No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
A Decade of Health Sector Reform in Developing Countries: What Have We Learned?
... Health systems, particularly in low-and middle-Income countries (LMICs), are commonly plagued by problems such as poor access and performance, as well as inefficient use, and inequitable distribution, of resources [1][2][3]. Recognising that such problems reflect system-wide deficiencies rather than weaknesses in particular health programmes or areas of service delivery, the World Bank proposed a first wave of 'health sector reforms', with the goals of improving health system efficiency, equity and effectiveness, in the World Development Report of 1993 [4]. The reforms emphasised at this time were decentralisation, user fees and social health insurance, pay for performance, public-private partnerships, contracting out of health services, and comprehensive primary health care [1,[4][5][6]. ...
... The changes resulting from the mid-1990s reforms were, however, varied [3], with authors such as Blaauw et al. [9] suggesting that the gains achieved were limited. Some authors specifically suggested that challenges resulted from the influence of health system software on reform implementation [9,12,13]. ...
... In view of the potential importance of organisational culture as an influence on the implementation of health sector reforms at local level in LMICs, this qualitative synthesis was undertaken to take stock of the current knowledge base, to draw on relevant research, and, if possible, policy implications. In this aim it was in line with other, recent qualitative synthesis work (special issue of Health Policy and Planning 29 [3], December 2014). It reviews existing empirical literature from LMICs to identify, interpret and synthesise evidence on organisational culture and its influence on the implementation of such reforms. ...
Background: Health systems, particularly in low- and middle-income countries, are commonly plagued by poor access, poor performance, inefficient use and inequitable distribution of resources. To improve health system efficiency, equity and effectiveness, the World Development Report of 1993 proposed a first wave of health sector reforms, which has been followed by further waves. Various authors, however, suggest that the early reforms did not lead to the anticipated improvements. They offer, as one plausible explanation for this gap, the limited consideration given to the influence over implementation of the software aspects of the health system, such as organisational culture – which has not previously been fully investigated.
Objective: To identify, interpret and synthesise existing literature for evidence on organisational culture and how it influences implementation of health sector reforms in low- and middle-income countries.
Methods: We conducted a systematic search of eight databases: PubMed; Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Econlit, PsycINFO, SocINDEX with full text, Emerald and Scopus. Eight papers were identified. We analysed and synthesised these papers using thematic synthesis.
Results: This review indicates the potential influence of dimensions of organisational culture such as power distance, uncertainty avoidance, and in-group and institutional collectivism over the implementation of health sector reforms. This influence is mediated through organisational practices such as communication and feedback, management styles, commitment and participation in decision-making.
Conclusion: This interpretive review highlights the dearth of empirical literature around organisational culture and therefore its findings can only be tentative. There is a need for health policymakers and health system researchers to conduct further analysis of organisational culture and change within the health system.
... No se cuenta con métricas estandarizadas y comparables sobre la calidad de la atención en países de ingreso bajo y medio (PAHO/OPS 2008;Berman and Bossert 2000). La baja calidad frecuentemente se atribuye a recursos limitados (PAHO/OPS 2008;Beaglehole et al. 2008;Peabody et al. 2006); sin embargo, alta variación en los procesos de atención ha sido observada entre y al interior de los países (Peabody et al. 2006). ...
... Perspectivas de calidad de los usuarios y pacientes de la atención médica cada vez están disponibles con mayor frecuencia (Dansereau et al. 2015;Puig, Pagán, and Wong 2009). Aun así, de las tres categorías descritas por Donabedian (estructura, proceso y resultado) (Donabedian 1988), sigue habiendo una gran brecha en el conocimiento sobre el desempeño de los procesos de atención (Berman and Bossert 2000). La atención a la salud es tanto sobre el proceso como el resultado (Berwick and Knapp 1987;Kahn et al. 1990). ...
Objetivo: Presentar métodos para medir métricas estandarizadas, replicables y comparables para medir la calidad de la atención en países de ingresos bajos y medios.
Diseño: Construimos indicadores de calidad para atención materna, neonatal e infantil. Para minimizar los juicios de valor del revisor, transformamos a los criterios de listas de chequeo a datos y las decisiones en algoritmos condicionados. Establecimos criterios específicos para el nivel de atención y tipo de cuidados. Vinculamos a los indicadores con diagnósticos de egresos. Diseñamos herramientas electrónicas de abstracción de datos utilizando programas para entrevistas asistidas por computadora.
Contexto: Presentamos resultados para datos recolectados en las áreas más pobres de Belice, El Salvador, Guatemala, Honduras, Nicaragua, Panamá y el estado de Chiapas en México (enero—octubre 2014).
Resultados: Recolectamos datos de 12,662 expedientes médicos. Los indicadores mostraron variaciones en la calidad de la atención entre y dentro de los países. Intervenciones rutinarias, como la calidad de la atención prenatal, cuidados neonatales inmediatos y anticoncepción postparto, mostraron bajos niveles de cumplimiento. Los expedientes que cumplieron con atención prenatal con calidad pasaron de 68·8% [CI:64·5—72·9] en Costa Rica a 5·7% [CI:4·0—8·0] en Guatemala. Menos del 25% de las complicaciones obstétricas y neonatales fueron manejadas de acuerdo a estándares en todos los países.
Conclusiones: Nuestro estudio resalta que, con recursos adecuados y conocimientos técnicos, recolectar datos de indicadores de calidad a gran escala en países de ingresos bajos y medios es posible. Nuestros indicadores ofrecen un marco comparable, replicable y estandarizado para identificar variaciones en la calidad de la atención. Los indicadores y métodos descritos son altamente transferibles y pueden utilizarse para medir la calidad de la atención en otros países.
... In some cases, they achieved relatively satisfactory results; however, other cases showed that due to poor implementation, the reform increased discontent. Countries encountered new issues even after successful reforms, requiring a repetition of the reform cycle [7][8][9]. De-spite the importance of this issue, existing studies on the reasons for reform failure have been conducted case-by-case, and a clear-cut analysis is required of the reasons for the failure of health reforms. ...
... Inefficiency in financing and distribution of resources: Inequalities in resource allocation across regions or improper geographic distribution of health facilities are the most noteworthy problems in this category [13,17]. Other causes include excessive attention to wealthier areas [8] or the prevention of regional transfer of medical insurance policies based on regional economic and social conditions [23]. Health needs are greater among rural residents than city dwellers, but those residents need the power to lobby and negotiate to receive more resources [7], especially in reform policies pursuing decentralization. ...
Objectives:
The health system reform process is highly political and controversial, and in most cases, it fails to realize its intended goals. This study was conducted to synthesize factors underlying the failure of health system reforms.
Methods:
In this systematic review and meta-synthesis, we searched 9 international and regional databases to identify qualitative and mixed-methods studies published up to December 2019. Using thematic synthesis, we analyzed the data. We utilized the Standards for Reporting Qualitative Research checklist for quality assessment.
Results:
After application of the inclusion and exclusion criteria, 40 of 1837 articles were included in the content analysis. The identified factors were organized into 7 main themes and 32 sub-themes. The main themes included: (1) reforms initiators' attitudes and knowledge; (2) weakness of political support; (3) lack of interest group support; (4) insufficient comprehensiveness of the reform; (5) problems related to the implementation of the reform; (6) harmful consequences of reform implementation; and (7) the political, economic, cultural, and social conditions of the society in which the reform takes place.
Conclusions:
Health system reform is a deep and extensive process, and shortcomings and weaknesses in each step have overcome health reform attempts in many countries. Awareness of these failure factors and appropriate responses to these issues can help policymakers properly plan and implement future reform programs and achieve the ultimate goals of reform: to improve the quantity and quality of health services and the health of society.
... Therefore, a patient satisfaction survey is essential for patients, healthcare providers, and healthcare payers. 13,[19][20][21][22][23][24][25] As patient satisfaction is considered to be a healthcare outcome and predictor of treatment utilization and adherence to the care and support, assessment of the level of patient satisfaction is vital. In addition, knowing the needs of the patient is of paramount for the achievement of sustainable development goal on health service delivery. ...
... 23 Patients who are not satisfied with service may have worse outcomes than others, because they miss more appointments, leave against advice or fail to follow treatment plans. 24,25 At the hospital level, providing a quality service is usually challenged by burdensome patient flow and the urgent nature of care in the emergency department (ED) further suppresses the effort. 13 According to a study done in different countries there was patient satisfaction with the outpatient healthcare services. ...
Background:
Client satisfaction reflects the gap between the expected service and the experience of the services from the client's point of view. As patient satisfaction is considered to be a healthcare outcome and predictor of treatment utilization and adherence to the care and support, assessment of the level of patient satisfaction is vital.
Objective:
To assess satisfaction of outpatient service and its associated factors toward the health service given among outpatients at Jimma medical center, southern western Ethiopia, 2019.
Methods:
An institutional-based cross-sectional study design was employed at Jimma Medical center from May 1 to May 30, 2019 GC. The respondents were selected by systematic random sampling method. The data were cleaned, coded, interred into EPI data version 3.1 and transferred and analyzed using SPSS version 23. Descriptive statistics was used to summarize the data. Binary logistic regressions were used to analyze the association between dependent and independent variables. A P-value <0.05 was considered significant.
Results:
A total of 284 respondents were included in the study with a response rate of 96.6%, from which 174 (61.3%) were male and 183 (64.4%) were Oromo by ethnicity. The overall satisfaction was 79 (27.8%) (CI = 20.0-30.4). Satisfaction was high if the patients had kept their privacy (AOR = 13.332; 95% CI = 2.282-77.905) and understandability of the patient problem (AOR = 21.830; 95% CI = 0.054-77.500).
Conclusion:
The overall satisfaction level of the patients is low, so this demands the hospital to take further action on the identified problems to improve the services delivered to the patients.
... Roberts and colleagues (Roberts et al., 2003) analysed many countries' policy experiments in improving their health system to find which structural components of a health system influence each of the ultimate health system goals (Berman & Bossert, 2000). They identified five major components that states can regulate and modify to affect the ultimate health system goals. ...
... These include: financing, payment, organization, regulation, and consumer behavior. They used the metaphor of 'control knobs' for these components referring to mechanisms and processes that reformers can adjust to improve health system performance (Berman & Bossert, 2000;Hsiao, 2003;Roberts et al., 2003). By exploring these control knobs health sector reformers can examine the causes of the problems in their health systems (Roberts et al., 2003). ...
The vast literature shows a fast growing health expenditures worldwide, growing at a faster rate than the economy. The recent economic crisis has further increased concerns over health system performance and value for money. These challenges have led health systems globally to embark on various health sector reforms to find more effective cost containment strategies. To bend the cost curve, policy makers across the globe are increasingly turning to supply side strategies and most specifically payment methods to providers (individuals and organizations). Methods of payment to providers create incentives to influence behavior of individuals and organizations in order to achieve policy objectives such as efficiency, quality, and access. These methods also influence whether, how, how much, and by whom care is provided. This report aims to shed light on different payment methods and incentive regimes to hospitals from a policy lever perspective. It aims to help policy makers, decision makers, and other stakeholders understand how different payment methods work and how they change providers' behaviour and influence health system objectives. With existence of many payments methods and feasibility of combining them, policy makers face several choices and must choose which method, or combination of them, best meets their policy objectives and fits within their constraints. This report hopes to help policy makers in making such decisions and to enable them to prepare for future reforms and developments. The report reveals three waves of reforms in methods of payment to hospitals worldwide. It also shows that different policy objectives have guided these reforms. Review of common methods of payment to hospitals reveals a number of criteria/dimensions and seven typologies that help improve communication and a common understanding among policy-makers, researchers, and other stakeholders about different payment methods. Finally, this report lays the groundwork for future direction and calls for additional research and policy analysis to explore payment methods from a policy lens.
