Assessing the performance of primary health centres under decentralized government in Kerala, India

CONTEXT: Kerala's government health-care system functions relatively well compared with other Indian States, but utilization levels are decreasing due to lack of essential facilities. The opportunity cost of seeking medical care from the government sector is high, even for the poor, with 60-70% of the poor seeking care from the private sector and spending disproportionately on health care (about 40% of income compared with 2.4% by the rich). In 1996, the Kerala government brought primary health centres (PHCs) under the control of local governments (panchayats). OBJECTIVE: To provide an approach to assess PHC performance under decentralized government. METHODS: The study was conducted in three stages. The first stage included all 990 village panchayats in Kerala. The second stage covered 10 panchayats (their respective 10 PHCs and 65 sub-centres) occupying the top five and bottom five ranks in terms of resource allocation to health. Two panchayats (their respective PHCs and sub-centres), one each from the top five and the bottom five, were chosen for the third stage. Published and unpublished government data, panchayat development reports, panchayat and PHC records, facility checklist, and key informant and client exit interviews were used for data collection. FINDINGS: Panchayats in Kerala allocated a lower proportion of resources to health than that allocated by the state government prior to decentralization; while panchayat resources grew at an annual rate of 30.7%, health resources grew at 7.9%. PHCs were funded to the extent of 0.7-2.7% of the total cost. An additional 2% in PHC resources was associated with improved patient load (63.5%), cost-effectiveness (50.8%), medicine supply (49.4%), information (32.8%) and patient satisfaction (12.7%). An annual increase of US$940 in PHC resources would help to extend primary care facilities to 3000 (15.5%) more users. CONCLUSION: Decentralization brought no significant change to the health sector. Active panchayat support to PHCs existed in only a few places, but wherever it was present, the result was positive. Kerala should find an alternative strategy to channel panchayats towards health before health loses its battle for resources.     

政府购买农村基本公共卫生服务的实践与思考

介绍了河南省武陟县开展购买农村基本公共卫生服务的试点经验和主要做法,就"购买服务+绩效合同管理"这一农村公共卫生服务提供新模式的实施效果进行了深入思考和分析,建议:加强乡、村两级基本公共卫生服务适宜技术培训,规范乡、村两级服务协议内容,强化双向转诊管理,建立农村公共卫生服务管理信息系统,为城乡居民提供规范的、有质量保证的公共卫生服务.     

Progressivity in the financing of decentralized government health programs: a decomposition

In many countries health services and/or health insurance are delivered but also partly financed by subnational entities that vary in their fiscal or financial capacity, e.g. local governments and social health insurance schemes. The central government typically mandates a specific (or at least minimum) level of benefit or expenditure per intended beneficiary, and sets rules about enrollment and coverage. It also typically contributes to the cost of the program, partly because the resources of subnational entities may be insufficient, on average, to meet the expenditure requirements, but partly for equity reasons. These two problems are typically addressed through tax-transfer schemes. In practice, there is considerable institutional heterogeneity across countries in the mix of vertical and horizontal schemes, and the way each works. In this Note, we show how the progressivity of health outlays by subnational entities can be decomposed into contributions from vertical and horizontal schemes, and how each of these can be further decomposed into contributions from taxes and transfers. We suggest that, in addition to providing a foundation for future empirical work, the decomposition provides some insights into the reasons for different institutional choices, and into the way vertical and horizontal tax-transfer schemes operate in practice.     

Improving government health services through contract management: a case from Cambodia

Most government health facilities in Cambodia perform poorly, due to lack of funds, inadequate management and inefficient use of resources, but mostly due to poor motivation of staff. This paper describes contracting as a possible tool for Ministries of Health to improve health service delivery more rapidly than the more traditional reform approaches. In Cambodia, the Ministry of Health started an experiment with contracting in eight districts, covering 1 million people. Health care management in five districts was sub-contracted to private sector operators, and their results were compared with three control districts. Both internal and external reviews showed that after 3 years of implementation, the utilization of health services in the contracted districts improved significantly, in comparison with the control districts. There was adequate competition in awarding the contracts. A Ministry of Health Project Co-ordinating Unit measured the performance of the contractors, and contributed pro-actively. There was no evidence of rent-seeking practices by either the contracting agency or the contractors. This paper describes in more detail the successes and failures in one of the contracted districts, where HealthNet International applied the contracting approach. Despite significantly increased official user fees, constituting 16% of recurrent costs, the utilization of services was equally increased. Patients thought the fees were reasonable because they were still lower than the fees demanded if government health workers charged informally. They also thought that the services were of better quality than in the unregulated private sector. Another important result was that combining strict monitoring with performance-based incentives demonstrates a decrease in total family health expenditure of some 40% from US dollars 18 to US dollars 11 per capita per year. Innovative and decisive management proved to be essential, which is more likely to be achieved by a contracted manager than by regular government managers with life-long employment. This paper discusses how the contractor addressed the deeply rooted problems of informal private activities of government health workers. The NGO district management experimented with two management systems: first by individual contracts with health workers, and secondly by sub-contracting directly with the health centre chiefs and hospital directors. A reason for concern is that poli-pharmacy and excessive use of injectables continued. Also, the participation of the central level of the Ministry of Health was positive in the contracting process, but the role and participation of the provincial level of the Ministry was more tentative.     

