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.
This article addresses several issues pertinent to health systems governance for health equity. It argues the importance of health systems using measures of positive health (well-being), discriminating in favour of historically less advantaged groups and weighing the costs of health care against investments in the social determinants of health. It cautions that the concept of governance could weaken the role of government, with disequalizing effects, while emphasizing the importance of two elements of good governance (transparency and participation) in health systems decision-making. It distinguishes between participation as volunteer labour and participation as exercising political rights, and questions the assumption that decentralization in health systems is necessarily empowering. It then identifies five health system roles to address issues of equity (educator/watchdog, resource broker, community developer, partnership developer and advocate/catalyst) and the implications of these roles for practice. Drawing on preliminary findings of a global research project on comprehensive primary health care, it discusses political aspects of progressive health system reform and the implications of equity-focused health system governance on health workers' roles, noting the importance of health workers claiming their identity as citizens. The article concludes with a commentary on the inherently political nature of health reforms based on equity; the necessary confrontation with power relations politics involves; and the health systems governance challenge of managing competing health discourses of efficiency and results-based financing, on the one hand, and equity and citizen empowerment, on the other.
David Katzenstein, Sinata KoullaâShiro, Marie Laga, JeanâPaul Moatti
The extraordinary success of antiretroviral therapy (ART) in the North during the closing years of the last century directly led to the United Nations' resolutions in 2000, about universal access to HIV treatment, and to the inclusion of this target among the Millenium Development Goals [1]. A previous AIDS supplement, supported by the French Agency for AIDS Research (ANRS) and published as early as 2003, presented the evaluation of the first national pilot programs for access to antiretroviral HIV treatment in three African countries (CĂŽte d'Ivoire, Senegal and Uganda). These results contributed to a consensus on the feasibility of scaling-up access to HIV treatment in low-resource settings, an issue that had been heavily debated among clinical, public health and development experts [2]. Since then, antiretroviral therapy coverage rose from 7% in 2003 to 42% in 2008, with especially high coverage achieved in eastern and southern Africa (48%) [3]. There are no longer doubts that access to ART results in a remarkable reduction in mortality, which may be as high as 95% in comparison to no intervention [4]. In addition, retention in care and treatment may exceed levels seen in the North: for example, a remarkable 79% of adults enrolled in the early stages of Botswana's antiretroviral therapy scale-up are alive five years later [5]. On a macro scale, Bendavid and Bhattacharya [6] found that after four years of the US President's Emergency Plan for AIDS Relief (PEPFAR) funding and support for ART, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, although trends in adult prevalence did not differ. Despite the community stigma, political denial and tensions between government policy and medical practice, South Africa with the largest number of HIV infected individuals is also home to the largest antiretroviral therapy program in the world with accelerating impact. In the Western Cape Province, six-month mortality among patients at an HIV treatment centre fell from 12.7% to 6.6% between 2001/2002 and 2005 as access expanded [7]. The recent statement, on World AIDS Day on December 1st 2009, about universal access to HIV care and treatment by the new South-African President, Jacob Zuma, raises hope that South Africa will henceforth assume a leadership role in the region [8]. However, scaling-up access to HIV treatment in Africa, home to two thirds of those living with HIV/AIDS, poses new and largely unexplored challenges in the delivery of a complex set of public health, medical and psychosocial interventions. The transition from an emergency response to robust and sustainable health services delivery systems for HIV is a work in progress. Building these systems must be mindful of cultural context and existing health systems in the affected communities. The most recent [9] report on the epidemic describes a highly varied picture of remarkable progress in some African countries and huge unmet needs in others. Access to treatment in Africa is often taking place in the context of fragile states, struggling with social, political and economic turmoil, where investment in healthcare systems has been limited. Particularly in resource limited settings, there is an unavoidable competition for infrastructure, resources and personnel between donor driven programs targeting specific diseases (ie. AIDS, TB and malaria) and long standing programs in primary care, maternal and infant health. The âMaximizing Positive Synergies Collaborative Groupâ (MPSCG), coordinated by WHO, has recently synthesized the existing evidence regarding interactions between disease-targeted programs and country health systems [10]. Although it concluded that this impact âon health outcomes and health systems, though variable, has been positive on balance and has helped to draw attention to deficiencies in health systemsâ, available evidence also pointed out that further improvements and efficiency gains are needed especially to strengthen the health workforce, align health information systems, and to reduce out-of-pocket payments for financing health-care expenditures. Operational research encompasses a broad range of investigation, primarily the evaluation of outcomes among the health programs. Systematic observation and analysis of data collected alongside ART programs can provide guidance to implementers and policy makers with the aim of achieving sustainable access to care. Critical