... Roberts and colleagues (Roberts et al., 2003) analysed many countries' policy experiments in improving their health system to find which structural components of a health system influence each of the ultimate health system goals (Berman & Bossert, 2000). They identified five major components that states can regulate and modify to affect the ultimate health system goals. ...
... These include: financing, payment, organization, regulation, and consumer behavior. They used the metaphor of 'control knobs' for these components referring to mechanisms and processes that reformers can adjust to improve health system performance (Berman & Bossert, 2000;Hsiao, 2003;Roberts et al., 2003). By exploring these control knobs health sector reformers can examine the causes of the problems in their health systems ( Roberts et al., 2003). ...
The vast literature shows a fast growing health expenditures worldwide, growing at a faster rate than the economy. The recent economic crisis has further increased concerns over health system performance and value for money. These challenges have led health systems globally to embark on various health sector reforms to find more effective cost containment strategies. To bend the cost curve, policy makers across the globe are increasingly turning to supply side strategies and most specifically payment methods to providers (individuals and organizations). Methods of payment to providers create incentives to influence behavior of individuals and organizations in order to achieve policy objectives such as efficiency, quality, and access. These methods also influence whether, how, how much, and by whom care is provided. This report aims to shed light on different payment methods and incentive regimes to hospitals from a policy lever perspective. It aims to help policy makers, decision makers, and other stakeholders understand how different payment methods work and how they change providers' behaviour and influence health system objectives. With existence of many payments methods and feasibility of combining them, policy makers face several choices and must choose which method, or combination of them, best meets their policy objectives and fits within their constraints. This report hopes to help policy makers in making such decisions and to enable them to prepare for future reforms and developments. The report reveals three waves of reforms in methods of payment to hospitals worldwide. It also shows that different policy objectives have guided these reforms. Review of common methods of payment to hospitals reveals a number of criteria/dimensions and seven typologies that help improve communication and a common understanding among policy-makers, researchers, and other stakeholders about different payment methods. Finally, this report lays the groundwork for future direction and calls for additional research and policy analysis to explore payment methods from a policy lens.
... Standardized, replicable and comparable metrics for quality of medical care in low-and middle-income countries are lacking [1,2]. Poor quality is often attributed to lack of resources [1,3,4]; however, high variation in processes of care has been observed within countries and between countries [4]. ...
... Quality perspectives from users and patients are also increasingly available [9,10]. Yet, of the three categories described by Donabedian (structure, process and outcome) [11], a gap remains for the performance of processes of care [2]. Adequate healthcare is as much about process as it is about outcome [12,13]. ...
Objective:
Present methods to measure standardized, replicable and comparable metrics to measure quality of medical care in low- and middle-income countries.
Design:
We constructed quality indicators for maternal, neonatal and child care. To minimize reviewer judgment, we transformed criteria from check-lists into data points and decisions into conditional algorithms. Distinct criteria were established for each facility level and type of care. Indicators were linked to discharge diagnoses. We designed electronic abstraction tools using computer-assisted personal interviewing software.
Setting:
We present results for data collected in the poorest areas of Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the state of Chiapas in Mexico (January-October 2014).
Results:
We collected data from 12 662 medical records. Indicators show variations of quality of care between and within countries. Routine interventions, such as quality antenatal care (ANC), immediate neonatal care and postpartum contraception, had low levels of compliance. Records that complied with quality ANC ranged from 68.8% [confidence interval (CI):64.5-72.9] in Costa Rica to 5.7% [CI:4.0-8.0] in Guatemala. Less than 25% of obstetric and neonatal complications were managed according to standards in all countries.
Conclusions:
Our study underscores that, with adequate resources and technical expertise, collecting data for quality indicators at scale in low- and middle-income countries is possible. Our indicators offer a comparable, replicable and standardized framework to identify variations on quality of care. The indicators and methods described are highly transferable and could be used to measure quality of care in other countries.
... La gobernanza de los recursos humanos es un componente central de la dimensión regulatoria que debería asumir la rectoría de las autoridades de salud. 18 El campo de políticas de recursos humanos abarca la formación de los futuros trabajadores de la salud, así como su inserción y desempeño en el mercado de trabajo. Avanzar en el plano nacional hacia los objetivos de la salud universal implica esta-blecer un conjunto de políticas, regulaciones e intervenciones para ordenar y alinear la producción, las competencias, la movilidad interna y externa de los profesionales, el empleo, las condiciones laborales y la distribución del personal en relación con las necesidades, por solo nombrar algunos aspectos cruciales. ...
... Desde que se dio inicio a las reformas comenzaron a formularse mecanismos para el monitoreo de los procesos y la supervisión de los agentes y agencias; de modo que en la actualidad existen más evidencias para apreciar qué funciona y qué no, y aprender de las experiencias propias y de otras regiones. 18,19,20,21 Los procesos de evaluación de los resultados son importantes y relevantes para todos los países, y así tener una capacidad de aprendizaje 22, 23, 24 con el fin de realizar ajustes para seguir avanzando. ...
... Yet, client dissatisfaction remains high, ranging from 22% to 80.1% [3,11]. It is because of the fact that Ethiopia's and most developing countries' healthcare systems are severely lacking in terms of financing, efficiency, equity, and quality, and they are ill-prepared to face these issues [12]. Client perceptions of healthcare systems appear to have been largely ignored by healthcare managers in developing countries, and clinicians lack awareness and adequate training to address patients' expectations [13]. ...
Background. Client satisfaction with seeking healthcare is generally regarded as one of the core outcomes of the health system. Various efforts are underway to provide hospitals with the necessary manpower, medical equipment, and other services to suit the demands of their patients. The goal of this study was to determine the level of client satisfaction with outpatient department services and the factors that influence it at Dilla Referral Hospital in Ethiopia. Methodology. A cross-sectional investigation was undertaken in a hospital setting. An interviewer-administered quantitative data were collected on socio demographic characteristics of respondents and their satisfaction level with the different components of the outpatient services. SPSS version 20 was used to conduct the analysis. The connection between independent and dependent variables was evaluated using bivariate analysis ( p < 0.25 ). To discover the determinants of client satisfaction and control cofounding, multivariate logistic regression was performed ( p ≤ 0.05 ). Result. The study enrolled a total of 419 individuals, with a response rate of 98.3%. Overall, 52.2 percent of clients were satisfied with the health services provided by the hospitals’ outpatient departments. Client satisfaction was significantly predicted by the cleanliness of the consultation room (AOR = 2.05, 95% CI: 1.06–3.95), payment status (AOD = 1.68, 95% CI: 1.08–2.63), and telling clients about the etiology of sickness (AOR = 0.55, 95% CI: 0.34–0.87). Conclusion. The general satisfaction of outpatients with Dilla referral hospital’s OPD clinics healthcare services was low. The cleanliness of the consultation room, payment status, and readiness to suggest the service to others were all linked to a positive outcome.
... www.turkishstudies.net/social Sağlık, eğitim ve sosyal güvenlik alanlarında devletin sorumluluğunun artması, bu alanlarda yapılacak uygulamalarda eldeki kıt kaynakları en iyi şekilde kullanarak öncelikli ihtiyaçlara cevap verilebilmesi için planlamanın gelişmini gerekli kılmıştır (Tatar, 1993;Berman & Bossert, 2002;Ekiz & Somel, 2005). Amerika Birleşik Devletleri, sağlık planlaması eksikliği açısından diğer sanayileşmiş ülkeler arasında istisnai bir konumdadır. ...
Today, health services must be provided in a quality, accessible, sustainable, and equitable manner with the scarce resources available with increasing costs. In this, there is a need to be managed effectively and efficiently with a professional management approach. The success of the planning function, which is the first stage of management, will also affect other functions of management. In the rapidly changing environmental conditions of the health sector, the success in the management of health institutions comes to the fore in providing low-cost, accessible, and high-quality health services. The management of health institutions can be expressed as the whole of activities in which the functions of planning, organization, execution, coordination, and control are applied systematically and consciously while the health institutions realize their objectives in an economical, efficient and effective manner. In the provision of high quality, fast, accessible, effective, and equitable health services, investments to be made in health institutions and new health investments should be determined by the needs and correctly, and efficient use should be ensured without causing idle capacity and waste of resources. In this respect, health planning is among the issues that should be handled carefully. Health care planning is an essential component of the health system and is a tool used by decision-makers in conjunction with other policy tools. Setting planning goals aligned with overall health system goals can contribute to effective planning. In addition, for effective health planning, a whole system perspective should be considered between different sectors of the health sector, inputs in service production, and geographical areas. Structured Abstract: Nowadays, health services must be provided in a quality, accessible, sustainable, and equitable manner with the scarce resources available with increasing costs. In this, there is a need to be managed effectively and efficiently with a professional management approach. The success of the planning function, which is the first stage of management, will also affect other functions of management. The separation of health services from other sectors with their unique features necessitates the management of health services in a more specific way. Planning is about future thinking, evaluation, research, and analysis, and it is a dynamic process that requires constant change due to the emergence of unpredictable situations in the future. Since this process is structured for the future, it also brings uncertainty and risk. In this uncertain and risk environment, businesses should take timely precautions against threats from the external environment and eliminate the crises that these threats will create. Planning is the determination of the ways to be followed in advance. While planning at the macro and micro level in health institutions, some factors should be considered in terms of the operability of the plans
... A growing number of implementation research findings suggest that regular monitoring and evaluation have a strategic role in improving policy decisions' relevance, efficiency, and effectiveness in the LMIC settings [47,48]. Therefore, monitoring and evaluation need to be integrated into the design of policy implementation so that poor enforcement or resource wastage can be avoided [48]. ...
Introduction
In Bangladesh, to address the challenges of ensuring adequate human resources for health (HRH), the government began implementing a digital tool for HRH management in 2017. However, evidence suggests institutionalizing such tools in low-and-middle-income countries is impeded by policy aspects like implementation strategy and poor regulatory framework. Therefore, we aimed to explore factors in the current policy landscape that might facilitate and challenge the implementation of the tool in Bangladesh.
Methods
We conducted a review of policies related to ICT implementation and human resources management in the health sector in Bangladesh using qualitative content analysis method. Ten policies have been identified, and extensive reading was done to ascertain common themes and patterns. A document analysis matrix was developed to synthesize and help interpret the findings.
Results
Regarding facilitators, strong upstream level commitments were reflected in the content of policies in terms of setting out specific objectives, targets, timelines, and budget allocation. However, the lack of explicit monitoring strategy and extent of stakeholders’ engagement was not well-defined, ultimately creating chances for impeding downstream implementation. In addition, effective coordination among stakeholders and different HRH and ICT policies could be strengthened.
Discussion
Findings support the current discourse that national commitment plays a vital role in the integration of ICTs in health services. However, well-defined monitoring strategy and inter-ministry and intra-ministry policy coordination are crucial.
... A growing number of implementation research ndings suggest that regular monitoring and evaluation has a strategic role in improving the relevance, e ciency and effectiveness of policy decisions in the LMIC settings (45,46). Therefore, monitoring and evaluation need to be integrated into the design of policy implementation so that poor enforcement or resource wastage can be avoided (46). ...
Introduction: In Bangladesh, to address the challenges of ensuring adequate human resources for health (HRH), the government began implementing a digital tool for HRH management in 2017. However, evidence suggests institutionalizing such tools in low-and-middle-income-countries are impeded by policy aspects like implementation strategy and poor regulatory framework. We aimed to explore factors in the current policy landscape that might facilitate and challenge the implementation of the tool in Bangladesh.
