William Newbrander, Chavanne L. Peercy, Megan Shepherd‐Banigan, 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.
OBJECTIVE: Scaling up antiretroviral treatment (ART) through decentralization of HIV care is increasingly recommended as a strategy toward ensuring equitable access to treatment. However, there have been hitherto few attempts to empirically examine the performance of this policy, and particularly its role in protecting against the risk of catastrophic health expenditures (CHE). This article therefore seeks to assess whether HIV care decentralization has a protective effect against the risk of CHE associated with HIV infection. DATA SOURCE AND STUDY DESIGN: We use primary data from the cross-sectional EVAL-ANRS 12-116 survey, conducted in 2006-2007 among a random sample of 3,151 HIV-infected outpatients followed up in 27 hospitals in Cameroon. DATA COLLECTION AND METHODS: Data collected contain sociodemographic, economic, and clinical information on patients as well as health care supply-related characteristics. We assess the determinants of CHE among the ART-treated patients using a hierarchical logistic model (n = 2,412), designed to adequately investigate the separate effects of patients and supply-related characteristics. PRINCIPAL FINDINGS: Expenditures for HIV care exceed 17 percent of household income for 50 percent of the study population. After adjusting for individual characteristics and technological level, decentralization of HIV services emerges as the main health system factor explaining interclass variance, with a protective effect on the risk of CHE. CONCLUSION: The findings suggest that HIV care decentralization is likely to enhance equity in access to ART. Decentralization appears, however, to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced.
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.
Lizardo Huamán-Angulo, Lindaura Liendo-Lucano, Manuel Núñez
Los recursos humanos son el eje del accionar del sector salud; sin embargo, no necesariamente son el aspecto mejor atendido, por ello el Ministerio de Salud del Perú (MINSA) conjuntamente con los gobiernos regionales generó el Plan Sectorial Concertado y Descentralizado para el Desarrollo de Capacidades en Salud 2010-2014 (PLANSALUD) con el propósito de fortalecer las capacidades de los Recursos Humanos en Salud (RHUS) y contribuir para que la atención de salud se desarrolle con eficiencia, calidad, pertinencia, equidad e interculturalidad en el marco de la descentralización, el Aseguramiento Universal de la Salud (AUS) y las políticas de la salud. Con ese objeto se han propuesto tres componentes (asistencia técnica, capacitación y articulación educación - salud) que agrupan a un conjunto importante de intervenciones, las cuales son planteadas y definidas de acuerdo al contexto nacional, regional y local, contribuyendo de ese modo a la mejora de las capacidades de gobierno, de gestión por competencias y la prestación de servicios de salud. El presente artículo muestra una primera aproximación de PLANSALUD, incluyendo aspectos relacionados a su planificación, gestión, financiamiento, estructura y funcionamiento, así como las medidas de monitoreo y evaluación.<br>Human resources are the backbone of health sector actions; however, they are not necessarily the area with the greatest attention, therefore, the Ministry of Health of Peru (MINSA) together with regional governments, led the Decentralized and Agreed Sector Plan for the Capacity Development in Health 2010-2014 (PLANSALUD) with the aim of strengthening the capacities of Human Resources for Health (HRH) and contribute to health care efficient development, quality, relevance, equity and multiculturalism, in the context of descentralization, the Universal Health Insurance (AUS) and health policies. To achieve this goal, they have proposed three components (technical assistance, joint training and education - health articulation) that bring together an important set of interventions, which are planned and defined according to the national, regional and local levels, thus contributing to improve the government capacity, capability management and delivery of health services. This paper presents a first approach of PLANSALUD, including aspects related to planning, management, financing, structure and functioning, as well as monitoring and evaluation measures.
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.
