The health financing schemes is the foundation for the nationâs health care system, and the health insurance is a main one of some options for financing health care. This article compares two health care financing schemes in urban areas before and after the health reform, and targets at the impacts facing coverage groups, the financing methods, decision-making power or financial management (i.e. the distribution of responsibility and rights between the central government and local governments), payment arrangement and cost containment of health care financing mechanisms. Prior to reform, the equal access and universal coverage of health care services were implemented through the employment-based health insurance in a state-controlled economy with guaranteed full employment and central control in general. The decentralization reforms of fiscal system and tax sharing reforms disrupts the past economic foundation, the rebuilding health insurance system which still benefits the employed bring the limited coverage. The next trend is to make transition from health insurance covering only part of the employed population to what are in effect national health services covering the whole population in urban areas.
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.
Yuslely Usman, Ni Ketut Aryastami, Harimat Hendarwan
Since 2001, Indonesia has entering its new era of democratization called decentralization in all sectors, including health. From now and then, the District Health Office has been forced to be able to implement its health policy and function such as 1) stewardship, 2) health resources management, 3) health financing, and 4) health services provision. Basic function of health system is needed to achieve the health purpose that shown the performance of the health offices and its structure. The performance is related to the quality of management. European Foundation for Quality Management (EFQM) is a tool to quantify and assess the quality of management in an institution, so that it will be understood what is the weakness and the strength of the institution. EFQM was developed in Europe that has been proved that it can formulate an excellent management and performance by then. This study implements the EFQM model towards performance improvement model development in district/municipality health office. The objective of the study is implement EFQM model in improving health system performance in district/municipality. Type of study is a health system research with a cross sectional design in three selected district health office based on Human Development Index criteria, that is high, medium and low. Analysis has been done implementing the EFQM method called RADAR. The study location were Tabanan district (Bali), Bandar Lampung Municipality (Lampung), and Belu District (East Nusa Tenggara). The qualitative analysis was quantified using the RADAR for the nine pillars in the method. The nine criteria were grouping into enables and results criteria, such as 1) enables criteria of leadership, policy and strategy, employment, partnership and resources as well as process; 2) results criteria were: clients satisfaction, staff satisfaction, social results of the community as well as the main key. Each criteria has some sub-criteria. Each sub-criteria then be valued using the RADAR, and quantified ranged from 0-10 as no prove and anecdote only; 15-35 as there are some prove; 40-60 as proved; 65-85 as strongly proved, and 90-100 as completely proved. The final evaluation of each pillars done by counting the average values of the sub-criteria multiplied by each weight of the pillars that already formatted. The formatted weight was 1.0 for the leadership; 0.8 for the policy and strategy, 0. 9 for the employment; 0. 9 for the resources and partnership; 1.4 for process; 2. 0 for clients satisfaction; 0. 9 for staffs satisfaction; 0.6 for community social satisfaction and the 1.5 for the key indicator, with a total weight of 10. Results showed that the final results of the health office performance were Tabanan has the highest of 250, Bandar Lampung Municipality 239, and Belu 217. This scoring seems directly reflects the management achievement level of District Health office that correlate to the HOI Index. The EFQM method can be used as a model to improve staff performance in the district health office by maintaining the weaknesses found in the field as constraints. Key words: EFQM, district health offices, scores, performances
The case of Spain reflects to a marked extent the more general European tendency toward the proliferation of new institutions called on to meet social and demographic challenges. Health care in Spain has traditionally been dispersed among a host of largely autonomous agencies associated with various levels of political authority (national. provincial, or municipal.) The creation of the National Health System (SNS) as a single, albeit decentralized system, has brought important organizational changes and led to a generalized reconsideration of institutional equilibria by establishing the Governments of the Autonomous Communities as the primary interlocutors of the Ministry of Health. Also present are professional associations, labor unions, and other organizations such as NGOâs or patientâs associations. These have, with more or less success, attempted to influence the decision-making process. The present article analyzes the evolution of actor networks involved in the «governance of health» in Spain, an evolution characterized at once by strong decentralizing tendencies and by new forces of public management often bringing a reinforcement of the regulatory role of the state.
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.