in any operational research project is the development of partnerships and capacity building between the wide array of actors who contribute to deliver healthcare, including national health services, community based organizations and advocacy groups, national and transnational NGOs, as well as the international donor agencies on the one hand, and academic researchers and research organizations on the other [11]. There are certainly general principles of treatment that can be broadly applied and evaluated in Africa. But ultimately, in each context, it may be anticipated that the design of programs for access to ART will vary. Critical unanswered questions remain about how access to ART will impact social stigma, individual risk behavior and ultimately the course of the epidemic. Because of the heterogeneity of affected populations and societies, the psychosocial and behavioral consequences of ART access and methods to ensure adherence, retention and to provide sustained treatment across Africa are not likely to be distilled to a single set of best practices. Thus, in the face of the HIV epidemic in Africa, operational research is a process of âlearning by doingâ in each of the diverse contexts, sharing the outcomes and observations among countries and programs. A myriad of local evaluations of process and outcome may be the most flexible way to effect sustainable implementation of ART access and the development of robust medical and social responses to AIDS in various contexts across a continent. One regrets that in spite of significant investment in evaluation exercises, global health initiatives such as the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), PEPFAR or the World Bank still have limited contributions to effective operational research [12,13]. Operational issues in scaling up access to ART This supplement presents original results documenting the progress, as well as obstacles, in scaling up HIV treatment in Africa. Papers from Burkina-Faso and Cameroon are based on operational research carried out alongside the national ART programs of these two countries that have been directly supported by ANRS. Other papers present fruitful experiences from operational research in additional African countries (Botswana, Lesotho, Mozambique and South Africa) while one paper (Celletti et al., S45âS57) focuses on a multi-country effort associating four African countries (Ethiopia; Malawi; Namibia and Uganda) and Brazil. It must be noted that the paper by Bassett et al. (S37âS44) about initiation of ART in Durban, Kwazulu-Natal, South Africa, one of the epicenters of the epidemic, was awarded the joint International AIDS Society (IAS)/ ANRS âYoung Investigator Prizeâ for Operations Research at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, that took place in Capetown in July 2009. Finally, one paper (Jerome & Ivers, S73âS78) deals with rural Haiti, a non-African country, whose experience with ART in very deprived and vulnerable populations has been worthwhile for other low-resource settings. The process of improving and sustaining access to ART begins with surveillance and testing to understand the magnitude of the epidemic locally, and requires assessment and consultation with Ministries, healthcare providers, communities and stakeholders to identify the key operational issues in access. Access to ART begins with the effective implementation of voluntary testing on a scale not yet realized, effective post-test counseling, linkage to care, and has already led to monitoring, care and retention of 3 million people on ART in Africa. How to accomplish each of these tasks with health systems that are often insolvent and frequently understaffed is the focus of the papers presented in this supplement. All papers emphasize that advances in access to ART have only been made possible through implementation of innovative ways of delivering and monitoring care, and also illustrate some of these innovations. Clinical research programs continue to evaluate new, less toxic and potentially less costly drug cocktails, more effective monitoring algorithms and programs to reinforce and maintain treatment adherence that would be better adapted to the practical constraints of health systems with very scarce resources. Notably, the DART study results in Uganda and Zimbabwe suggest that some of the accepted guidelines for laboratory monitoring need careful reassessment [14], and the forthcoming results of the STRATALL study in Cameroon will evaluate the impact of the WHO public health approach to monitor ART at a decentralized level of care [15]. Similarly, the management of first-line ART is fraught with issues even in the choice of Non-nucleoside reverse transcriptase inhibitors (NNRTIs). Consideration of Efavirenz and Nevirapine as first line NNRTIs as described in the paper by Wester et al. (S27âS36) in Botswana reflect trade-offs among cost, potency, potential side-effects and concerns about teratogenicity and toxicity. These issues will continue to expand as additional drugs become available and as the price proposed by pharmaceutical firms for new first-line and for second-line regimens, as recommended by WHO, remain prohibitively high compared to those of the âoldâ generation of antiretroviral drugs [16]. It is estimated that at least 57 countries, mostly in sub-Saharan Africa, face crippling health workforce shortages, and there are simply not enough physicians and nurses on the ground to begin to address the magnitude of the HIV epidemic through traditional clinic based care. Rational redistribution of tasks between physicians and other healthcare personnel, and the introduction of community and family health aids and NGO volunteers, as medical officers, adherence counselors or treatment âbuddiesâ is a key part of the âtask-shiftingâ agenda articulated by WHO [17]. The multi-country paper by Celletti et al. (S45âS57), papers by Sherr et al. (S59âS66) on Mozambique, Jerome and Ivers (S67âS72) on Haiti and Ivers et al. (S73âS78) on the Haiti-Lesotho collaborative model detail the certain conditions that have to be fulfilled for the reorganization of clinical services under a task shifting model to be successful. One of the most innovative contributions of HIV programs