A gendered users′ perspective on decentralized primary health services in rural Tanzania

Since the 1990s, Tanzania has been implementing health sector reforms including decentralization of primary healthcare services to districts and users. The impact of the reforms on the access, quality and appropriateness of primary healthcare services from the viewpoint of users is, however, not clearly documented. This article draws on a gendered users' perspective to address the question of whether the delivery of gender‐sensitive primary health services has improved after the reforms. The article is based on empirical data collected through a household survey, interviews, focus group discussions, case studies and analysis of secondary data in two rural districts in Tanzania. The analysis shows that the reforms have generated mixed effects: they have contributed to improving the availability of health facilities in some villages but have also reinforced inter‐village inequalities. Men and women hold similar views on the perceived changes and appropriateness to women on a number of services. Gender inequalities are, however, reflected in the significantly low membership of female‐headed households in the community health fund and their inability to pay the user fees and in the fact that women's reproductive and maternal health needs are as yet insufficiently addressed. Although over half of users are satisfied with the services, more women than men are dissatisfied. The reforms appear to have put much emphasis on building health infrastructure and less on quality issues as perceived by users. Copyright © 2013 John Wiley & Sons, Ltd.     

A case for government ownership of primary care services in New Zealand: weighing the arguments.

Primary care services provide continuing and coordinating care, cater to most health care needs, and serve as a point of first contact with the health system. This article addresses the issue of government ownership of primary care. Ownership confers governance responsibility (ultimate control) for an organization, and accountability for its actions. Primary care organizations can be classed as government owned and operated or privately owned and operated, the latter with or without community governance. The authors address two policy questions: Does the ownership form of a primary care organization matter? What ownership frameworks should be used to guide policymaking? Arguments for and against government ownership are examined from political and economic perspectives, informed by a governance framework. Government ownership of primary care may solve problems associated with private for-profit ownership that are related to lack of control of strategic assets, lack of direct political accountability, contracting, and market failure, but it may raise potential problems of lack of responsiveness to minority and local needs and capture by interest groups. In response to the problems associated with government ownership, community-governed private nonprofits have an essential role as a vehicle for indigenous self-determination, catering for minority populations, experimenting with policy options, and providing public goods particularly for minority populations. The authors argue that private organizations that lack community governance have a lesser role.     

Trends and development of occupational health services in Norway

Occupational Health Services (OHS) in Norway cover approximately 1.2 million employees, equivalent to 60% of the total work force. They employ nurses (800), physicians (500), physiotherapists (360), safety engineers (400), psychologists (30) and others (400), a total of 2500 full time employmancy. The average cost of the OHS amounts to 150 euros per employee, a total cost of 180 million euros per year. In 1998, the OHS in Norway were evaluated. The evaluation, initiated by the Ministry, revealed that although 80% of the enterprises are fairly satisfied with their OHS, there is still much to be improved, in particular quality development and customer focus. By 2000 the National Practice Guidelines. ("Good OHS") were developed as a joint effort of the professional OHS associations, representatives from the social partners and the NIOH. These guidelines have been evaluated and well accepted by the OHS. Last year the Ministry of Labour appointed an advisory group of experts on OHS. The group was asked to examine: the "branch provision" on obligatory OHS and the availability of health resources; the legislation on OHS tasks; the quality improvement of OHS; and the OHS in small enterprises The report was ready in May 2001 stating that the OHS may be a useful contributor to the improvement of the health, environment and safety in enterprises and included the following recommendations: to establish the OHS for all within 10 years and to ratify relevant ILO convention; to develop a certification system for the OHS; to ensure financial public support of the OHS for the small enterprises; and to expand the OH hospital departments as important supportive agents for the OHS. The report will be a background document for the revision process of the Work Environment Act to be soon put into force.     

Integrating mental health services within primary care settings: the Hamilton Family Health Team

For 16 years, the Hamilton Family Health Team Mental Health Program has successfully integrated mental health counselors, addiction specialists, child mental health professionals, and psychiatrists into 81 offices of 150 family physicians in Hamilton, Ontario. Maximising the potential of a "shared care" model requires changes within the primary care setting, to support the addition of mental health and addiction professionals, active involvement of primary care staff in managing mental health problems of patients, and collaborative practice. This coordinated effort allow mental health treatment through onsite support from a mental health team and supplants the need to refer most patients to the mental health setting. This article reviews the evolution of the program and the changes made by practices with key lessons learnt.     

Health services and the public health

The 16th Duncan Memorial Lecture. Given at Henry Cohen lecture theatre, Duncan Building, Daulby Street, Liverpool, UK on Wednesday 25 November 1998 by Professor Sir Liam J Donaldson, Chief Medical Officer for England.     