Albert J. Jovell, Robert J. Blendon, MarĂa Dolors Navarro, Channtal Fleischfresser · 7 authors
BACKGROUND: Fifteen years ago, public opinion surveys in Spain showed substantial dissatisfaction with the health-care system. Since that time, health-care in Spain has undergone significant changes, including a decentralization of the system, an increase in spending and a change in the way the system is financed. OBJECTIVE: This study examines how Spanish citizens rate the performance of their health system today, both as compared with other sectors of society and as compared with earlier time periods. METHODS: Data are drawn from nationally representative telephone surveys of the non-institutionalized adult Spanish population (age 18 years and over). The study was carried out in two phases: October-November 2005 (n = 3,010) and January 2006 (n = 2,101). RESULTS: The majority of the Spanish population thinks the health system needs to be changed. The problems cited relate mostly to long wait times to get health-care. Nevertheless, over the last 15 years, the proportion of people who have very negative views about the health system has decreased by half. The majority believes that not enough money is spent on health-care, but few people would support an increase in taxes to provide additional funding. The survey finds the National Health System's institutions and health professionals to be more highly trusted than other institutions and professional groups in the country. CONCLUSIONS: Government policy-makers in Spain face a dilemma: the public wants more health spending to decrease wait times, but there is substantial resistance to increasing taxes as a means to finance improvements in the system's capacity.
This paper analyzes the policy model of the Brazilian Ministry of Health from 1990 to 2002. The methodology included interviews with key actors in the national health policy, document review, and analysis of the Federal budget and official databases. The Brazilian Ministry of Health underwent major changes under the influence of the health reform agenda and the liberal State reform agenda prevailing in the 1990s, shaped by two movements: institutional unification of national policy control and political/administrative decentralization. The Federal role was diminished in terms of direct services provision, and there were changes in financing and regulation. The model in the late 1990s featured strong Federal induction of States and municipalities and the adoption of market regulation strategies. There is no record of a long-term planning effort, which favors distortions in the Federal intervention model and hinders solutions to structural problems in the Brazilian health system.
This thesis examines the Brazilian municipalism after the Constitution of 1988. It verifies the municipalities performance in the provision of local health services vis--vis the decentralization of this policy due to the creation of the SUS (Unified Health System). It argues that the process of health services decentralization developed during the 90's presented two different steps: the step of autonomist decentralization, between 1990 and 1998, when the municipalities were totally free to choose their own local health policies; and the step of the driven decentralization, after the creation of the Basic Assistance Floor -PAB, when the municipalities started receiving targeted incomes, which could be used exclusively for specific health programs, determined by the Health Department. However, as we demonstrate, the both steps were incapable to decrease the extant regional inequalities in what regards the supply, the access and the financing of municipal health services. To summarize, we demonstrate that the inequalities in health produced by our federalism were not balanced through the outline of policies that municipalized the health services.
Christine Lao Peña, Ariadna GarcĂaâPrado, Olympia Icochea
In recent years, Central American countries have been implementing strategies to expand basic health services to remote and poor rural areas. In most cases, health extension services have been carried out by contracting with nongovernmental organizations (NGOs) and other nonpublic entities to manage or deliver health services. However, contracting with non-state providers has not been easily accepted in these countries as it is often seen as arising out of an ideological desire to privatize publicly financed health services or ultimately to limit or end government involvement in health care. This is what is happening in Honduras, where the Ministry of Health is promoting the extension of services with a community based approach within a decentralization strategy framework. The new health services extension models in Honduras rely on organizational and management arrangements that differ from the traditional Ministry of Health (MOH) health facility model. In particular, the facilities are managed by their communities under different legal and institutional arrangements, depending upon their organizational structures. Their staff are not civil servants, and, as a result, their management has considerably more flexibility in hiring and firing workers. In addition, they have multiple sources of financing. Patients contribute to the financing of these arrangements either with co-payments or pre-payments according to level of income (the sliding scale is determined by the community). The purpose of this study is to identify and compare the costs, efficiency, quality and coverage, as well as the institutional arrangements and organizational structure of the alternative models with one another, and with the traditional services delivery approach of the MOH to determine the feasibility of scaling-up these innovative models of extension of health services. To this purpose, we conducted a health facility survey to collect information on (i) Perceived quality, (ii) Technical quality, (iii) Accessibility (with regards to providers), (iv) Accessibility to communities, and (v) Price/out of pocket payments from users. In addition, the cost of providing key elements of the service package is estimated, including: (i) coverage for vaccination, well-baby care, prenatal care and curative consultations for acute respiratory infection and diarrheic disease, (ii) use of iron supplementation among pregnant women, (iii) knowledge and use of oral re-hydration among women, and (iv) use of vaccination cards for infants. Information on outputs produced have been collected based on these components, as well as their inputs over the last 3 months at each of the facilities. The cost of providing selected components of the basic package of health services in each type of facility was calculated. Results from our analysis show that even though the overall cost of service delivery in the new community models is higher, access to basic health services and quality of care, both technical and perceived, are generally better than in the traditional public health care facilities. Findings also indicate that the new models are more cost efficient than the traditional MOH health care centers suggesting the feasibility of either scaling up these new models and/or alternatively reforming certain aspects of the traditional health care facilities.