has been to promote meaningful multi-stakeholder partnerships between governments, civil society and affected communities at the global and local levels. Civil society has critically important roles ranging from advocacy, demand creation, and service delivery, to policy-setting and providing oversight by emphasizing accountability to service users [18]. Papers by Desclaux et al. (S79âS85) on Burkina-Faso and Ivers et al. (S73âS78) on the south-south collaboration between Haiti and Lesotho illustrate how such involvement of civil society offer opportunities for creative operational research. Quite logically, it is the relationship between scaling up access to HIV treatment and health systems strengthening that bears the greatest scrutiny across most of the papers of this supplement. In a comprehensive evaluation of ART access through a national program in Cameroon, Boyer et al. (S5âS15) present analysis from the EVAL study where the quality and quantity of care at central, provincial and district levels was contrasted. This evaluation clearly shows that decentralization of ART delivery can increase equity in access for the poorest sectors of people living with HIV while maintaining clinical effectiveness, and even improving adherence and quality of life. Experiences in other African countries, like Uganda, suggest that even further decentralization of ART may be effective and cost-effective [19], but this needs more investigation and may differ according to each specific socio-economic and health systems context. Future challenges for long term sustainability of ART In this supplement, another paper on Cameroon by Marcellin et al. (S17âS25) provides compelling evidence that access to ART at higher CD4 levels reduces reported risk behaviors and can improve quality of life. This paper, and the one from Bassett et al. (S37âS44) describing considerable gaps in bringing and retaining people with AIDS into treatment in a well resourced program in South Africa, supports the recent revision of WHO guidelines [20]. These new guidelines increase the recommended CD4 count for starting treatment to 350 cc/mm3 (rather than the previous lower 200 threshold) and imply that an additional number of 5 million HIV-infected patients world-wide should be considered eligible for immediate access to ART. These papers, however, anticipate some of the new challenges and tensions that would logically derive from this extension of treatment eligibility and from the urgent need to revisit the relationship between HIV prevention and treatment. Despite the actions of many agencies and national health autorities, an estimated 1.9 million [1.6 millionâ2.2 million] new HIV infections occurred in sub-Saharan Africa in 2008. This high incidence, and consequent increase in unmet treatment needs over time, represents an additional key challenge for ART program scale up to remain feasible and sustainable [21]. The recognition that the speed at which people are infected exceeds the speed at which they can be put on treatment has been a powerful message to advocate for enhancing prevention efforts. Treatment programs offer many opportunities to strengthen prevention, through increased uptake of testing, viral load reduction in patients and models of âprevention counselingâ for and by positive people. These synergies should be fully recognized and monitored. As an illustration, in a paper on Cameroon in this supplement (Marcellin et al. [S17âS25]), patients not yet on ART reported more frequent inconsistent condom use compared to those on ART, confirming positive effects of intense patient-healthcare worker contact on behavior. (Re)-emphasizing and maximizing synergies between the ART roll out and prevention is essential and urgent but should be seen as a component of a comprehensive âTreatment and Prevention Combinationâ approach, including behavioral, social and structural interventions. Over the coming decade, the challenges of expanding, enhancing and sustaining treatment for the more than 22.4 million people living with HIV in Africa, will consume immense monetary, human and social resources. Evaluating the long-term outcomes of access to ART on a population level across diverse urban and rural and multiple cultural contexts in Africa present a formidable challenge. If the patterns of behavior and transmission observed in the North are any indication, large-scale access to care may increase transmission of drug resistant viruses [22]. The best way to prevent this will be the development of robust and affordable programs for retention, monitoring and management of ART by skilled providers and robust systems of care. Papers in this supplement support the optimistic view that innovative solutions can be found to tackle the multiple medical, public health, socio-economic and logistic issues related to long term sustainability of ART programs in Africa. Ensuring their financial sustainability through appropriate growth of domestic and international funding however remains a prerequisite for success, and this is far from guaranteed in the context of one of the worst economic crises the world has ever faced. Because overall demand has been higher than anticipated in the funding scenario of its previous replenishment, the Global Fund faces a resource gap for the period 2009â10 for the first time since its creation. Its future contribution to scaling up the response to the HIV epidemic will depend on the willingness of donor governments to provide significantly higher pledges for its next replenishment (2011â2013) than the 9.8 billion US$ obtained for the previous one (2008â2010) [23]. In the US, a debate is growing about whether or not a further expansion of PEPFAR would be the best use of international health funding [24]. Demonstrations, as presented in this supplement, contribute evidence-based advocacy in favor of sustainability of HIV/AIDS treatment and provide clear examples of how health systems are adapting to meet the challenges of HIV. Of course, we also present these examples to underscore the importance of continuing, flexible operational research and evaluation to maintain international and domestic funding, the life-blood of treatment access for millions in Africa, and around the world.