Methods: We conducted a review of policies related to ICT implementation and human resources management in health sector in Bangladesh using qualitative content analysis method. Twelve policies have been identified and comprehensive reading was done to ascertain common themes and patterns. A document analysis matrix was developed to synthesize and help interpreting the findings.
Results: Regarding facilitators, strong upstream level commitments were reflected in the content of policies in terms of setting out specific objectives, targets, timeline, and budget allocation. However, lack of explicit monitoring strategy and extent of stakeholders’ engagement was not well-defined, ultimately create chances for making downstream implementation disjointed. In addition, effective coordination among stakeholders and different HRH and ICT policies could be strengthened.
Discussion: Findings support the current discourse that national commitment plays a vital role in integration of ICTs in health services. However, well-defined monitoring strategy and inter-ministry and intra-ministry policy coordination is crucial.
... 5 Studies have shown that most hospitals in developing countries have enormous material, manpower and monetary challenges and are inadequately prepared to solve such problems. 8 A study done in Tanzania showed that clients preferred a good quality hospital with well educated staff well cultured and good prescriptions to poor hospitals with low quality staff, inadequate prescriptions, and arrogant staff. 9 Furthermore, studies in Ethiopia showed that poor economic indices such as gross domestic product and annual economic growth rate etc have linear relationship with quality of health care services provided to the people. ...
Introduction: Clients perception of satisfaction in a
health system has been be a very effective tool in assessing
health care deliveries in Nigeria. Patients’ and clients’
satisfaction with health care is an integral component of
quality monitoring in health care systems. Quality of health
care includes characteristics such as efficiency, efficacy,
effectiveness, equity, accessibility, comprehensiveness,
acceptability, timeliness, appropriateness, continuity, privacy
and confidentiality.
Material and Methods: In this study the methodology
employed was a descriptive cross sectional approach. The
study was carried out among inpatient and outpatients
respondents from January 3rd to 12th 2017, on a sample of 255
service users of the hospital using systematic random sampling
technique. Data were collected using structured questionnaires
and analysed by SPSS for windows version 20. Statistical tests
such as Chi x2 and frequency tables were employed where
necessary. P-values of ≤ 0.05 were considered as statistically
significant.
Results: Overall 53% and 61.5% of the respondents were
satisfied with food and courtesy and respect respectively
while 49.2% were dissatisfied with cleanliness of the wards
and 42.8% with beddings. There were statistically significant
associations between age (0.042), educational status (0.005),
payment status (0.003) and address (0.000).
Conclusion: Efforts must be made to provide health facilities
with the necessary infrastructure and maintain high level of
cleanness since these can ultimately influence users positively
or negatively in the way they use the services provided by the
hospital.
Key words: Perception, Quality, Teaching Hospital, Nigeria.
... Improving the health care system is the main priority of the Mongolian government. However, public health sector reform is difficult and time intensive, even in developed countries [41,42]. In addition, in several Asian countries [43,44], private health insurance industries are well developed despite efficient public health sectors. ...
Background
High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia.
Methods
This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed.
Results
Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 ( p < 0.001) and ₮16,661 ( p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP.
Conclusion
To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.
... It is necessary to monitor and evaluate sterilization services under pre-established criteria and pursue opportunities for improving services. There is a need for replicable, standardized, and comparable metrics for the quality of medical care in low and middle-income countries [56]. Policies to improve population health mainly focus on the expansion of access to essential health services and often neglect the need to address the QoC [25]. ...
Female sterilization is the most popular contraceptive method among Indian couples, and the public sector is the major source of sterilization services in the country. However, concerns remain on the quality of services provided, deaths, failures, and complications following sterilization. In this paper, we study the complexities around the quality of care in female sterilization services at public health facilities and identify strategies for improving the measurement of such quality. A better understanding of these issues could inform pragmatic strategies for enhancing quality. This study uses data from the National Family Health Survey (NFHS) 2015–16 and District Level Household and Facility Survey (DLHS) 2012–13. The study is limited to only districts whose data are available in both DLHS 2012–13 and NFHS 2015–16. The methods of analysis include bivariate statistics, Pearson’s chi-square test, and two-level mixed-effects logistic regression. We found that the quality of care (QoC) in sterilization service at the public health facilities in India is associated with facility readiness and the socio-economic characteristics of the clients. There is a significant association between household wealth and the QoC received. Our study provides empirical shreds of evidence on the role of structural attributes in delivering quality sterilization services. The spatial analyses revealed the geographies in the country where the QoC and facility readiness are low. Quality should be an overriding priority to establish the credibility of any health care delivery system. It is essential to provide safeguards against adverse events to develop the client’s confidence in the services, which is the key to success for any voluntary family planning program like in India.
... The reforms were championed by the World Bank, which provided a rationale for structural changes to the health sector based on their failure to improve health systems stemming from the lack of alignment between government actions and goals of economic development (Onyango, 2001). The driving forces behind these reforms vary, but limited governmental resources, combined with rapid demographic and technological changes often serve as the rationale for the desired change (Eriksson, 2001, Berman andBossert, 2000). For example, behind health sector reform in sub-Saharan Africa, often influenced by donors, the main driving force has been the severe crisis in health sector budgets, weak capacity to manage and regulate the health sector in a sustainable and equitable ways, and limited civil society engagement (Standing, 2002). ...
1 We are very grateful to the members and corresponding members of the WGEKN, and the authors of background papers for their willingness to write, read, comment and send material. Special thanks are due to Linda Rydberg and Priya Patel for their cheerful and competent support at the different stages of this report. We would also like to thank Beena Varghese for her inputs to the report. ii Members Rebecca Cook
... Permission to audio-record for the interview was also obtained. Participants were not face any harm and were not receive any financial incentive for participating and it was solely on voluntary based [28]. ...
Patient satisfaction could be a result of each patient's perception of the care designed for that patient to eliminate his/her problems. Patient satisfaction, in most countries, is considered to be an indicator of the quality of healthcare and an important component of the care. The aim of this study is to assess adult patient satisfaction and associated factors with nursing care among admitted patient in medical, surgical and obstetrics and gynecology ward. The study was utilized an institutional based cross-sectional study design that employed both quantitative and qualitative data collection methods. Study participants were selected by random sampling technique. The data was collected through face to face interview using structured questionnaires. Both bivariate and multivariate logistic regression analysis was done. Overall proportion of adult inpatient satisfaction among the respondents was 184 (61.3%) and 116(38.7%) were dissatisfied with the nursing health care service provided at the inpatient. concluded that, adult inpatient satisfaction related to the health care services provided by the nurses is inadequate.
... This problem arises from complex interrogative procedures, followed by insurance companies. People do not want to get into trouble for a small ailment and ignore to seek medical advice [20]. Another reason for not going to a medical care provider is; having to wait long hours to see a doctor. ...
This paper investigates the connotation, and some of the realistic implications, of the economic reform of health sector in under developed countries. The paper investigates the issues that economic reforms have to address, and the policy targets they are considered to accomplish. The work argues that the development of economic reform is not connected only with understanding the priorities and refining them, furthermore with reformation and restructuring the organizations through which health policies are employed. Considering various organizational values, that are likely to be regular to all economic reform programs, a regulatory approach to institutional reform is unsuitable. The paper further investigates the selection of economic reform that may as well influence via technical suggestions and analysis, but the verdict to continue, and the consequent success of execution, eventually depends on the progressive political sustainability. The paper concludes by giving examples of institutional reforms from various underdeveloped countries and includes recommendation of the responsibility and control of donor organizations.
... Production and localization of credible scientific evidence for the promotion of higher education of health the reform plans for several reasons (14,15). Considering the reasons for reforms in other countries, we could say that their reforms will respond to one problem based on the challenge. ...
Introduction: Lack of a clear policy for the development of health human resources has created inconsistencies. These imbalances are threats to the health system to achieve its goals. Therefore, the development of human resources through proper performance of higher education health system is an important part of the policy development process of the health sector. The present paper aims to introduce the methods applied for the compilation of evolution and innovation program of medical sciences training as well as the most important directions for evolution and innovation. Methods: In this study, we evaluated the methodology for designing packages of Iran's higher education health system evolution and innovation. For this purpose, the evaluation of the policy process was conducted based on Michelle and Scott's policy process models. This policy evaluation model starts by problem identification and definition and continue by agenda setting, policy formation, legitimation, implementation, evaluation, and policy modification, using the proper feedback. Qualitative content analysis method was used as a research method for subjective interpretation of the content of the text data. Results: Twelve policies, 68 strategies and their translation in the health system were adopted in a comprehensive plan for higher health education. Eleven practical packages were also developed in order to implement these policies as packages for reform and innovation in medical education. These packages were organized based on the IPOCC pattern. Conclusion: The lack of a comprehensive look at each project or program could bring about irreparableness consequences. However, the MoHME of Iran, relying on the integration of health higher education with health care system and comprehensive method used for transformation and innovation plan in the field of health higher education could take an important step towards improving the nation's health. Abstract Iran's National Medical Education Evolution and Innovation Plan Pourabbasi A et al.
... In 2009, the reform plan in China with 125 billion dollars budget until 2020, takes five key activities for developing basic insurance, creating national system of necessary drugs, improving primary health care, increasing coverage of primary public health care, and promoting public hospital management (7,8). Moreover, there is a long list of countries that in the recent decade accepted basic reforms on searching suitable responses for health systems (1,9). In Iran, in the recent years, the health system has encountered challenges such as high ratio of out of pocket payment to total health expenditure, and high prevalence rate of non-communicable diseases that required basic reforms in the performance of health system (10). ...
Background:
Health reform in Iran began in 2014, aimed at improving financing pattern of health services. We assessed the reform by changes in variables representing distribution of health payments and catastrophic expenditures.
Methods:
Using data from households' income-expenditure survey, this study computed the financial variables, representing poverty line and households at poor state, household's catastrophic health expenditure, fairness in financial contribution (FFC) index, and household's impoverishment state, in the years 2010-2016, in urban and rural areas. The variables were computed by special software designed for this study, based on C-Sharp(C#) programming language, with yearly data on more than 38000 households, each with 1072 information sources.
Results:
The food share-based poverty line after sharp rise in 2010-2013, in 2014-2016 raised slowly, and the average percent of households facing catastrophic health expenditure, after sharp rise in 2011-2013, left at 3.25 in 2014-2015 and raised to 3.45 in 2016. The average FFC index remained at 0.839 to 0.837 in 2013-2016. However, interestingly, the average percent of households impoverished after out-of-pocket payments improved from 1.36 to 0.912 in 2013-2016.
Conclusion:
In three years of health reform, the major impact of reform was considerable improvements in the rate of the impoverished after out-of-pocket payments. The reform had limited impacts on the rates of households facing catastrophic health expenditure, and on FFC indexes, for the rural and urban residents.
... Production and localization of credible scientific evidence for the promotion of higher education of health the reform plans for several reasons (14,15). Considering the reasons for reforms in other countries, we could say that their reforms will respond to one problem based on the challenge. ...
Introduction: Lack of a clear policy for the development of health
human resources has created inconsistencies. These imbalances
are threats to the health system to achieve its goals. Therefore, the
development of human resources through proper performance of
higher education health system is an important part of the policy
development process of the health sector. The present paper aims
to introduce the methods applied for the compilation of evolution
and innovation program of medical sciences training as well as
the most important directions for evolution and innovation.