Since the decade of 1939 the mexican governments focussed the health cure of the poor, children and peasants as public health problems. During the decade of 1980 financement, demographic transition, epidemiological transition problems and the prevailing political situation geared to a health services' decentralization. Presently the mexican health system is composed by public organisms, social security services and private health services. This paper examines some of their problems -resources, eficiency, equity, patients' satisfaction and quality- from the social medicine perspective.
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.
<abstract language="eng">The constitution of Brazil directs that the countryâs health system, the Unified Health System (Sistema Ănico de SaĂșde), be politically and administratively decentralized. Nevertheless, handing over competencies, responsibilities, and resources to subnational levels, especially to municipal governments, has been a slow process, lasting almost two decades. Advances have been brought about by the Unified Health System, which, from a analytical perspective, is a public and universal system. Despite that, the decentralization process needs to overcome norms that keep all levels of management dependent on Brazilâs federal Government. The subnational levels have consistently faced difficulties in performing their macromanagement functions with autonomy, especially when it comes to financing and to the establishment or organization of health care networks. Boldness and responsibility will be needed to prevent Brazilâs health decentralization process from leading to fragmentation. New political agreements between different levels of government, with a reassignment of responsibilities and the enhancement of a culture of technical cooperation, are fundamental requisites to making the Unified Health System have a health policy that is truly public and universal.
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.
The constitution of Brazil directs that the country's health system, the Unified Health System (Sistema Unico de SaĂșde), be politically and administratively decentralized. Nevertheless, handing over competencies, responsibilities, and resources to subnational levels, especially to municipal governments, has been a slow process, lasting almost two decades. Advances have been brought about by the Unified Health System, which, from a analytical perspective, is a public and universal system. Despite that, the decentralization process needs to overcome norms that keep all levels of management dependent on Brazil's federal Government. The subnational levels have consistently faced difficulties in performing their macromanagement functions with autonomy, especially when it comes to financing and to the establishment or organization of health care networks. Boldness and responsibility will be needed to prevent Brazil's health decentralization process from leading to fragmentation. New political agreements between different levels of government, with a reassignment of responsibilities and the enhancement of a culture of technical cooperation, are fundamental requisites to making the Unified Health System have a health policy that is truly public and universal.
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.
Contracting is one of the tools increasingly being used to enhance the performance of health systems in both developed and developing countries; it takes different forms and cannot be limited to the mere purchase of services. Actors adopt contracting to formalize all kinds of relations established between them. A typology for this approach will demonstrate its diversity and provide a better understanding of the various issues raised by contracting. In recent years the way health systems are organized has changed significantly. To remedy the under-performance of their health systems, most countries have undertaken reforms that have resulted in major institutional overhaul, including decentralization of health and administrative services, autonomy for public service providers, separation of funding bodies and service providers, expansion of health financing options and the development of the profit or nonprofit private sector. These institutional reshuffles lead not only to multiplication and diversification of the actors involved, but also to greater separation of the service provision and administrative functions. Health systems are becoming more complex and can no longer operate in isolation. Actors are gradually realizing that they need to forge relations. The simplest way to do that is through dialogue, although some prefer a more formal commitment. Interaction between actors may take various forms and be on different scales. There are several types of contractual relations: some are based on the nature of the contract (public or private), others on the parties involved and yet others on the scope of the contract. Here they are classified into three categories according to the object of the contract: delegation of responsibility, act of purchase of services, or cooperation.
Health quasi-markets aim to introduce competition into the public sphere by separating functions in order to improve efficiency and quality. In different public-private mixes, according to the morphology of health systems, different regulations can govern insurance, financing, and provision of services. The objective is to link financing to productivity, coverage, performance, and accomplishment of goals. Specifying guarantees to provide services for determined beneficiaries implies the formation of a purchase function based on strategic criteria involves three financing decisions: which interventions will be purchased, how they will be purchased, and from which providers. Some health systems in the region have established a separation of functions and some initial finance mechanisms based on results that allow them to be considered developing quasi-markets. On the other hand, some of them have introduced guarantees for various health services. Although such guarantees in all cases aim to improve equity in the level of health enjoyed by the population, they have very different repercussions in terms of the general organization of the related health systems depending on the level of development and the characteristics of the health coverage that the population already has. This study considers in the first place the introduction of health benefits guarantees in quite underdeveloped health systems, analyzing with more detail the case of Guatemala and briefly, Bolivia. Afterwards, a thorough analysis of Chile is done, showing how the health guarantees imply a partial overcome of the fundamental duality of the health system. Finally is considered the recent experience of the popular health insurance in Mexico, whose health insurance system is highly segmented. As we shall see in all the experiences, both the decentralization process and the specific public-private mix play an important role in the organisation of the health guarantees.