Health care is widely considered to be an important determinant of health. The health care systems of Western Europe have recently experienced significant reforms, under pressure from economic globalization. Similarly, in Eastern Europe, health care reforms have been undertaken in response to the demands of the new market economy. Both of these changes may influence equality in health outcomes. This article aims to identify the mechanisms through which health care may affect inequalities. The authors conducted a literature review of the effects on health inequalities of European health care reforms. Particular reference was paid to interventions in the fields of financing and pooling, allocation, purchasing, and provision of services. The majority of studies were from Western Europe, and the outcomes most often examined were access to services or income distribution. Overall, the quality of research was poor, confirming the need to develop an appropriate impact assessment methodology. Few studies were related to pooling, allocation, or purchasing. For financing and purchasing, the studies showed that publicly funded universal health care reduces the impact of ill health on income distribution, while insurance systems can increase inequalities in access to care. Out-of-pocket payments increase inequalities in access to care and contribute to impoverishment. Decentralizing health services can lead to geographic inequalities in health care access. Nationalized, publicly funded health care systems are most effective at reducing inequalities in access and reducing the effects on health of income distribution.
There is an avalanche of interest in health systems with countries, donors, international experts and academic institutions all rushing to promote, fund or build capacity to address this wave of interest. As Anne Mills documents in an article in this volume, there is also a growing literature on how to think about health systems, how to use research on health systems to improve their performance, and pleas for greater investment in knowledge about health systems. We are probably riding on the crest of this new wave and it will be important to make use of it to further our knowledge about how to achieve health system effectiveness. With continuing global economic uncertainty, this wave may pass if we do not take advantage of it now. It is useful to reflect on why there is such interest in this theme now. There are probably many converging causes but the most important, to my mind, is a replay of an old debate between vertical programmes and horizontal, integrated approaches that has experienced swings of interest at least since the Alma Ata Conference in 1978 emphasized the integrated primary health care approach. During the last decade or more, there has been a major focus on vertical disease-specific programmes supported by greatly increased funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Alliance for Vaccines and Immunisation (GAVI), US President’s Emergency Plan for AIDS Relief (PEPFAR), Bill and Melinda Gates Foundation, among other donors. The major claim of these programmes was that by focusing on clear disease-specific objectives they would be more effective in shorter time periods and they could be held more accountable to donors (since the results could be more measurable) than the difficult and diverse efforts to improve the many elements of a health system through the horizontal integrated approach. While there were evident successes in these programmes, there was also a growing recognition that health system constraints—especially in human resources and logistics systems—were becoming major obstacles to achieving even their limited objectives of increased coverage of HIV/AIDS, tuberculosis, malaria and immunizations. With the added emphasis on the Millennium Development Goals (MDGs) and the slow progress toward their achievement in many countries, the international community and national governments have turned increasingly toward attempting to reduce the health system constraints—an approach that is closer to the integrated horizontal approach. Both GAVI and the Global Fund have added a separate fund for health systems interventions. In 2008, the G8 called for greater attention to health system strengthening as compatible with the prior focus on vertical programmes (Reich et al. 2008). In 2009, the World Bank convened a seminar on health system strengthening attended by representatives from the World Health Organization (WHO), GAVI and Global Fund. A task force on Healthy Women and Healthy Children calling for a health system funding platform was initiated at the UN General Assembly. In 2010, the WHO and others sponsored the First Global Symposium on Health Systems Research in Montreux, Switzerland. While many observers are trying to argue that the two approaches are now more compatible, at least in rhetorical terms it seems that the pendulum is shifting toward greater attention to health system strengthening. So how do we, the readers of Health Policy and Planning, take advantage of this interest? Health Policy and Planning is dedicated to the publication of high quality research that, as the name implies, improves decisions on policy and planning. This poses for us a central question: how can we do research that will improve health systems? The answer is complex for it requires attention to the kind of knowledge that is both researchable and leads to practical, implementable recommendations. The place to start is with a framework of analysis that is both analytical, in that it provides empirically based categories about health systems, and purposive, in that it is oriented toward how to improve the system. Many of the frameworks that are available provide a recognizable set of functional issues whose boundaries help focus attention on specific interactions that can be studied, such as financing, service delivery, human resources, governance (Mills et al. 2001). The WHO Building Blocks framework is a very popular approach that is guiding much of the discussion and research in health systems (WHO 2007). Another approach developed by Harvard School of Public Health faculty is