Methods: In this study, we evaluated the methodology for
designing packages of Iran’s higher education health system
evolution and innovation. For this purpose, the evaluation of the
policy process was conducted based on Michelle and Scott’s policy
process models. This policy evaluation model starts by problem
identification and definition and continue by agenda setting, policy
formation, legitimation, implementation, evaluation, and policy
modification, using the proper feedback. Qualitative content
analysis method was used as a research method for subjective
interpretation of the content of the text data.
Results: Twelve policies, 68 strategies and their translation in the
health system were adopted in a comprehensive plan for higher
health education. Eleven practical packages were also developed
in order to implement these policies as packages for reform and
innovation in medical education. These packages were organized
based on the IPOCC pattern.
Conclusion: The lack of a comprehensive look at each project
or program could bring about irreparableness consequences.
However, the MoHME of Iran, relying on the integration of health
higher education with health care system and comprehensive
method used for transformation and innovation plan in the field
of health higher education could take an important step towards
improving the nation’s health.
... Manajemen perubahan menjadi cara untuk mencapai hasil yang diharapkan yaitu perubahan 14 Berbagai cara baru telah dilakukan di Puskesmas sesuai arahan Kementerian Kesehatan berupa pembebasan biaya berobat ke Puskesmas termasuk jaminan kesehatan, sumber-sumber baru dan kendali pembiayaan Puskesmas, perubahan kedudukan Puskesmas menjadi UPTD, kebijakan dasar Puskesmas, dan perubahan pemberian pelayanan menjadi komprehensif. Dalam tinjauan tentang efektifitas perubahan hal-hal tersebut menunjukkan pengelolaan tombol perubahan yang meliputi pembayaran, pembiayaan, organisasi, kebijakan, dan perilaku. ...
Revitalisasi Puskesmas merupakan upaya Kementerian Kesehatan RI untuk meningkatkan kinerja Puskesmas melalui berbagai perubahan dalam penyelenggaraan Puskesmas. Perubahan-perubahan tersebut sejalan dengan semangat reformasi pembangunan khususnya reformasi otonomi daerah. Penelitian ini bertujuan untuk melakukan eksplorasi manajemen perubahan dalam revitalisasi Puskesmas yang dilakukan oleh Dinas Kesehatan. Metode Desain penelitian yang dipergunakan adalah kualitatif dengan paradigma konstruktivism dan strategi studi kasus. Metode analisis yang digunakan adalah tematik. Subyek penelitian ini adalah kepala dinas kesehatan dan kepala Puskesmas. Hasil Model manajemen perubahan dalam sistem pengembangan manajemen kinerja klinis WHO SEA-NURS mendukung hasil yang menunjukkan bahwa fungsi-fungsi manajemen perubahan menjadi dasar konstruk perubahan penyelenggaraan Puskesmas oleh Dinas Kesehatan. Simpulan Manajemen perubahan dalam revitalisasi Puskesmas oleh Dinas Kesehatan Kabupaten Sumedang fokus pada fungsi implementasi yang merupakan tahap penekanan terhadap masalah yang mulai muncul dalam tugas perubahan yang harus dilakukan.Kata kunci : manajemen perubahan, revitalisasi Puskesmas
... In recent years, decentralization has become a dominant theme in many countries where health sector reforms are adopted, aiming to increase efficiency, to achieve effectiveness and equity and to tailor health care to the needs of local populations (Berman and Bossert, 2000;Robalino et al., 2001;Goddard and Mannion, 2006;Regmi, 2014). Decentralization of health services is not a simple process, as it is not always evident which functions should be decentralized and transferred and which should be retained under central control (Litvack and Seddon, 1999;Jutting et al., 2005). ...
Purpose
Greece has legislated health decentralization several times since the 1920s, but none had been implemented until 2001. Even so, the decentralized system was subsequently modified several times, curtailing the powers that were initially delegated to the health regions, while the whole process has been criticized as limited in scope. The purpose of this paper is to explore the reasons that the decentralization process did not fulfil its initial aims.
Design/methodology/approach
Elite interviews were conducted with 37 of the 50 directors of health regions who served between 2001 and 2009. Interview transcripts were divided into four themes and analyzed using thematic analysis.
Findings
The participants agreed that health decentralization in Greece was only administrative rather than political and did not include fiscal decentralization. They described problematic and competitive relations with party officials and civil servants. They blamed their short tenure for the inability to fulfil their plans. Findings indicate that decentralization in Greece did not achieve its objectives because of the dominant mentality of centralized control, the lack of political support, the discontinuity in health policies and opposition from vested interests.
Originality/value
The value of the present study lies in the fact that it examines in depth the issue of health decentralization drawing on the experiences of the former directors of the Greek health regions, i.e. the persons who were called on to put into practice the process of regional decentralization.
... Health care systems in the new member states have had to undergo major changes in structure -'Big R' reforms in the terminology of Berman and Bossert (2000). We illustrate what this implies by taking the cases of Poland, the Czech Republic and Estonia, which between them cover large, medium and small-sized countries. ...
The welfare state in Europe has been reformed gradually over the past two decades, with the intensification of the economic and monetary union and the addition of fifteen new members to the EU. This book explores the pressures that have been placed on the welfare state through a variety of insightful and thought-provoking contributions.
... Findings also showed that the control group of physicians showed higher percent of correct answers within the family planning section. This is probably due to the stress of MOHP through its vertical programs on family planning as a key factor when dealing with the country's population challenges (Berman and Bossert, 2000). This is another area HSR needs to support as a horizontal program when it tackles all health challenges facing Egypt to have a demographic eye rather than diluting family planning efforts within its other instruments. ...
An essential component of quality of reproductive health (RH) care, which has often been overlooked in the Egyptian literature, is the physicians' knowledge. This study attempts to assess the RH knowledge of physicians working under two different primary health care (PHC) settings and compare them with a control group of RH physicians working in the regular primary health care units. The first setting belonged to the health sector reform (HSR) program that Egypt attempts to scale-up while the second came from a special RH intervention initiative conducted by an NGO (ESPSRH) in Egypt. Two tools were developed to test physicians' RH knowledge in the three groups of PHC clinics. A questionnaire was designed to test several aspects of RH knowledge and an in-depth interview schedule was used to collect detailed information from the physicians. Despite the fact that the three groups received training courses but with varying degrees of content and frequency, their learning level was low. None of the training settings had a significant influence on the physicians learning levels of RH knowledge unlike the situations in other countries. Findings clearly indicated that the training of the HSR group of physicians was lagging in various components of RH. However, since HSR program in Egypt is an irreversible route and to guarantee technical RH quality of care, all its theoretical training components of RH should be revised very carefully. It is expected that the amount of training time given to RH needs to be expanded. It is recommended that officials continuously conduct pre and post assessment of knowledge and analyze results to identify weak points in its training programs. Physicians need more frequent training as well as to attend weekly seminars to keep them up to date. HSR needs to be more aware of RH goals and becomes an effective advocate for these goals. It is recommended that HSR RH training programs be more area specific to emphasize local challenges in addition to general challenges facing Egypt. HSR needs to have a demographic eye and emphasizes family planning efforts within its other instruments.
... 31 Health sector reform in the Africa is focused on new methods of financing, organizing, managing, and implementing social insurance programs. 32,33 The transition economies of Eastern Europe have proposed many new social insurance schemes. 34 Some countries have had some achievements to solve this problem. ...
Background: One of the objectives of the health transformation plan (HTP) in Iran is to reduce out-of-pocket (OOP) payments for inpatient services and eradicate informal payments. The HTP has three phases: the first phase (launched in May 5, 2014) is focused on reducing OOP payments for inpatient services; the second phase (launched in May 22, 2014) is focused on primary healthcare (PHC) and the third phase utilizes an updated relative value units for health services (launched in September 29, 2014) and is focused on the elimination of informal payments. This aim of this study was to determine the OOP payments and the frequency of informal cash payments to physicians for inpatient services before and after the HTP in Kurdistan province, Iran.
Methods: This quasi-experimental study used multistage sampling method to select and evaluate 265 patients ischarged from hospitals in Kurdistan province. The study covered 3 phases (before the HTP, after the first, and third phases of the HTP). Part of the data was collected using a hospital information system form and the rest were collected using a questionnaire. Data were analyzed using Fisher exact test, logistic regression, and independent samples t test.
Results: The mean OOP payments before the HTP and after the first and third phases, respectively, were US$59.4, US$17.6, and US$14.3 in hospital affiliated to the Ministry of Health and Medical Education (MoHME), US$39.6, US$33.7, and US$13.7 in hospitals affiliated to Social Security Organization (SSO), and US$153.3, US$188.7, and US$66.4 in private hospitals. In hospitals affiliated to SSO and MoHME there was a significant difference between the mean OOP payments before the HTP and after the third phase (P<.05). The percentage of informal payments to physicians in hospitals affiliated to MoHME, SSO, and private sector, respectively, were 4.5%, 8.1%, and 12.5% before the HTP, and 0.0%, 7.1%, and 10.0% after the first phase. Contrary to the time before the HTP, no informal payment was reported after the third phase.
Conclusion: It seems that the implementation of the HTP has reduced the OOP payments for inpatient services and eradicated informal payments to physician in Kurdistan province.
... In Low and Middle Income Countries (LMICs), health system reform has followed a global trend towards decentralization of services from central governments and large hospitals to local governments and district health clinics [15]. This involves the transfer of decisionmaking from the central governmental body, to local officials in order to tailor health care to the needs of local populations and increase access to medicines and treatments across all regions of a nation [4]. Decentralization has been promoted as a reform that will improve health system performance through improved efficiency, responsiveness and local accountability [5]. ...
Background
In March 2013, Kenya transitioned from a centralized to a devolved system of governance. Within the health sector, this entailed the transfer of service provision functions to 47 newly formed semi-autonomous counties, while policy and regulatory functions were retained at the national level. The devolution process was rapid rather than progressive.
Methods
We conducted qualitative research within one county to examine the early experiences of devolution in the health sector. We specifically focused on the experience of change from the perspective of sub-county managers, who form the link between county level managers and health facility managers. We collected data by observing a diverse range of management meetings, support supervision visits and outreach activities involving sub-county managers between May 2013 and June 2015, conducting informal interviews wherever we could. Informal observations and interviews were supplemented by fifteen tape recorded in depth interviews with purposively selected sub-county managers from three sub-counties.
Results
We found that sub county managers as with many other health system actors were anxious about and ill-prepared for the unexpectedly rapid devolution of health functions to the newly created county government. They experienced loss of autonomy and resources in addition to confused lines of accountability within the health system. However, they harnessed individual, team and stakeholder resources to maintain their jobs, and continued to play a central role in supporting peripheral facility managers to cope with change.
Conclusions
Our study illustrates the importance in accelerated devolution contexts for: 1) mid-level managers to adopt new ways of working and engagement with higher and lower levels in the system; 2) clear lines of communication during reforms to these actors and 3) anticipating and managing the effect of change on intangible software issues such as trust and motivation. More broadly, we show the value of examining organisational change from the perspective of key actors within the system, and highlight the importance in times of rapid change of drawing upon and working with those already in the system. These actors have valuable tacit knowledge, but tapping into and building on this knowledge to enable positive response in times of health system shocks requires greater attention to sustained software capacity building within the health system.
... With the adoption of the Primary Health Care approach, planning shifted in the 1980s from clinical services expansion to access to selective vertical interventions [11]. With the structural adjustment and public sector reforms of the 1990s, this planning process again shifted to management of downsizing of services and strengthening decentralized planning [12]. By the time we entered the current global health phase in the 2000s, the planning process shifted towards scaling up provision of country specific essential services [13]. ...
