (death rates) trends in Zimbabwe show that the population is still affected by the traditional preventable diseases and conditions that include nutritional deficiencies, communicable diseases, pregnancy and childbirth conditions and the conditions of the new born. The deterioration of the Zimbabwean health services sector has also partially been due to increasing shortages of qualified personnel. The public sector has been operating with only 19 per cent staff since 2000. Many qualified and competent health workers left the country because of the unfavourable political environment. The health system in Zimbabwe has been operating under a legal and policy framework that in essence does not recognize the right to health. Neither the pre-independence constitution nor the Lancaster House constitution, which is the current Constitution of Zimbabwe, made specific provisions for the right to health. Progress made in the 1980s characterized by adequate financing of the health system and decentralized health management and equity of health services between urban and rural areas, which saw dramatic increases in child survival rates and life expectancy, was, unfortunately, not consolidated. As of 2000 per capita health financing stood at USD 8.55 as compared to USD 23.6, which had been recommended by the Commission of Review into the Health Sector in 1997. At the beginning of 2008 it had been dramatically further eroded and stood at only USD 0.19 leading to the collapse of the health system. Similarly, education in Zimbabwe, in addition to the changes it has undergone during the different periods since attainment of independence, also went through many phases during the colonial period. From 1962 up until 1980, the Rhodesia Front government catered more for the European child. Luckily, some mission schools that had been established earlier kept on expanding taking in African children who could proceed with secondary education (high school education). Inequity in education existed when the ZANU-PF government came into power in 1980. It took aggressive and positive steps to redress the inequalities that existed in the past. Unfortunately, the government did not come up with an education policy or philosophy in spite of massive expansion and investment. The government had cut its expenditure on education because of economic and political instability. This has happened particularly in rural areas, where teachers have left the teaching profession.