oriented toward using analytical categories in a purposive manner that starts with an ethically derived vision of what we would like to achieve, and works back toward finding the reasons why we have not achieved those objectives. It then focuses our attention on what we can change using evidence on the effectiveness of changing different ‘control knobs’ or policy levers, including financing, payments, organization, regulation and persuasion (Roberts et al. 2004). There is a great deal of overlap in these models and they are compatible in many ways that can guide research toward practical recommendations for policy. A second question is about levels of analysis. Should we attempt to research whole national systems, with typologies of systems and comparisons of the achievements of the different models? We often hear this orientation used in policy arguments such as the recent arguments over whether the USA should adopt the Canadian single payer model. However, this approach suffers from methodological challenges such as the ‘small number’ problem (which limits the ability to use sophisticated quantitative analysis due to the few comparable national systems) and the many different characteristics and historical trajectories that confound the analysis. Few countries—Chile, China, Colombia, Ghana, Taiwan, Turkey and Eastern European countries—have even attempted broad multifaceted health system reforms and they have tended to develop their own reform models rather than copying others. Nevertheless, there are many country studies of health reforms that provide evidence and much can be gained by detailed evaluation of the effectiveness of these models that can inform policy choice in different contexts. An alternative means of assessing health systems is to focus on sub-systems or analysis of specific policy changes, focusing on different social health insurance approaches, pay for performance, contracting, decentralization or other reforms, and assessing their performance in terms of achieving health system objectives like the MDGs, reduction in catastrophic expenditures caused by paying for illness, or broader responsiveness and accountability to citizens. The advantage of this approach is that, if the research is well designed, the causality of the impact of the changes on health system objectives can be more clearly demonstrated, and it allows a more focused attention to policy changes that different countries can adopt in an incremental way. This approach can address both systems issues and vertical programme needs. For instance, the work that I am involved in on decentralization—looking at the relationship between choice, capacity and accountability at different levels of a health system—can be used to make policy recommendations on general health system reform as well as specific reforms of logistic systems, vertical immunization or family planning programme effectiveness (Bossert et al. 2007). The challenge in this approach is to account for the general national context factors—political, economic, social and cultural—which may influence the performance of these initiatives. What works in Chile may not work in China due to many different characteristics of the country contexts. This is a major lacuna in the current research in health systems often covered over by focusing only on the differences in average income levels, assuming for instance that health system changes in low-income countries are all relatively similar. However, governance issues, cultural and ethical differences, past histories with different health systems, all play a role in constraining the lessons learned from one country to another. The recent concern with political economy and political institutionalism may inform future work in this area (Fox and Reich, forthcoming). In addition, focus on one subsystem or one policy lever is likely to miss the interactions among different subsystems changes that synergistically influence outcomes. For instance, changes in decentralization may be enhanced by changes in social insurance programmes, or the creation of a new cadre of health workers. Focusing on one in order to evaluate its separate impact will miss the role of the combined changes on achieving objectives. However, if we are aware of these limitations, it might be possible to move collectively toward setting a research agenda in which multidisciplinary researchers assess the different subsystems in ways that inform each other. Those of us who focus on organizational issues like decentralization and human resources need to be aware of and incorporate in our studies, the work of experts in economics, ethics, politics and other behavioural sciences, as well as epidemiologists and biostatisticians who help us understand the underlying population and social processes underpinning those systems. There is also an imbalance of research on functional areas of analysis with a much greater body of knowledge on financing and payment issues than on organizational issues and governance and regulation. In recent years, there has been greater interest in governance, politics and human resources issues, but these areas are so complex that they require much greater attention and more funded research than is currently in the pipeline. This poses an additional requirement for multidisciplinary studies that address these under-researched areas to bring the level of knowledge up to that of the more economic themes. This is a huge task of course and current funders have little patience for large research projects in health systems. Indeed there is considerable pressure for evaluating the performance of programmes and projects that have been funded in a very short and unrealistic time frame. It suggests that we need to be nimble and develop cadres of multidisciplinary experts to be able to quickly do the solid research necessary but within limited funds and short time horizons to provide well-documented policy recommendations. If we do not, we are likely to have missed the opportunities of this wave of interest as funding for health systems declines due to alternative priorities, donor fatigue or general global economic restrictions. None declared.