The health status in the African Region has increased in the past 15 years, though still faced with many challenges and threats. To move forward, improvements in the health planning process are needed as part of the effort to strengthen health governance. The history of health planning is rich in effort, and shows evolution with the prevailing paradigm of health management at each point in time. As a result, with the advent of SDGs as health security preparedness needs, it is imperative that the heath planning process be realigned with the governance needs and expectations of countries. Recognizing persisting planning challenges relating to poor policy dialogues, uneven prioritization capacity , rigid processes, poor linkages of planning tools and with inter-sectoral actions and implementation guidance, the WHO regional office is proposing adoption of a comprehensive planning framework and process that takes cognizance of these challenges. It defines the respective tools and processes needed for effective health planning, including their relationships and linkages. Adoption of a comprehensive planning process will support attainment of health objectives, and guide movement towards SDGs in countries. Appropriate tools, and procedures will be developed in line with the comprehensive planning process to facilitate its application in countries.
... En una perspectiva histórica, el concepto de la CUS se remonta a las reformas sectoriales de los sistemas de salud capitaneadas a partir del final de los años 1980 por corporaciones fi-nancieras internacionales, especialmente por el Banco Mundial, cuya mayor preocupación era alcanzar la "sustentabilidad de financiamiento" y la "eficiencia" de los sistemas de salud mediante la reducción de los gastos públicos en favor del aumento de la participación del capital privado 39 y de las asociaciones público-privadas 40 . Esto significa que las propuestas iniciales de la CUS no fueron establecidas por investigadores, agentes públicos o instituciones vinculadas a la salud, sino por economistas y agentes ligados al mercado financiero y a las corporaciones internacionales, particularmente el Banco Mundial. ...
Resumen Tomando como referencia la institución supranacional más importante, la Organización de las Naciones Unidas (ONU), y su agencia subordinada, la Organización Mundial de la Salud (OMS), este artículo se propone hacer un análisis del acceso a la salud como derecho humano en políticas internacionales intergubernamentales. Inicialmente se discute el tema de la salud al interior de la ONU, destacando el concepto de salud global; posteriormente, se discute el concepto de salud global considerando la salud como un derecho humano; luego, se presenta el debate cobertura versus acceso a la salud como un derecho humano, abordando algunas de sus implicaciones éticas; a partir de entonces, se discuten la cobertura versus el acceso a la salud, tomando como marco de referencia las teorías constructivista y crítica de las Relaciones Internacionales. Finalmente, se concluye que frente a la persistencia de una fuerte inequidad global, la OMS comenzó a remodelarse dejando la noción de la salud como derecho humano de lado, imponiendo el desafío de disminuir la larga distancia que separa la realidad de las leyes y políticas internacionales intergubernamentales.
... They are designed to improve the functioning and performance of the health sector and ultimately the health status of the population. The major aims of the reforms were to bring healthcare services closer to the people and make the health system responsive [21][22][23]. ...
Background
The shortage of a skilled health workforce is a global crisis. International efforts to combat the crisis have shown few benefits; therefore, more country-specific efforts are required. Tanzania adopted health sector reforms in the 1990s to ensure, among other things, availability of an adequate skilled health workforce. Little is documented on how the post-reform training and deployment of medical doctors (MDs) have contributed to resolving Tanzania’s shortage of doctors. The study aims to assess achievements in training and deployment of MDs in Tanzania about 20 years since the 1990s health sector reforms.
Methods
We developed a human resource for health (HRH) conceptual model to study achievements in the training and deployment of MDs by using the concepts of supply and demand. We analysed secondary data to document the number of MDs trained in Tanzania and abroad, and the number of MDs recommended for the health sector from 1992 to 2011. A cross-sectional survey conducted in all regions of the country established the number of MDs available by 2011.
Results
By 1992, Tanzania had 1265 MDs working in the country. From 1992 to 2010, 2622 MDs graduated both locally and abroad. This translates into 3887 MDs by 2011. Tanzania needs between 3326 and 5535 MDs. Our survey captured 1299 MDs working throughout the country. This number is less than 40% of all MDs trained in and needed for Tanzania by 2011. Maldistribution favouring big cities was evident; the eastern zone with less than 30% of the population hosts more than 50% of all MDs. No information was available on the more than 60% of MDs uncaptured by our survey.
Conclusions
Two decades after the reforms, the number of MDs trained in Tanzania has increased sevenfold per year. Yet, the number and geographical distribution of MDs practicing in the country has remained the same as before the reforms. HRH planning should consider the three stages of health workforce development conceptualized under the demand and supply model. Auditing and improvement of the HRH database is highly recommended in dealing with Tanzania’s MD crisis.
... The key objectives of a health system are to (i) address the health needs of local population and increase access to medicines and treatments for all [20]; and (ii) to expand the reach of health services beyond large cities to the diverse rural areas [21]. It is argued that decentralization can have huge impact on health service functioning, and therefore, has been widely recommended as a reform measure for increasing efficiency in the financing and quality of service delivery which are essentially dimensions of health care system. ...
IntroductionOne of the principal goals of any health care system is to improve health through the provision of clinical and public health services. Decentralization as a reform measure aims to improve inputs, management processes and health outcomes, and has political, administrative and financial connotations. It is argued that the robustness of a health system in achieving desirable outcomes is contingent upon the width and depth of ‘decision space’ at the local level. Studies have used different approaches to examine one or more facets of decentralization and its effect on health system functioning; however, lack of consensus on an acceptable framework is a critical gap in determining its quantum and quality. Theorists have resorted to concepts of ‘trust’, ‘convenience’ and ‘mutual benefits’ to explain, define and measure components of governance in health. In the emerging ‘continuum of health services’ model, the challenge lies in identifying variables of performance (fiscal allocation, autonomy at local level, perception of key stakeholders, service delivery outputs, etc.) through the prism of decentralization in the first place, and in establishing directed relationships among them. Methods
This focused review paper conducted extensive web-based literature search, using PubMed and Google Scholar search engines. After screening of key words and study objectives, we retrieved 180 articles for next round of screening. One hundred and four full articles (three working papers and 101 published papers) were reviewed in totality. We attempted to summarize existing literature on decentralization and health systems performance, explain key concepts and essential variables, and develop a framework for further scientific scrutiny. Themes are presented in three separate segments of dimensions, difficulties and derivatives. ResultsEvaluation of local decision making and its effect on health system performance has been studied in a compartmentalized manner. There is sparse evidence about innovations attributable to decentralization. We observed that in India, there is very scant evaluative study on the subject. We didn’t come across a single study examining the perception and experiences of local decision makers about the opportunities and challenges they faced. The existing body of evidences may be inadequate to feed into sound policy making. The principles of management hinge on measurement of inputs, processes and outputs. In the conceptual framework we propose three levels of functions (health systems functions, management functions and measurement functions) being intricately related to inputs, processes and outputs. Each level of function encompasses essential elements derived from the synthesis of information gathered through literature review and non-participant observation. We observed that it is difficult to quantify characteristics of governance at institutional, system and individual levels except through proxy means. Conclusion
There is an urgent need to sensitize governments and academia about how best more objective evaluation of ‘shared governance’ can be undertaken to benefit policy making. The future direction of enquiry should focus on context-specific evidence of its effect on the entire spectrum of health system, with special emphasis on efficiency, community participation, human resource management and quality of services.
... Dans le domaine sanitaire, le pays s'est lancé dans une réforme du système de santé basée sur la mise en place des districts de santé, sur la décentralisation, l'amélioration de la gestion et de la qualité des services, l'intégration du secteur privé lucratif et le développement de mécanismes de financement alternatifs. Ces options rencontrent celles formulées par différents auteurs et partenaire au développement (voir par exemple McPake et Kutzin, 1997 ;Berman & Bossert, 2000). Ainsi, au lendemain de la fin de la guerre et du génocide, le Ministère de la Santé avec l'appui de l'Organisation Mondiale de la Santé a formulé une « Politique nationale » pour orienter la reconstruction d'un système de santé (Ministère de la Santé, 1995). ...
New public management in healthcare has emerged by using best practices of business models of public service delivery, relevant in the contemporary context. The pioneering work on innovative technologies in global access to essential medicine and diagnostics- highlights emerging issues related to the management of public health facilities by studying the case of drug management. The empirical work aims to understand new public management practice in healthcare service delivery system. The study has shown structural, functional and operational aspects of drug management through an autonomous organization in the public healthcare service delivery. Considering the current changes and multiple complexities in the public healthcare delivery system, We propose that there is a greater significance of autonomous organizations in healthcare management. The case study validates the new initiatives being undertaken by the government to improve delivery of essential medicines and diagnostics and draw lessons for emerging economies. The book would be useful for practitioners and scholars in the fields of healthcare management, public policy, social entrepreneurs, comparative policy studies and medicine.
A comparative Analysis of Health care Reforms in Argentina, Brazil and Mexico in the 1990s
This paper discusses health sector reforms and what they have meant for sexual and reproductive health advocacy in low-income countries. Beginning in the late 1980s, it outlines the main macro-economic shifts and policy trends which affect countries dependent on external aid and the main health sector reforms taking place. It then considers the implications of successive macro-economic and reform agendas for reproductive and sexual health advocacy. International debate today is focused on the conditions necessary for socio-economic development and the role of governments in these, and how to improve the performance of health sector bureaucracies and delivery systems. A critical challenge is how to re-negotiate the policy and financial space for sexual and reproductive health services within national health systems and at international level. Advocacy for sexual and reproductive health has to tread the line between a vision of reproductive health for all and action on priority conditions, which means articulating an informed view on needs and priorities. In pressing for greater funding for reproductive health, advocates need to find an appropriate balance between concern with health systems strengthening and service delivery and programmes, and create alliances with progressive health sector reformers.
Résumé
Cet article décrit les réformes du secteur sanitaire et leurs conséquences sur le plaidoyer pour la santé génésique dans les pays á faibles revenus. Il souligne les réorientations économiques et les tendances politiques touchant les pays dépendants de l’aide extérieure et les principales réformes qui s’y déroulent depuis la fin des années 80. Puis il étudie les conséquences des mesures macro-économiques et des réformes successives sur le plaidoyer. Le débat international est aujourd’hui centré sur les conditions du développement socio-économique et le rôle des gouvernements dans celles-ci, et sur les moyens de relever les performances des administrations du secteur sanitaire et des systèmes de services. Il importe de renégocier l’espace politique et financier pour les services de santé génésique aux niveaux national et international. Jusqu’á récemment, les réformes du secteur sanitaire et le plaidoyer pour la santé génésique suivaient des voies parallèles, sans beaucoup de communication. Le plaidoyer doit concilier une vision de la santé génésique pour tous et l’action sur les conditions prioritaires, en comprenant les besoins et les priorités. Lorsqu’ils demandent d’accroı̂tre le financement de la santé génésique, les responsables du plaidoyer doivent trouver un juste équilibre entre leurs préoccupations pour les systèmes de santé et les programmes et la prestation de services, et créer des alliances avec des réformateurs progressistes du secteur de la santé.