BACKGROUND: The independent evaluation of the Cameroonian antiretroviral therapy (ART) Programme, which reached one of the highest coverage in the eligible HIV-infected population (58%) in Sub-Saharan Africa, offered the opportunity to assess ART outcomes in the context of the decentralization of HIV care delivery. MATERIALS AND METHODS: A cross-sectional survey (EVAL, ANRS 12-116, 2007) was carried out in a random sample of 3151 HIV-positive patients (response rate 90%) attending 27 treatment centres at the different level of the healthcare delivery (central, provincial and district), as well as in the exhaustive sample of doctors in charge of HIV care in these centres (response rate 92%, n = 97). Multivariate two-level analyses were conducted to assess the impact of the level of healthcare delivery on CD4 cell gains since initiation of treatment and adherence to treatment in the subsample of patients who were ART-treated for 6 months or more (n = 1985). RESULTS: District treatment centres were characterized by more limited technical and human resources but a lower workload. ART-treated patients followed up in these centres had significantly lower socioeconomic status. After adjustment for other explanatory factors, immunological improvement was similar in patients followed up at the central and district level, whereas adherence to ART was better both at provincial and district levels. CONCLUSION: Success in scaling-up access to ART in Cameroon has been facilitated by decentralization of the healthcare system. Long-term sustainability urgently implies better integration of this HIV-targeted programme in the global healthcare reform of financing mechanisms, management of human resources and drug procurement systems.
The implementation of decentralization policies in the health sector of many developing countries has been a major issue in international health. The objectives were to focus on health sector reform, health financing system, and human resource development. However, less attention has been paid to the institutional capacity development of health systems. In this paper, institutional capacity refers to the abilities of organizations to make effective management in order to build local capacity and to achieve goals with local ownership. The aims of this paper were to explore the developmental process of districts institutional capacity by assistance of an NGO in Cambodia, and to identify the key factors influencing this development. We chose five operational districts (ODs) and two of them were contracted to NGO for management assistance. We conducted semi-structured in-depth interview to 17 managers and 16 key informant interviews. For analysis, we used qualitative analysis based on a grounded theory approach to clarify a conceptual framework for understanding management practices at district health institutions. There is a 4-stage capacity developmental process at the district-level institution. Supportive supervision and widening of decision-making authority were identified as key factors for sustainable institutional capacity development. They have complementary function each other. External agencies such as NGOs can use these key factors to develop local management capacities, and also this capacity development can be done internally within institutions such as OD health offices and by upper authorities such as the PHD.
Recent research has shown how federalism affects health care finance, health care reform, and health policy innovation. The purpose of this article is to extend this research program to study the linkages between federalism and technological change. It does so using comparative case studies spanning five countries to examine innovation and diffusion of two blood technologies-enzyme-linked immunosorbent assays (ELISA blood tests) and heat treatment-in response to the threat to the blood supply posed by HIV during the 1980s. Prior research has produced three contradictory models of the federalism-innovation relationship. This article attempts to resolve these contradictions, posits new hypotheses, and highlights sources of omitted variable bias that have important implications for understanding technological change. The case studies show that overall decentralization, rather than federalism alone, aids technological progress by allowing its supporters to "venue shop" around political resistance. Decentralization also makes the state less vulnerable to capture by status-quo interest groups. Moreover, political decentralization may have a positive effect on technological diffusion, but a far weaker effect on innovation. Thus, prior research that conflates these two effects should be revisited.
BACKGROUND: In recent years there have been innovations in immunization financing and new technologies, and the scaling up of investment by the Global Alliance for Vaccines and Immunization (GAVI) in the Asia region. The main mechanism for coordination of this global health initiative (GHI) investment is country-level 'Inter-Agency Coordination Committees' (ICCs). AIM: The aim of the evaluation was to determine the utility and future perspectives of stakeholders regarding the role of ICCs in improving immunization services in the Asian Region. METHODS: A literature review, documentary analysis and semi-structured interviews (n = 65) were undertaken in five countries (India, Bangladesh, Nepal, Sri Lanka and Indonesia), with senior level members of Ministries of Health and the GAVI partnership. RESULTS: The evaluation has identified that there have been significant changes recently in the strategic environment for immunization, including developments in new vaccines, increasing GAVI investment, trends towards health system integration and decentralization, and institutional development of the non-government sector. This evaluation found that ICCs are functioning well in relation to information sharing and GAVI application processes. However, they are performing less well in the areas of evaluation, strategic gap analysis and coordination of immunization technical co-operation. CONCLUSIONS: There are high levels of institutional and contextual complexity at country level that require a more focused global response by GAVI to the governance challenges of institutions and partners implementing GHIs at the country level. ICCs should be maintained and strengthened in the more pluralistic context of an 'immunization coordination system' that is represented by the wider health sector, regulatory authorities, and civil society and private sector interests. Managing through systems, rather than being over-reliant on committees, will broaden participation in implementation and, in doing so, expand the reach of immunization and maternal and child health care services in developing countries.