The functions of the health system, according to the key objectives and relationships within the sub-systems that are available to the policy makers and managers in the Health Care system in Bosnia and Herzegovina - B&H, have been elaborated in detail, with the analytical overview of relevant indicators, thus confirming the limitations of the health promotion in B&H. The ability to overcome the expressed problems is in the startup of process for structural adjustment of the health sector, reform of the health care system and its financing. The reform in health system implies fundamental changes that need to take place, in B&H, as a state in health policy and institutions in the health care system, in order to improve the functioning of health systems with the aim of ensuring better health of the population. Reform implies the existence of documents with clearly formulated health policy objectives, for which the state stands, and for which a consensus was reached on the national level with all key actors in the political structure: public promotion of the basic principles for carrying out the reform, its implementation within a reasonable time frame, the corresponding effects for providers and customer satisfaction, as well as improving health services' efficacy (i.e. micro and macro) and the quality of healthcare. In this article, we elaborated the criteria for the classification of health systems, whereby the scientifically-based and empirical analysis is conducted on the health system in B&H and elaborated the key levers of the system. Leveraged organizational arrangements relating to the economic and political environment, organization and management functions, in connection with the services of finance, funds, customers and service providers, from which it follows the framework of state legislation related to health policy and health institutions at the state level are responsible for finance, planning, the organization, payment, regulation and conduct. If we start from the administrative criteria for the classification of "health sub-systems" in B&H, it is difficult to fit them in a pluralistic, decentralized or monistic, because in the system for each organization, there should be health policy at the state level, which is in the most countries represents the Ministry of Health.
Introduction of the market, privatization and decentralization have been the dominant corner stones throughout the first two decades of China’s reform line after the introduction of the open door policy in 1978. Many China researchers (e.g. Wang 2008; Wu 2008) thereby judge, that China’s development path was not merely a transition from planned economy to market-oriented economy, but that a “market society” emerged, in which market principles permeate also noneconomic arenas and “threatened to become the dominant mechanism integrating all of society (and even political life)” (Wang 2008: 18). The marketization of the health sector thereby entailed that social security schemes and therewith financing of public health care collapsed almost completely and out-of-pocket payment became the dominant factor defining people’s access to health care. These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
Rini Sasanti Handayani, Max Joseph Herman, Selma Siahaan
Background: Since decentralization era the health budgets including drug budget has been allocated into the development regional budget through formula-based DAU, based on regional revenues and fiscal needs. Health budget is included in DAU, though not explicitly stated. Therefore the health sector practically has to strive for their own budget in every province or every district. This is a new kind of phenomenon for regional governments especially related to the health sector. They should have strategic plan in financing while competing with other sectors to obtain it. Drug consumption in Indonesia is lower than in other ASEAN countries. To ensure access to drugs in primary heath care, the government (Ditjen Bina Farmasi dan Alkes) in the mid-year of 2003 in collaboration with WHO has facilitated a meeting among districts. This meeting leads to an agreement that the regional government should allocate Rp5.000,00 per capita annually for drug budget. Methods: A cross sectional descriptive study was done in ten districts in Indonesia in the year of 2006 on how far the realization of the district agreement of drug budget allocation, particularly in relation with improving drug access issues. District Health Office and Drug Management Unit were taken as samples and data were collected by structured interviews. Results: 1) Drug budget for most districts/cities is still less than Rp5.000,00 per capita per annum so that it can be assumed a shortage in terms of kind of, as well as, quantity of drugs. 2) Some districts showed an increase in drug budget, while the other ones showed just the opposite. 3) Not all districts had all essential and/or generic drug procurement. Conclusion: We suggest more intensive socializations for drug financing to districts in order to improve the commitment to the agreement on the allocation of drug budget and, secondly, a better technical training with topics: planning, advocacy and negotiation with relevant stakeholders. Key words: drug financing, drug budget, districts/cities
Pharmaceutical Economics and Policy
Healthcare Systems and Reforms