Resumen
Este artı́culo trata de las reformas del sector salud y su significado para la promoción y defensa de la salud sexual y reproductiva en los paı́ses de bajos ingresos. Traza los cambios macroeconómicos principales y las tendencias polı́ticas que afectan los paı́ses que dependen de la ayuda externa desde los finales de los ochenta, además de las principales reformas del sector salud ya en curso. El debate internacional de hoy estȧ enfocado en las condiciones necesarias para el desarrollo socio-económico y el papel de los gobiernos en ellas, y en cómo mejorar el desempeño de las burocracias y los servicios del sector salud. Un desafı́o crı́tico es cómo re-negociar el cuadro polı́tico y financiero correspondiente a los servicios de salud sexual y reproductiva dentro del sector salud, tanto a nivel nacional como internacional. La promoción y defensa de la salud sexual y reproductiva tiene que seguir una lı́nea entre una visión de la salud reproductiva para todos, por un lado, y el tratamiento de condiciones prioritarias, por otro, el cual significa articular un punto de vista informado acerca de las necesidades y prioridades. Quienes insisten en incrementar el financiamiento para la salud reproductiva deben encontrar un equilibrio apropiado entre su interés en fortalecer los sistemas de salud, y la creación de alianzas con reformadores del sector salud progresistas.
We assessed the health care reform and its effects on household’s welfare such as access to health care and household economic burden. We used descriptive analysis on 2002-2011 Ministry of Health and OECD Health Statistics. The main result is about using health care. Access to health care increased after health care reform in Turkey. Number of applications to health care service server and its units rose. On the other hand, financial burden of health care on household’s budget decreased number of applications. The main result percentage of not consulting a specialist even needed to consult a specialist but did not during the past 12 months is %4.9 in 2003 and %19.9 in 2010. To improve health care access, policy makers should improve public sector provision of health care, increase social security benefit packages and protect poor and vulnerable.
Sağlıklı olmak, acı çekmeden uzun bir yaşam sürdürebilmek için insanlık tarihi
boyunca hissedilen doğal bir ihtiyaçtır. Dünyadan ayrılmak ve bir daha geri dönememek gibi ciddi bir sonucu olan sağlık, bu özelliği ile diğer tüm ihtiyaçlardan
ayrılmaktadır. “Tam bir iyilik hali” olarak özetlenen bu kavram, kimilerine göre
fiziki iyiliğin çok daha ötesinde anlamlar içerdiğinden, ihtiyacın kapsamı ve şiddeti
de bu çerçevede değişmektedir. Yoksulluk, işsizlik, açlık, gelir dağılımı bozukluğu
ya da evsizlik gibi insanı acıya sevk eden tüm unsurların ortadan kaldırılması, geniş
anlamda ihtiyaç duyulan sağlığın boyutlarını ortaya koymaktadır. Dolayısıyla insanoğlu, hayatı boyunca sağlıklı olabilmek için yaşamakta ve bütün varlığını buna
adamaktadır.
Due to inadequacy of data on the effectiveness of medicines regulatory
systems in Zambia, this study was framed. The aim was to evaluate
legislative provisions for medicines regulation under three legal-regulatory-frameworks
in place over the period from 1995 to 2015. The study was
structured in two distinct phases: the first involved document review of
available legislation and secondary data relevant to the subject matter,
covering the study period; the second involved a questionnaire survey for
health practitioners to gather opinions on the effectiveness of the
medicines regulatory systems in Zambia. Assessment of secondary data
reported by Ministry of Health, and World Health Organisation on
treatment outcomes and medicines regulation was conducted. Although it
is not a very comprehensive review of the regulatory systems in one
country, this book provides a basis for enthusiastic regulators, public
health enthusiasts and social readers to reflect and generate ideas around
medicines regulation.
Background: Imbalance between needs, demands and resources are commonly seen in the public sector. Management team needs to manage the available resources in the best possible way to meet the health needs. This is decided by the District Health Management Team (DHMT) in the district health. The concept of District Health Management Cycle (DHMC) was initially introduced by the World Health Organization (WHO) in its District Health Management Models as part of health sector reform initiatives. This review aim to discuss the principle and concept of DHMC in Malaysia.
Background
Since the early 1990s, Iran has initiated structural and decentralization reforms in the hospital system. This policy led to the formation of a Board of Trustees (BOTs) for the governing of public educational hospitals and making important modifications in hospitals' financing. This study was conducted to identify the barriers in implementing this policy.
Methods
All the Iranian Medical Sciences Universities and hospitals involved in the policy implementation were included in this qualitative study. The data were analyzed by using content analysis.
Results
In total, 403 problems were divided into 9 classes including problems related to implementing regulation, financial problems in policy implementation, problems related to faculty members, ambiguity in executive regulation, problems related to the BOTs, authority level, hospital structure, the quality and quantity of hospital human resources, and fee for services.
Conclusion
It appears that “implementing regulation” and “financial problems” embrace over 50% of the barriers. Apparently, the new approach to hospitals' autonomy has not achieved the desired goals. Considering the contextual factor, the evidence and identification of the clear role of various stakeholders should be essential determinants. Partial implementation of this policy without paying attention to the other aspects would end in failure. The results showed insufficient budget to be the most influential factor that posed a dilemma in implementing the BOTs' policy. However, BOTs in Iranian health system need to strive toward a higher level of performance that will improve effectiveness and efficiency now more than ever.
Introduction: The impact of reorganisation on health services delivery is a recurring issue in every health care system. In 2005 Vietnam reorganised the delivery of health services at the district level by splitting preventive, curative and administrative roles. This qualitative study explored how these reforms impacted on the organisation of maternal health service delivery at district and commune levels.
Method: Forty-three semi-structured interviews were conducted with health staff and managers involved in the provision of maternal health services from the commune to the central level within five districts of two Northern provinces in Vietnam. The data were analysed thematically.
Results: The results showed that 10 years after the reforms created three district-level entities, participants reported difficulties in management of health services at the district and commune levels in Vietnam. The reforms were largely perceived to negatively affect the efficient and effective use of clinical and other resources. At the commune level, the reforms are said to have affected the quality of supervision of the communes and their staff and increased the workload in Community Health Centres.
Conclusion: The findings from this study suggest that the current organisation of district health services in Vietnam may have had unintended negative consequences. It also indicates that countries which decide to reform their systems in a manner similar to Vietnam need to pay attention to coordination between a multiplicity of agencies at the district level.
Keywords: District health reform, Fragmentation of health system, Health service delivery, Maternal Health services, Health Workforce, Vietnam.
Abstract: Today, 215 million of people live outside their countries of birth. Also, according to the estimations, one population of Montenegro (around 600.000) of Montenegrin citizens and their descendants live all around the world. This paper is analysing migration trends in Montenegro, and its impact on labour market and social exclusion. The analysis is focused both on emigration and immigration, but also on internal migration trends. A special focus is put on two periods between censuses, from 1991 to 2003, and from 2003 to 2011. It is very hard to extrapolate the impact of migration on demographic trends, labour market and social picture of the country. However, this paper, based on available data, studies, and information obtained through expert interviews, showed that impact of migration in Montenegro on above mentioned trends is significant.
Key words: migration, internal migration, population aging, labour market, social exclusion
Özet: II. Dünya Savaşı'ndan sonra devletin ekonomiye müdahalesi, yapılan devletleştirme çalışmaları ile yeni bir boyut ve nitelik kazanarak, özellikle piyasa ekonomisinin rekabetçi alanı daraltılmış ve sosyal haklar temelinde kamu kesimi için faaliyet alanı oluşturulmuştur. Bu çerçevede refah devleti anlayışı kendine eğitim, sağlık, tam istihdam, gelir dağılımı, çalışma koşulları ve konut sorunu gibi çok geniş bir alanda daha kapsamlı hedefler belirlemiş ve bu hedefler refah devleti kurgusu içine sosyal politikalarla taşınmıştır. Ancak 1970'lerde yaşanan küresel ekonomik kriz sonrasında refah hizmetleri maliyetleri yükselten bir unsur olarak görülmeye başlanmış ve IMF ve Dünya Bankası gibi uluslararası örgütlerin öncülüğünde bireyselcilik, piyasalaşma ve desantarilizasyon prensipleri ile neoliberal ekonomik, sosyal ve siyasal yapılanma sürecine girilmiştir. Neoliberal yapılanma sürecinden sağlık sistemleri de etkilenerek, sağlık hizmetlerinde desantarilizasyon, özelleştirme, hizmet sunumu ile finansmanın birbirinden ayrılması, sağlık harcamalarının azaltılması ve sağlık finansmanın devlet-özel sigorta etkinliği ile sürdürülmesini içeren bir dizi sağlık reformları uygulanmıştır. 1980 sonrası döneminde, ülkemizde ekonominin ve toplumun neoliberal politikalarla dönüştürülmesinden sağlık hizmetleri de önemli ölçüde etkilenmiş ve bu çerçevede, ülkemizde sağlık sisteminin neoliberal dönüşümü bugün Dünya Bankası destekli Sağlıkta Dönüşüm Projesi adı altında devam etmektedir. Anahtar Kelimeler:Refah Devleti, Sağlık Hakkı, Neoliberal Dönüşüm, Sağlık Reformları, Türkiye'de Sağlık Hakkı 1 GİRİŞ Refah devletinin gelişiminde sanayileşmenin getirdiği sorunlar, I. ve II. Dünya Savaşları süresince uygulanan güdümlü politikalar, sınıf çatışmaları, kapitalist ve sosyalist ideolojilerin rekabeti, ekonomik yaşamla ilgili gerekçeler ve demokratik anlayıştaki gelişmeler etkili olmuştur. II. Dünya Savaşı'ndan sonra devletin ekonomiye müdahalesi, yapılan devletleştirme çalışmaları ile yeni bir boyut ve nitelik kazanarak, özellikle piyasa ekonomisinin rekabetçi alanı daraltılmış ve sosyal haklar temelinde kamu kesimi için faaliyet alanı oluşturulmuştur. Fakat 1970 ekonomik krizinin ardından, kamu sağlık harcamalarının yüksek bir düzeye ulaşması ve kamunun sağlık hizmeti sunumunun kalitesiz ve verimsiz olması gibi gerekçeler ve uluslararası örgütlerin de desteğiyle, dünyadaki sağlık sistemlerini piyasa sağlık sistemlerine dönüştürmeye ve benzeştirmeye yönelik çalışmalar başlatılmıştır. Bu çerçevede, ülkelerin ekonomik ve siyasi liberal dönüşümleri paralelinde sağlık sistemlerinde benzer şekilde bazı devlet fonksiyonlarının desantarilizasyonu ve özelleştirilmesi, hizmet sunumu ile finansmanın birbirinden ayrılması, kamu sağlık harcamalarının azaltılması ve sağlık finansmanın da devlet özel sigorta etkinliği ile sürdürülmesine yönelik reformlar yapılmaktadır. Temelde emek yoğun bir yapısı olan ve topluma eşit, hakkaniyete uygun ve kaliteli sağlık hizmeti sunmayı esas alması gereken sağlık sistemlerinde yapılan reformlar, gerek sağlık hizmetine ihtiyaç duyanları, gerekse sağlık sistemi içinde aktif rol alanları önemli ölçüde etkilemektedir. Bu çalışmada, refah devleti ve sağlık hakkı yaklaşımı, sağlık sistemlerinde yaşanan neoliberal dönüşüm ve bu dönüşüme neden olan faktörler ve bu dönüşümün sağlık sistemi üzerindeki etkileri ele alınacak ve son olarak ülkemizde sağlık hakkının dönüşümü değerlendirilecektir. 2 REFAH DEVLETİNİN GELİŞİMİ İlk çağlarda insanlar sosyal risklere karşı, aile ve kabile içi dayanışma ve yardımlar ile güvenliklerini sağlamaktayken, orta çağla birlikte, dini kuruluşlar ve meslek kuruluşları etkinliklerini artırarak, bugünkü sosyal hizmet kurumlarının temelini oluşturmaya başlamıştır. Hristiyan ülkelerde manastırlar ve şövalye teşkilatları yoksulların gıda yardımı ve sağlık ihtiyaçlarını karşılarken, Müslüman ülkelerde sosyal güvenlik daha çok sosyal dayanışma ve yardımlaşma anlayışı içinde, aile ve akrabalık ilişkilerinin yanı sıra, dini ve gönüllü
This chapter presents the main puzzle that the book addresses: What political dynamics enabled the introduction of the Health Transformation Programme, Turkey’s healthcare reform? What kind of political conflicts did the reform generate? How and to whose benefit have these conflicts been resolved? The chapter situates these questions within a comparative framework of healthcare reforms and positions Turkey in this framework. The methods used in the research are also explained.