This paper analyses health reforms in Tanzania since 1924 to 1993 to determine how each paradigm influenced the next by using the recent World Health Organization (WHO) framework of health system. Published and gray documents were reviewed and analyzed for the four discrete attempts at reforming the health sector, focusing on the district health system decentralization. The findings revealed that for each wave, there was a review of the health system, making information from preceding efforts to be available to the subsequent reforms. After independence the political party in power played a major role in ensuring availability of information and its utilization. Predominant information in each wave showed that the health system was underfinanced, there was poor performance of PHC strategies, non-integration of DMO and poor health workers income. Health reforms should focus on health system finance, integrated district health system, health workers welfare and community participation.
Neonatal mortality in the country continues to be unacceptably high and unrelenting with wide variations across states. Six high population states account for 60% burden of neonatal deaths. Most of the evidence-based interventions are reflected in the programs, but the coverage levels are low due to poor implementation resulting from missed opportunities and weak health systems. Action is required at the home and community level, as well as at the outreach and facility levels in rural and urban settings. ASHAs must be engaged in home care of neonates. Private sector needs to be involved for providing care to neonates of poor families. Demand side financing and incentives could be game-changers in enhancing care seeking and service uptake. Effective programming would require still higher budgets, decentralized planning, managerial support, proper monitoring and a massive human resources capacity development. Community mobilization is essential for which panchayati raj institutions can play an important role. Advoa.cy efforts should not be diluted because there still is a long way to attain an acceptable level of newborn survival.
The objective of the study was to analyze the status and explore the challenges to decentralization policy implementation in Nepal. Thirty seven key informants rich in experience and knowledge, seven focus group discussions, observation of six health facilities and analysis of about 25 key policy documents provided the data for this study. The study identified the challenges to the implementation of decentralization reforms in the public health sector as: (i) centralised and weak management and programming practices of the government; (ii) weak legal and institutional framework; (iii) conflicting policy objectives; (iv) lack of implementation strategy; (v) poor financial and human resource management system; (vi) lack of adequate preparation for managing the reform; (vii) weak capacity at all levels; (viii) political instability. It was revealed that the implementation of the policy in Nepal was extremely poor as many of the important policy measures were either never initiated or they were only partially implemented. The challenges lie both at - policy design and implementation phase. Clear policy objectives, appropriate structure, sound planning, financing and human resources policy, adequate capacity, responsive information system, defined service packages, active participation of stakeholders and a conducive socio-political environment are considered imperative for successful implementation of the policy. Preparation for managing reform implementation at national and district levels is prerequisite for decentralization to work. Pushing for decentralization in a politically fragile environment may rather lead to further fragmentation, instead of strengthening government legitimacy.
Abstract Globally, post-Alma Ata health care system reforms have included reorganization of government health agencies, establishment of rationalized, evidence-based systems of care, implementation of user charges for public services, and experiments with third party financing. Drawing on materials collected in the context of long-term ethnographic research in Mongolia, this chapter reveals that there is a mismatch between the economic rationality that underlies current health reform programs and the realities of the lived experiences of illness in poor communities. Coupled with decentralization and poor regulatory oversight, current health reform efforts can result in fragmentation of the health system, increasing opportunity costs for health care seeking by poor households, reduced access to essential drugs, and an overall increased risk for health-cost related impoverishment. The chapter concludes by arguing that ethnographic information on health care seeking in poor communities can inform health reform efforts through explaining how features of health reform produce health inequities.