Health Systems, Economic Evaluations, Quality of Life
Shoba Raja, Sarah Wood, Victoria de Menil, Saju C Mannarath
BACKGROUND: Limited evidence about mental health finances in low and middle-income countries is a key challenge to mental health care policy initiatives. This study aimed to map mental health finances in Ghana, Uganda, India (Kerala state), Sri Lanka and Lao PDR focusing on how much money is available for mental health, how it is spent, and how this impacts mental health services. METHODS: A researcher in each region reviewed public mental health-related budgets and interviewed key informants on government mental health financing. A total of 43 key informant interviews were conducted. Quantitative data was analyzed in an excel matrix using descriptive statistics. Key informant interviews were coded a priori against research questions. RESULTS: National ring-fenced budgets for mental health as a percentage of national health spending for 2007-08 is 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda. Budgets were not available in Lao PDR. The majority of ring-fenced budgets (76% to 100%) is spent on psychiatric hospitals. Mental health spending could not be tracked beyond the psychiatric hospital level due to limited information at the health centre and community levels. CONCLUSIONS: Mental health budget information should be tracked and made publically accessible. Governments can adapt WHO AIMS indicators for reviewing national mental health finances. Funding allocations work more effectively through decentralization. Mental health financing should reflect new ideas emerging from community based practice in LMICs.
Decentralization involves the dispersion of power, functions and finances from a central authority to regional and local authorities. Decentralization reforms have become widespread in low- and middle-income countries, mainly due to movements towards democratiza-tion, the spread of multi-party electoral systems and transitions towards market economies. In particular, decentraliza-tion of financing systems, particularly for health, is now a common aspect of reform in these countries. The main advantage is the dynamism it can bring into the resource allocation mechanism; it also can facilitate re-allocation of funds through a visible, vibrant and bottom-up approach.
This paper firstly introduces the NRCMS(New Rural Cooperative Medical System) and mainly analyses the problems of the financing system and compensation effect: the first problem is the instability of the reverse fundraising system which goes against stable fundraising system and sustainable development.The second problem,then,is the irrationality of the general allowance mode,such as capital decentralizing,the low single compensation and unsatisfactory effects.As a result,farmers are still likely to get poor again because of some serious diseases.This paper puts forward four measures to make the system more appealing,make the farmers more actively participate in social insurance and finally achieve sustainable development of the system.
This paper is part ofa research program supported by the Health Research Institute for Health Security, with the objectives to monitor and evaluate the efficiency of health subdistrict offices in Thailand. Cost efficiency was empirically investigated based on primary surveyed data comprising 246 units operated in 12 provinces. First, descriptive statistics related to outputs (4 variables) and cost (3 variables inclusive of wages and salaries, compensation to officers, and operating expenses) are presented and discussed. All revenue and expense figures refer to fiscal year 2008. Two types of efficiency models (namely SCF and DEA) based an the input-orientation approach were applied to estimate the efficiency scores. We found that 45 units lied on the cost frontier and that represented 18 percent of the total units; in most cases, efficiency scores (DEA, VRS assumption) ranged from 0.60 to 0.75 and averaged to 0.69-implying that there was an ample room for cost-saving, specifically 31 percent, ifoutput slack or excess input were eliminated thus implying the scope for management improvement. Our estimates should be considered preliminary and an in-depth investigation needs to be taken in order further to understand the special circumstances and uncontrollable factors that might have affected the higher cost to those units, but our models failed to take note. The last section discusses policy implications and the health decentralization program in Thailand, which is a topic of policy interest. Improving the efficiency ofpublic agencies and effective public service delivery are among the goals of Thailand's public sector reform. Over the past decade, devolution of responsibilites from central agencies to local govemment units have fairly succeeded in areas of public infrastructure and social welfare-but have been less successful in primary education, public health, and environmental regulation. The transfer of the health subdistrict office is high on the national agenda, and the National Decentralization Committee strongly endorses this connection, it is important to disseminate information related to health subdistrict management, budgeting, and financing to the public, especially local administrators.
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.