This chapter investigates the emergence and subsequent role of private healthcare provider organisations during the reform process. The chapter shows how the inclusion of private hospitals into the public health insurance plan led to the emergence of private healthcare provider organisations as a strong actor in healthcare policy. The chapter examines the discourse these organisations employ in influencing the reform, the content of their demands and concerns about the reform, and the strategies they use to reach out to the relevant members of the government and the healthcare bureaucracy.
This chapter analyses the role of the World Bank in Turkey’s healthcare reform in order to understand how and to what extent the global healthcare reform agenda was able to make its way into healthcare policy circles in Turkey. This chapter investigates the historical and ongoing institutional ties between the World Bank and successive Turkish governments in the healthcare policy domain. The chapter offers insights into the World Bank experts’ subjective understanding of the World Bank’s reform proposals and the HTP.
Background: In spite of notable achievements, medical education in Iran has faced some
challenges during last years. Looking at these challenges and in line with upstream national
policies in higher education, the packages for reform and innovation in medical education was
designed by ministry of health and medical education.
Methods: The national plan was drafted in three step: summarizing the national upstream documents
in health care, writing comprehensive plan for higher health education, designing packages
for reform and innovation in medical education. Authors were used expert panel method
for data gathering in macro level.
Results: Twelve policies, 68 strategies and their translation in health system were adopted in
comprehensive plan for higher health education. Eleven practical packages were also developed
in order to implementation of these policies as packages for reform and innovation in
medical education.
Conclusion: Special attention to national upstream documents, cross relation between main
policies, practical packages and translation of policies in health system are the main strength
of this method. Of course, designing practical packages is not enough and achieving its main
goals depends on implementation of policies by designing and running action plans and clear
projects.
This book is about the paradox of states that have been weakened by crisis just as their capacity to encourage economic development and provide for effective governance most needs to be strengthened. Case studies of Mexico and Kenya document the challenge of dealing with this paradox. In these two countries, crisis underscored the need for the state to strengthen, reform, or reinvent itself. In assessing responses to pressure to improve the insitutional, technical, administrative, and political capacities of government, the author analyzes the opportunities available for political leadership in moments of crisis. It also provides insight into the constraints set by leadership goals and existing economic and political structures on the potential for innovation. The author indicates that political leadership and structures of political power, while frequently part of the problem, are also part of the solution to building more efficient, effective, and responsive states. Engendering a shared vision of the future, building coalitions of interests, mobilizing electoral support, attracting talented people to public service, encouraging responsiveness to public needs, and mediating conflict in the interest of political stability - these are all tasks that are essential to promoting economic and political development and they are ones traditionally assumed by political leaders and institutions.
This paper concludes that structural adjustment programs in Africa did not reduce public health expenditures. In fact, many countries experienced higher real expenditures after adjustment. The fact that many indicators of health status deteriorated during the 1980s, however, presents somewhat of a paradox. This is resolved by an investigation of the intrasectoral allocation of health expenditures, which reveals that there are systematic biases in public expenditures towards tertiary and curative care, and a general weakness in the public sector's capacity to deliver adequate health care services even with higher real health sector budgets. In many countries, these biases have persisted despite government and donor intentions to promote health care reform. Finally, the paper reviews a set of policy and institutional issues which hinder the efficient use of budget resources, and catalogs those instances where progress is being made.
PIP
Stressing the importance of institutional reform, the author explores the meaning, and some of the practical implications, of health sector reform in less developed countries. He reviews the problems which reforms have to address and the policy objectives they are designed to achieve. What health sector reform is and why it is necessary are first considered. Then, with regard to movement toward a more coherent approach to health sector reform, there is discussion of the context, understanding health care systems, sources of ideas and experience, information versus institutions, and the key principles of institutional reform. A section on the issues and options to implementing reform is followed by consideration of the role of donor agencies. It is argued that the process of reform is not concerned only with defining priorities and refining policies, but also with reforming and restructuring the institutions through which health policies are implemented. While some organizational principles will probably be common to all reform programs, a prescriptive approach to institutional reform in inappropriate. The choice of reform options can be influenced by technical advice and analysis, but the decision to proceed, and the subsequent success of implementation, depends upon political support. Examples of institutional reform from several less developed countries are presented.
This paper reviews recent experiences with increases in user charges and their effect on the utilization of health care. Evidence from several countries of differences in utilization between rich and poor is presented, and recent accounts of sharp, and often sustained, drops in utilization following fee increases, are presented and discussed.
Fee income, appropriately used, represents a small but significant additional resource for health care. Recent national experiences appear to have concentrated on achieving cost recovery objectives, rather than on improving service quality and health outcomes. Appraisal of financing changes must be linked to probable health outcomes. Successful large-scale experience in linking these two is in short supply.
La presente obra sobre las prácticas de la política social en Latinoamérica y su reforma reúne varios trabajos al respecto: Una visión general de los estudios de caso; Sistemas de entrega de los servicios sociales: la experiencia chilena; Los sistemas de entrega de servicios sociales: una agenda para la reforma en Costa Rica; Sistema de servicios sociales en la República Dominicana; Un marco analítico para el estudio de los servicios sociales en América Latina.
In the late 1970s China launched its agricultural reforms which initiated a decade of continued economic growth and significant transformation of the Chinese society. The agricultural reforms altered the peasants' incentives, weakened community organization and lessened the central government's control over local communities. These changes largely caused the collapse of the widely acclaimed rural cooperative medical system in China. Consequently China experienced a decreased supply of rural health workers, increased burden of illnesses, disintegration of the three tier medical system, reduced primary health care, and an increased demand for hospital medical services. More than ten years have elapsed since China changed its agricultural economic system and China is still struggling to find an equitable, efficient and sustainable way of financing and organizing its rural health services. The Chinese experiences provided several important lessons for other nations: there is a need to understand the limits of the market forces and to redefine the role of the government in rural health care under a market economy; community participation in and control of local health financing schemes is essential in developing a sustainable rural health system; the rural health system needs to be dynamic, rather than static, to keep pace with changing demand and needs of the population.
Recent experience in China helps to answer a global question: Does economic development necessarily improve health status, nutrition, and health care? In the late 1950s, when China was a very poor nation, it developed an innovative system of medical care. Each community or town organized funds from the government, households, and communes to finance village health stations and “barefoot doctors” to deliver preventive and basic health services to more than 90 percent of the population.1 Between 1952 and 1982, China reduced the rate of infant mortality from 250 to 40 deaths per 1000 live births, decreased the prevalence of malaria . . .
This paper estimates total expenditure on health care in Poland in 1994 and provides new evidence on high levels of private spending on health care. The analysis shows that health care expenditures in Poland are higher than has usually been maintained, and are comparable with the prevailing levels in many other European countries. Private expenditure on health is a significant proportion of total expenditure on health, and in particular on financing outpatient care. Available evidence indicates that informal payments made by patients to physicians contribute as much as double of the physician's salary, and thus form an important source of earnings for physicians. This situation of high private expenditures on health care and informal payments to physicians is likely to be true of other transitional economies of Central and Eastern Europe as well. One policy implication that emerges is these transitional economies face a big challenge in managing existing resources, as opposed to finding new resources, in the health sector more effectively to meet the health care needs of their population. The paper highlights the need for better understanding of the current availability and distribution of resources in the health sector and their directions of flow, in both public and private sectors, and suggests using tools such as National Health Accounts to track and monitor changes in the financing of the health care system.
Decentralization has long been advocated as a desirable process for improving health systems. Nevertheless, we still lack a sufficient analytical framework for systematically studying how decentralization can achieve this objective. We do not have adequate means of analyzing the three key elements of decentralization: (1) the amount of choice that is transferred from central institutions to institutions at the periphery of health systems, (2) what choices local officials make with their increased discretion and (3) what effect these choices have on the performance of the health system. This article proposes a framework of analysis that can be used to design and evaluate the decentralization of health systems. It starts from the assumption that decentralization is not an end in itself but rather should be designed and evaluated for its ability to achieve broader objectives of health reform: equity, efficiency, quality and financial soundness. Using a "principal agent" approach as the basic framework, but incorporating insights from public administration, local public choice and social capital approaches, the article presents a decision space approach which defines decentralization in terms of the set of functions and degrees of choice that formally are transferred to local officials. The approach also evaluates the incentives that central government can offer to local decision-makers to encourage them to achieve health objectives. It evaluates the local government characteristics that also influence decision-making and implementation at the local level. Then it determines whether local officials innovate by making choices that are different from those directed by central authorities. Finally, it evaluates whether the local choices have improved the performance of the local health system in achieving the broader health objectives. Examples from Colombia are used to illustrate the approach. The framework will be used to analyze the experience of decentralization in a series of empirical studies in Latin America. The results of these studies should suggest policy recommendations for adjusting decision space and incentives so that localities make decisions that achieve the objectives of health reform.
This paper discusses the basic conditions necessary for the successful implementation of health sector reforms. Lessons from health sector reforms in the 24 western industrialized member countries of the Organization for Economic Cooperation and Development (OECD) are discussed and applied in the context of reform efforts in developing countries. Reform areas addressed include: public and private institutional infrastructure development, financing arrangements, benefit design, eligibility determination, reimbursement and cost control methods, and service delivery system configurations.
The radical changes which have been taken place in the Chinese economy since the late 1970s have influenced the health sector and the health care financing system. A rapid increase in medical care costs in the last decade has placed a heavy financial burden on the government and enterprises and a vast majority of the rural population. The public service medical scheme for government employees and labor insurance for enterprise workers are facing a great challenge of cost containment through a series of reforms in the mechanisms of fund collection and management. In the meanwhile, the collapse of the cooperative medical care scheme in most rural areas has raised the issue of gaining access to basic health care for the rural population and in particular the poor. This paper provides a description, with some explanation, of how and why the health care financing system had been changed and experienced such a sharp increase in expenditure. In conclusion, how to develop and improve a financing system appropriate to the level of socio-economic development in China is addressed.
Health sector reform is underway or under consideration.in countries throughout the world and at all levels of income. This paper presents an overview of key concepts and approaches to health sector reform in developing countries. Reform implies sustained, purposeful, and fundamental changes in the health sector. While it is difficult to define precisely what constitutes a true reform, there is widespread consensus that reform is a process of change involving the what, who, and how of health sector action. Health is increasingly included as an important goal of national development. It can make development more sustainable. The paper outlines some general and specific health sector reform strategies that can contribute to sustainable development for countries at all levels of income, although the strategies will differ in content and emphasis. Health sector reform should be based on an holistic view of the health sector. The paper presents two frameworks to aid in reform design: one highlighting the linkages between different institutional actors in the health sector; the second addressing linkages across different functional areas of reform action. In order to develop and carry out reform, information and analysis is needed. A variety of practical tools now available for this purpose are discussed, encompassing all the different areas of action. While tool development should continue, reform proponents already have much to work with. Given global interest, the importance of health sector reform in development strategies, and significant existing knowledge and experience, country level analysis and action should proceed vigorously.