BACKGROUND: During the Suharto era public funding of health in Indonesia was low and the health services were tightly controlled by the central government; district health staff had practically no discretion over expenditure. Following the downfall of President Suharto there was a radical political, administrative and fiscal decentralization with delivery of services becoming the responsibility of district governments. In addition, public funding for health services more than doubled between 2001 and 2006. It was widely expected that services would improve as district governments now had both more adequate funds and the responsibility for services. To date there has been little improvement in services. Understanding why services have not improved requires careful study of what is happening at the district level. METHODS: We collected information on public expenditure on health services for the fiscal year 2006 in 15 districts in Java, Indonesia from the district health offices and district hospitals. Data obtained in the districts were collected by three teams, one for each province. Information on district government revenues were obtained from district public expenditure databases maintained by the World Bank using data from the Ministry of Finance. RESULTS: The public expenditure information collected in 15 districts as part of this study indicates district governments are reliant on the central government for as much as 90% of their revenue; that approximately half public expenditure on health is at the district level; that at least 40% of district level public expenditure on health is for personnel, almost all of them permanent civil servants; and that districts may have discretion over less than one-third of district public expenditure on health; the extent of discretion over spending is much higher in district hospitals than in the district health office and health centers. There is considerable variation between districts. CONCLUSION: In contrast to the promise of decentralization there has been little increase in the potential for discretion at the district level in managing public funds for health - this is likely to be an important reason for the lack of improvement in publicly funded health services. Key decisions about money are still made by the central government, and no one is held accountable for the performance of the sector - the district blames the center and the central ministries (and their ministers) are not accountable to district populations.
Health sector reforms emerged as a major focus in the 1990s covering a wide range of structural and institutional changes. The components of a fundamental health sector reform includes: decentralization of power and resources; improving function of national health ministries; improving the performance of civil service (and managers); broadening health financing mechanism; introducing managed competition; guaranteeing access, redressing equity and pro-poor orientation; as well as broadening ownership and impact. Nigeriaâs overall health system performance was ranked 187th among the 191 Member States by the WHO in 2000. The issue of financing and user fees has implications for reproductive health services uptake.
Where maternal services are rendered free there was an increase in service uptake where the quality of the services that are being provided are guaranteed. Local authorities or communities should be allowed to set their priorities based on their peculiar needs and problems of their locality, but such should not go against the main objective of the health reform. The approach of âbasket fundingâ should be continued to ensure quality monitoring and evaluation of the health system in general and assuring the quality of health related data.
Key words: Health sector reforms, Reproductive health, Health financing mechanism, Nigeria
Dov Chernichovsky, Gabriel MartĂnez, Nelly Aguilera
OBJECTIVE: Tanzania, Mexico, and the United States are at vastly different points on the economic development scale. Yet, their health systems can be classified as "developing": they do not live up to their potential, considering the resources available to them. The three, representing many others, share a common structural deficiency: a segregated health care system that cannot achieve its basic goals, the optimal health of its people, and their possible satisfaction with the system. Segregation follows and signifies first and foremost the lack of financial integration in the system that prevents it from serving its goals through the objectives of equity, cost containment and sustainability, efficient production of care and health, and choice. METHOD: The chapter contrasts the nature of the developing health care system with the common goals', objectives, and principles of the Emerging Paradigm (EP) in developed, integrated--yet decentralized--systems. In this context, the developing health care system is defined by its structural deficiencies, and reform proposals are outlined. FINDINGS: In spite of the vast differences amongst the three countries, their health care systems share strikingly similar features. At least 50% of their total funding sources are private. The systems comprise exclusive vertically integrated, yet segregated, "silos" that handle all systemic functions. These reflect and promote wide variations in health insurance coverage and levels of benefits--substantial portions of their populations are without adequate coverage altogether; a considerable lack of income protection from medical spending; an inability to formalize and follow a coherent health policy; a lack of financial discipline that threatens sustainability and overall efficiency; inefficient production of care and health; and an dissatisfied population. These features are often promoted by the state, using tax money, and donors. POLICY IMPLICATIONS: The situation can be rectified by (a) "centralizing"--at any level of development and resource availability--health system finance around a set package of core medical benefits that is made available to the entire population and (b) "decentralizing" consumption and provision of care. The first serves equity and cost containment and sustainability. The second supports efficiency and client satisfaction. ORIGINALITY/VALUE OF CHAPTER: The chapter views commonly discussed problems of the health care system--a lack of insurance coverage and income protection--as symptoms of a large problem: health system segregation.
The right to participation is the "the right of rights"--the basic right of people to have a say in how decisions that affect their lives are made. All legally binding international human rights treaties explicitly recognize the essential role of participation in realizing fundamental human rights. While the substance of the human right to health has been extensively developed, the right to participation as one of its components has remained largely unexplored. Should rights-based health advocacy focus on participation because there is a relationship between an individual's or a community's active involvement in health care decision-making and the highest attainable standard of health? In the context of the human right to health, does participation mean primarily political participation, or should we take the right to participation to mean more specifically the right of persons, individually and as a group, to shape health care policy for society and for themselves as patients? Decentralization of health care decision-making promises greater participation through citizen involvement in setting priorities, monitoring service provision, and finding new and creative ways to finance public health programs. Between 1999 and 2008, Indonesia decentralized health care funding and delivery to regional governments, resulting in substantial exclusion of its poor and uneducated citizens from the health care system while simultaneously expanding the opportunities for political participation for educated elites. This article explores the tension between the right to participation as an underlying determinant of health and as a political right by reviewing the experience of Indonesia ten years after its decision to decentralize health care provision. It is ultimately argued that rights-based advocates must be vigilant in retaining a unified perspective on human rights, resisting the persistent tendency to separate and prioritize the civil and political aspects of participation over its social component.