The HiT profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The Ukrainian health system has preserved the fundamental features of the Soviet Semashko system against a background of other changes, which are developed on market economic principles. The transition from centralized financing to its extreme decentralization is the main difference in the health system in comparison with the classic Soviet model. Health facilities are now functionally subordinate to the Ministry of Health, but managerially and financially answerable to the regional and local self-government, which has constrained the implementation of health policy and fragmented health financing. Health care expenditure in Ukraine is low by regional standards and has not increased significantly as a proportion of gross domestic product (GDP) since the mid 1990s; expenditure cannot match the constitutional guarantees of access to unlimited care. Although prepaid schemes such as sickness funds are growing in importance, out-of-pocket payments account for 37.4% of total health expenditure. The core challenges for Ukrainian health care therefore remain the ineffective protection of the population from the risk of catastrophic health care costs and the structural inefficiency of the health system, which is caused by the inefficient system of health care financing. Health system weaknesses are highlighted by increasing rates of avoidable mortality. Recent political impasse has complicated health system reforms and policy-makers face significant challenges in overcoming popular distrust and fatigue in the face of necessary but as yet unimplemented reforms.
This article discusses the model of oral health care implemented in the Unified Health System of Brazil in the last decade. This model was conceived as a sub-sector policy that, over the years, has sought to improve the quality of life of the Brazilian population. Through a chronological line, the study presents the National Policy on Oral Health as a counter-hegemonic patient care model for the dentistry practices existing in the country before this policy was implemented. The reorganization of the levels of oral health care, the creation of reference facilities for secondary and tertiary care, through Centers of Dental Specialties and Regional Dental Prosthesis Laboratories, and the differential funding and decentralized management of financial resources were able to expand the actions of oral health for more than 90 million inhabitants. The evolution shown after the deployment of the National Oral Health Policy, as of 2004, demonstrates the greater integration of oral health care under the Unified Health System and provides feedback information to help this policy to continue to be prioritized by the Federal Government and receive more support from the state and local levels in the coming years.
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.
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.
The regional organization of the Spanish national health system offers a ‘unique field’ for exploring the sources of health inequalities as well as for testing the effects of political decentralization on health and healthcare inequalities. Drawing from the results of an empirical analysis where inequalities in three dimensions of health (outcome), healthcare (access) and healthcare payments (financing) are estimated, this article first explores the association between three such inequality dimensions alongside other system and socio-economic controls. Second, we examine whether the first wave of asymmetric healthcare devolution which took place in Spain between (1980—2001) — whereby health policy responsibilities were transferred to a few region states (autonomous communities [ACs]) — correlates with higher inequalities in health, healthcare and health financing. Our findings suggest that inequalities in health and healthcare appear to be driven by income inequalities and inequalities in use but not by inequalities in financing and health expenditure. Region states politically responsible for the organization of healthcare did not exhibit significant differences in health and healthcare inequalities and tend to exhibit a better equity performance.
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.
Options for health financing reform are often portrayed as a choice between general taxation (known as the Beveridge model) and social health insurance (known as the Bismarck model). Ten years of health financing reform in Kyrgyzstan, since the introduction of its compulsory health insurance fund in 1997, provide an excellent example of why it is wrong to reduce health financing policy to a choice between the Beveridge and Bismarck models. Rather than fragment the system according to the insurance status of the population, as many other low- and middle-income countries have done, the Kyrgyz reforms were guided by the objective of having a single system for the entire population. Key features include the role and gradual development of the compulsory health insurance fund as the single purchaser of health-care services for the entire population using output-based payment methods, the complete restructuring of pooling arrangements from the former decentralized budgetary structure to a single national pool, and the establishment of an explicit benefit package. Central to the process was the transformation of the role of general budget revenues - the main source of public funding for health - from directly subsidizing the supply of services to subsidizing the purchase of services on behalf of the entire population by redirecting them into the health insurance fund. Through their approach to health financing policy, and pooling in particular, the Kyrgyz health reformers demonstrated that different sources of funds can be used in an explicitly complementary manner to enable the creation of a unified, universal system.