Ministries of health are being called upon to lead major health reforms; at the same time they must reform themselves to become more modern institutions and assume new and different functions and roles in the more dynamic reformed system. The literature on public administration and on health reform has recommended many processes of institutional reform and development, building on private sector management techniques, popularized by 'reinventing government' and 'total quality management'. More recently, thoughtful insights have emphasized improving public management through a focus on creating 'public value'; on political, as well as administrative, leadership; improving institutional performance through strengthening the 'task networks' of organizations needed to achieve strategic objectives; and creating a learning culture within the organization. This article applies these recent approaches to the specific needs of ministries of health in order to improve their capacity to lead major health reforms. This combined approach is then used to analyze and make recommendations to the Ministry of Health in Colombia where the authors were providing technical support for a major new health reform.
Success in the provision of ambulatory personal health services, i.e. providing individuals with treatment for acute illness and preventive health care on an ambulatory basis, is the most significant contributor to the health care system's performance in most developing countries. Ambulatory personal health care has the potential to contribute the largest immediate gains in health status in populations, especially for the poor. At present, such health care accounts for the largest share of the total health expenditure in most lower income countries. It frequently comprises the largest share of the financial burden on households associated with health care consumption, which is typically regressively distributed. The "organization" of ambulatory personal health services is a critical determinant of the health system's performance which, at present, is poorly understood and insufficiently considered in policies and programmes for reforming health care systems. This article begins with a brief analysis of the importance of ambulatory care in the overall health system performance and this is followed by a summary of the inadequate global data on ambulatory care organization. It then defines the concept of "macro organization of health care" at a system level. Outlined also is a framework for analysing the organization of health care services and the major pathways through which the organization of ambulatory personal health care services can affect system performance. Examples of recent policy interventions to influence primary care organization--both government and nongovernmental providers and market structure--are reviewed. It is argued that the characteristics of health care markets in developing countries and of most primary care goods result in relatively diverse and competitive environments for ambulatory care services, compared with other types of health care. Therefore, governments will be required to use a variety of approaches beyond direct public provision of services to improve performance. To do this wisely, much better information on ambulatory care organization is needed, as well as more experience with diverse approaches to improve performance.
This study provides a comprehensive picture of the organization and delivery of ambulatory health care services in Poland. A main finding of the study is that, following the introduction of health insurance in 1999, the newly introduced Sickness Funds have become the main players in the medical services market, introducing new bidding procedures and contracts for provision of medical services. Contracts, and negotiations which precede them, have introduced elements of market competition, which has affected the number and types of services provided by health care centers operating under a contract. The health financing reforms have led to an even playing field for public and non-public providers, marked by a proliferation of structurally smaller health units. The introduction of a market environment has changed the way in which providers are compensated, with a discernible shift away from salary-based systems to capitation and fee-for-service compensation. The analysis of the provider market for outpatient care underscores the importance of understanding the organization and supply of health services, particularly insofar as it relates to the design of appropriate financial and other incentives for providers of health services and of policy interventions necessary for achieving systemic changes.
Exxon Mobil and ConocoPhillips stock price has been predicted using the difference between core and headline CPI in the United States. Linear trends in the CPI difference allow accurate prediction of the prices at a five to ten-year horizon.
Inside the Black Box of Health Care Systems
- William Hsiao
Hsiao, William. (2000) Inside the Black Box of Health Care Systems. Bulletin of the
World Health Organization, (forthcoming).
The role of the private sector in health care provision
- Barbara Mcpake
McPake, Barbara. (1997) The role of the private sector in health care provision. In Sara
Bennett, Barbara McPake, and Anne Mills, eds. Private Health Providers in
Developing Countries: Serving the Public Interest? London and New Jersey: Zed
Books.
Recent Experiences with Hospital Autonomy in Developing Countries-What can we learn? Report No. 32.2, Data for Decision Making Project
- Ramesh Govindaraj
- Mukesh Chawla
Govindaraj, Ramesh and Mukesh Chawla. (September 1996) Recent Experiences with
Hospital Autonomy in Developing Countries-What can we learn? Report No.
32.2, Data for Decision Making Project. Boston: The Harvard School of Public
Health.
Decentralization in Health Services in Senegal. Bethesda, MD: Partnerships for
- Grundman
- Christopher
Grundman, Christopher. (2000) Decentralization in Health Services in Senegal. Bethesda, MD: Partnerships for Health Reform Technical Report, (forthcoming).
Las Instituciones de Salud Previsional (ISAPRE) en Chile
- Ricardo Britrán
- Fernando Xavier Almarza
Britrán, Ricardo and Fernando Xavier Almarza. (1997) Las Instituciones de Salud
Previsional (ISAPRE) en Chile. Santiago: Comisión Económico para América
Latina y el Caribe.
La Decentralización de los Servicios de Salud en Bolivia (Primera Versión). Data for Decision Making Technical Report
- Fernando Ruiz
- Scarlett Escalante
- Marina Cardenas
- Katherina Capra
- Bruno Buissani
Ruiz, Fernando, Scarlett Escalante, Marina Cardenas, Katherina Capra, and Bruno
Buissani. (2000) La Decentralización de los Servicios de Salud en Bolivia
(Primera Versión). Data for Decision Making Technical Report. Boston: The
Harvard School of Public Health.
Data for Decision Making Project
- Ann G Lawthers
- S Bogdan
- Rózanski
Lawthers, Ann G. and Bogdan S. Rózanski. (May 1998) Quality of Outpatient Services.
Krakow Gmina. Report No. 60, Data for Decision Making Project. Boston: The
Harvard School of Public Health.
Bolivia's Mother and Child Health Insurance: Is It Working? Draft. Partnerships for Health Reform Technical Report
- Tania Dmytraczenko
- Katherina Capra Seoane
- Scarlet Escalante Carrasco
Dmytraczenko, Tania, Katherina Capra Seoane, Scarlet Escalante Carrasco. (1999)
Bolivia's Mother and Child Health Insurance: Is It Working? Draft. Partnerships
for Health Reform Technical Report. Bethesda: PHR.
Crisis and Reform of China's Health Care Insurance System JEL Classification: I18. World Health Organization, UNICEF, the World Bank, and the Zambian Ministry of Health Comprehensive Review of the Zambian Health Reforms
- Wei Yu
- Minghui Ren
Wei Yu and Minghui Ren. (1999) Crisis and Reform of China's Health Care Insurance System. Manuscript. Gerontology Center, Boston University. JEL Classification: I18. World Health Organization, UNICEF, the World Bank, and the Zambian Ministry of Health. (May 1997) Comprehensive Review of the Zambian Health Reforms. Unpublished Report. Volumes I, II, III.
Center for Health and Gender Equity. The Population Council
- Washington
Washington: Center for Health and Gender Equity. The Population Council.
User Financing of Basic Social Services: A review of theoretical arguments and empirical evidence. Evaluation, Policy and Planning Working Paper
- Sally Reddy
- Jan Vandemoortele
Reddy, Sally and Jan Vandemoortele. (1996) User Financing of Basic Social Services: A
review of theoretical arguments and empirical evidence. Evaluation, Policy and
Planning Working Paper. New York: UNICEF.
Decentralization of Health Systems in Zambia. Partnerships for Health Reform
- Bona Chita
Chita, Bona et al. (2000) Decentralization of Health Systems in Zambia. Partnerships for
Health Reform Technical Report. Bethesda: PHR, (forthcoming).
El Proceso de Descentralización y Financiamiento de los Servicios de Educación y Salud en Bolivia
- Fernando Ruiz
- Bruno Giusanni
Ruiz, Fernando and Bruno Giusanni. (1998) El Proceso de Descentralización y
Financiamiento de los Servicios de Educación y Salud en Bolivia. Santiago:
Comisión Económico para América Latina y el Caribe.
Reform of the Health Sector in Ghana and Zambia: Commonalities and Contrasts
- Andrew Cassels
- K Janovsky
Cassels, Andrew and K. Janovsky. (1996) Reform of the Health Sector in Ghana and
Zambia: Commonalities and Contrasts. Geneva: World Health Organization.
Crisis and Reform of China's Health Care Insurance System
- Wei Yu
- Minghui Ren
Wei Yu and Minghui Ren. (1999) Crisis and Reform of China's Health Care Insurance
System. Manuscript. Gerontology Center, Boston University. JEL
Classification: I18.
Decentralization, Decision Space and Performance in Latin America: Cases of Chile, Colombia and Bolivia. Data for Decision Making
- Thomas Bossert
Bossert, Thomas. (2000) Decentralization, Decision Space and Performance in Latin
America: Cases of Chile, Colombia and Bolivia. Data for Decision Making
Technical Report. Boston: The Harvard School of Public Health.
Health Financing Reform in Kenya: The Fall and Rise of Cost Sharing, 1989-94). Management Sciences for Health and U.S. Agency for International Development
- David H Collins
- Jonathan D Quick
- Stephen N Musau
- Daniel L Kraushaar
Collins, David H., Jonathan D. Quick, Stephen N. Musau, and Daniel L. Kraushaar.
(1996). Health Financing Reform in Kenya: The Fall and Rise of Cost Sharing,
1989-94). Management Sciences for Health and U.S. Agency for International
Development. Stubbs Monograph Series #1.
Decentralization in Health Services in Senegal. Bethesda, MD: Partnerships for Health Reform
- Christopher Grundman
Grundman, Christopher. (2000) Decentralization in Health Services in Senegal.
Bethesda, MD: Partnerships for Health Reform Technical Report, (forthcoming).
Report on Colombia Health Sector Reform and Proposed Master Implementation Plan
Colombia Health Sector Reform Project. (1996) Report on Colombia Health Sector
Reform and Proposed Master Implementation Plan. Boston: The Harvard School
of Public Health.
Decentralization of Health Services in Uganda: Moving Toward Improved Delivery of Services. In Health Care in Uganda: Selected Issues-In Collaboration with Demissie Habte and Mary Mulusa
- Paul Hutchinson
Hutchinson, Paul. (1999) Decentralization of Health Services in Uganda: Moving Toward
Improved Delivery of Services. In Health Care in Uganda: Selected Issues-In
Collaboration with Demissie Habte and Mary Mulusa. Washington: World Bank
Discussion Paper No. 404.
Major Applied Research Project on Decentralization of Health Systems: Preliminary Review of Four Country Cases. Partnerships for Health Reform Technical Report
- Thomas Bossert
- Joel Beauvais
- Diana Bowser
Bossert, Thomas, Joel Beauvais, and Diana Bowser. (2000) Major Applied Research
Project on Decentralization of Health Systems: Preliminary Review of Four
Country Cases. Partnerships for Health Reform Technical Report. Bethesda,
MD: PHR.
The Economics of Public and Private Participation in Health Care
- A S Preker
- A Harding
- N Girishankar
Preker, A.S., A. Harding, and N. Girishankar. (1999) The Economics of Public and
Private Participation in Health Care: New Insights from Institutional Economics.
Manuscript. World Bank.
Report of a Meeting of the Working Group for Reproductive Health and Family Planning. Washington: Center for Health and Gender Equity. The Population Council
Implications on Health Sector Reform on Reproductive Health Rights. (1998) Report of a
Meeting of the Working Group for Reproductive Health and Family Planning.
Washington: Center for Health and Gender Equity. The Population Council.
UNICEF, the World Bank, and the Zambian Ministry of Health) Comprehensive Review of the Zambian Health Reforms
World Health Organization, UNICEF, the World Bank, and the Zambian Ministry of
Health. (May 1997) Comprehensive Review of the Zambian Health Reforms.
Unpublished Report. Volumes I, II, III.