Two papers in this volume focus on public finance and decentralization as central to resolving India's systemic public health crisis. However, some states and districts have achieved success despite serious financial and administrative deficits; this suggests that factors such as political commitment, community participation, human resource management, women's empowerment, and governance may be as or more important. The success of the National Rural Health Mission will depend on state and local institutional capacity, including strong partnerships with civil society organizations and private-sector actors. Increased resources and decentralization will not be sufficient by themselves.
In this paper the problems of health services in China and India are related to some structural features of the two economies. Some similarities and differences exist across these two countries in terms of political economy, with differential results. Both countries have experienced remarkable economic growth during the past quarter-century, but this has not always translated into improvements in health for the poor. Although China used to have an egalitarian basic public health service, the system has become quite inegalitarian during the past quarter-century, with the disintegration of the communes and adoption of fee-based services under a system of decentralized public finance. India's health system has remained inegalitarian throughout.
Elmer S. Soriano, David M. Dror, Erwin Gaspar A. Alampay, Jolande
A sustainable health reinsurance system can be fashioned for the informal sector by mobilizing social and economic forces operating within individual communities. The economic analysis in part 1 of this book draws conclusions from success stories in industrial countries and failures in low- and medium-income countries. This analysis leads to the premise that decentralized development of microinsurance units, operating in a market segment left out by for-profit health insurance firms and by national schemes, can be stabilized financially through their affiliation with a reinsurance facility-Social Re' (part 1, this volume; Dror and Duru 2000, pp. 30-40; Dror 2001). Dror, Preker, and Jakab, in chapter 2 of this book, explain how the sociological dimension would theoretically affect the performance of a microinsurer. Findings of the Institute of Medicine reaffirm the active interplay of biology, psychology, behavior, and society in determining people's health attitudes. The institute further reports that, although people's attitudes and actions can readily be altered, these changes need support and reinforcement over time to guarantee better health. Attitudinal and behavioral changes are best prolonged through interventions at multiple levels, from the individual to society at large (Institute of Medicine 2001, pp. 1-1-1-8). Efforts are required to address the psychosocial factors that influence health status, including, for example, proposing measures such as microinsurance to persuade individuals to accept a healthy way of life and permanently modify their health behavior. Microinsurance schemes provide individuals, households, and communities mechanisms for financing their health through group risk-pooling mechanisms, leading to a sustained improvement in their access to health services. Higher up on the social scale, well-evaluated interventions at the organizational level should be encouraged, giving credit to organizations' vital role in influencing individual behavioL Still farther up the scale, community involvement in health-promotion strategies should not be overlooked, because some disease-related factors that are beyond an individual's capacity to modify can be significantly minimized through community efforts. Community empowerment, social support, and other values that protect members from stress are strengthened through community-level interventions. Finally, interventions at the societal level recognize the role of collective organizations influencing individuals' everyday existence (Institute of Medicine 2001, pp. 1-1-1-8). Underlying assumptions are that members' affiliation with microinsurers is voluntary (individuals can join, stay enrolled, or withdraw at will) and that microinsurers will voluntarily join Social Re. A clue is therefore needed about the considerations that shape individual and collective choices. According to one opinion, The underlying economic motivation for joining a microinsurance unit is assumed to be a desire to seek reciprocity in sustaining risk-sharing arrangements among essentially self-interested individuals (Dror and jacquier 1999, p. 79). This assumption implies that joining a microinsurance unit (and Social Re) is a predictable, rational economic choice by self-interested individuals to maximize total utility (optimal choice theory), and an act of reciprocity, in which giving and getting are somehow linked. According to the utility motive, people will join if they can benefit from joining. However, considering that many people will pay a health insurance premium without getting any cash benefits (if they stay healthy), is it really clear what each individual would consider as his or her exact utility from being insured? As Herrnstein points out, because utility cannot be directly observed, it must be inferred from behavior, from the choices individuals make. Thus, utility is synonymous with the modem concept of reinforcement in behavioral psychology (Herrnstein 1997, p. 226). Dror and Jacquier mention a second motive for joining a microinsurance unit: people's desire to improve their health by controlling their living and working conditions. This control is linked to a deep-rooted human need to seek voluntary and repeated interaction with others in daily life (Dror and Jacquier 1999, p. 80). These interactions may provide material reciprocity or they may reflect altruistic, nonmaterial interactions. The three authors mentioned above suggest that, to understand how microinsurers can attract and retain their clients, they have to know what shapes their clients' behavior in their specific operating context. The same reasoning applies to a microinsurer's decision to affiliate with Social Re. Since Social Re will be piloted in the Philippines, this examination will be done with reference to that country and culture. The rest of this chapter will provide an overview of the social and institutional structure of Philippine rural and informal society and the attitudes toward solidarity, risk, and insurance that influence choices and help shape the role of microinsurance. This role is quite different from what could be conjured from classical economic theory on utility, as will be shown. This analysis leads to the conclusion that in the rural Philippines, the introduction of insurance and reinsurance hinges as much, perhaps more, on the structure of society than on the profile of risks and the existence of a market for insurance.
Bangladesh has made significant progress in health indicators in recent years in spite of her low level of income. This is mainly due to the commitment of the state supported by donors in providing preventive care with respect to child health and family planning. However, there are serious problems related to both access and quality of curative care that hurt the poor most. Infrastructures for service delivery exist at local level in rural areas but they function inefficiently. This paper deals with the systemic weaknesses of decentralized service provision of primary healthcare in Bangladesh and focuses on accountability links between different actors and functions of delegation, finance, performance, information and enforcement. The study is based on facility- and household-based data collected during 2005 in Khulna Division. The main findings of the study are: the health system in rural areas represents deconcentration rather than decentralization of central government functions where inter-sectoral discipline works poorly; local health providers are not accountable to local government, and poor citizens/clients are neither aware of their rights nor are capable of expressing their needs as effective channels do not exist.
Pakistan has an extensive public sector service delivery infrastructure consisting of a three tiered healthcare delivery system which includes Basic Health Units and Rural Health Centers forming the core of the primary health model, secondary care including first and second referral facilities providing acute, ambulatory and inpatient care through Tehsil Headquarter and District Headquarter hospitals and Tertiary Care comprising teaching hospitals. Notwithstanding, most people receive healthcare through private out-of-pocket payments made directly to the providers at the point of care. Recently, many attempts have been made to mainstream alternative arrangements of service delivery at various levels in order to bridge gaps in the present system of service delivery, albeit with limited success. As one of the core areas of reform-related interventions, the Gateway Paper makes a strong case for introducing change at two levels in order to obviate these issues. Firstly, at the level of hospitals the hospital sustainability reform process calls for major structural and financing adjustments, the development of appropriate policy frameworks, decentralizing hospital management to autonomous hospital boards and providing legal, managerial and fiscal autonomy to hospitals with appropriate community representation. At the primary healthcare level, a system for restructuring BHUs and RHCs has been supported--one that makes a case for appropriate checks and balances in order to ensure sustained improvements by redefining the roles of management, quality assurance, regulation and community oversight the latter through linkages with the devolution initiative. The Gateway Paper dovetails these alternative service delivery arrangements with parallel financing models.
Pakistan currently principally uses three modes of financing health--taxation, out of pocket payments and donor contributions of which the latter is the least significant in terms of size. Less than 3.6% of the employees are covered under the social security scheme and there is a limited social protection mechanism, which collectively serves the health needs of 3.4% of the population. The main issues in health financing include low spending, lack of attention to alternate sources of financing and issues with fund mobilization and utilization. With respect to the first, health reforms proposed as part of the Gateway Paper make a strong case for promoting the reallocation of tax-based revenues and developing sustainable alternatives to low levels of public spending on health. With respect to alternative sources of health financing, the Gateway Paper lays stress on exploring policy options for private health insurance, broadening the base of Employees Social Security, creating a Federal Employees Social Security Programme, developing social health insurance within the framework of a broad-based social protection strategy, which scopes beyond the formally employed sector, establishing a widely inclusive safety net for the poor; mainstreaming philanthropic grants as a major source of health financing; developing a conducive tax configuration; generating greater corporate support for social sector causes within the framework of the concept of Corporate Social Responsibility and developing cost-sharing programmes, albeit with safeguards. The Gateway Paper regards efficient fund utilization a priority and lays stress on striking a balance between minimizing costs, controlling costs and using resources more efficiently and equitably--in other words, getting the best value for the money, on the one hand, and increasing the pool of available resources, on the other. Specific interventions such as the promotion of transparent financial administration, budgeting and cost controls and enhancing the capacity to overcome onerous financial management procedures and decentralizing decision-making are underscored as a priority as is the need for ensuring greater financial procedural clarity at the federal-provincial-district interface.