Delivering preventive oral health services in pediatric primary care: a case study

Dental disease, the most prevalent chronic disease of childhood, affects children's overall health and ability to succeed. Integrating oral health into routine well-child checkups is an innovative and practical way to prevent dental disease. The Washington Dental Service Foundation is partnering with Group Health Cooperative, a large integrated delivery system, and other providers in Washington State to change the standard of care by incorporating preventive oral health services into primary care for very young children. This paper describes systemic and policy changes for engaging primary care providers in oral health, including provider training, expanding access to dental care, and reimbursement.     

Community financed and operated health services: the case of the Ajo-Lukeville Health Service District.

The concept of a health service district, as a variation of the special tax district, is described and discussed. Tax districts have traditionally been used to support both capital construction (revenue bonds) and operational expenses of single-purpose governmental entities. The health service district, where authorized by state laws, may be used by local areas to subsidize the delivery of ambulatory health care. A particular case, the Ajo-Lukeville Health Service District in Arizona, illustrates what can be accomplished by this mechanism with the cooperation of local residents and outside agencies. Both the process of establishing such a district and the outcome of the Ajo-Lukeville experience is described. Reasons why health service districts may prove potentially attractive at this time are reviewed. Impediments to the development of more health service districts are also explored, including the lack of technical assistance, an inadequate awareness of the potential of health service districts, and the absence of a widespread orientation toward community financed and controlled health care. Movement in this direction should facilitate the development of additional health service districts.     

政府对卫生服务市场的宏观调控

政府对医疗卫生服务市场行为的基本作用就是调控。但对卫生服务市场要不要政府调控 ,存在着两种不同的看法。一种认为需要 ,另一种认为不需要。综观世界各国 ,不管社会制度如何 ,完全不要政府调控的卫生服务市场是不存在的 ,只是调控的力度和方式的差别。我国目前处在社会主义初级阶段 ,卫生事业是国家实行一定福利政策的公益性事业 ,政府对卫生服务市场必须是一种以市场调节为基础的宏观调控。这种调控是通过卫生机构的设置、卫生政策的制定、卫生体制的改革、宏观杠杆、卫生监督执法和评价等方面 ,来保护、利用卫生资源 ,改善卫生经济环境…     

社区卫生服务举办主体多元化与政府主导权被迫让渡的关系

目的:社区卫生服务机构中约有半数不属于政府直接举办,形成了多元化的举办主体格局。本文用定性研究的方法审视"举办主体多元化"对社区卫生发展的影响,并探讨监管权解决方案。方法:在陕西省T区和山东省X区,用最大差异抽样法选取不同专业的卫生技术人员以及卫生行政人员进行访谈。采用归纳式的主题分析方法,解释举办主体多元化格局形成的前因后果,并提炼出实务理论。结果:选择举办主体多元化是财力不足、体制约束和卫生资源多样化基础上的适应性策略。这一方面促进了服务网络的建立,另一方面政府被迫让渡主导权给举办主体,社区卫生服务机构缺乏自主管理,监管碎片化、监管弱化,最终社区卫生发展出现偏差。结论:多元举办主体格局的问题实质是治理权划分的问题。解决发展偏差、收回政府主导权的方法应是强化服务监管,放弃对机构的人、财、物等具体事务的管理,同时调整价格、医保等财务相关政策,使社区卫生服务机构具有独立经营能力。     

北京市农村基层卫生人员健康管理实施现状分析

目的了解北京市农村基层卫生人员健康管理的现状,为该地区健康管理服务质量提高提供参考。方法2012年,采用多阶段随机抽样方法选取北京市大兴、房山、密云、平谷郊区县部分乡镇医疗机构,以该机构所属的卫生人员为调查对象,了解其为农民开展健康管理情况,并对不同地区间的服务现状进行描述和比较。描述采用频数和率等统计学指标,地区间比较采用X。检验。结果调查对象参与健康体检工作的比例为66．3％（321／484）,参与精神病患者随访工作仅为19．1％（92／481）;健康管理重点管理人群集中在慢病患者和老年人,提供比例分别为44．7％（214／479）和38．0％（182／479）;对农村居民提供健康体检、健康教育及慢病随访管理的地点主要在乡镇卫生院,参与比例分别为62．1％（298／480）、52．4％（251／479）和42．8％（206／481）;在提供健康管理过程中与全科医师合作比例最高,为66．1％（292／442）,而与行政人员合作比例最低,仅为10．6％（47／443）;在提供健康管理过程中,与社区管理机构的合作关系最为密切,为41．4％（201／463）,而其与宣传部门合作的比例仅为10．6％（49／464）。上述活动地区分布间差异有统计学意义,包括开展健康体检、常见慢性病随访管理等活动,健康管理活动覆盖青少年、老年人、儿童以及慢性病患者情况,在乡镇卫生院和村卫生室开展健康体检、健康教育和慢性病随访情况,健康管理活动与全科医师等人员合作情况。结论北京市农村健康管理服务开展情况距离国家公共卫生均等化服务要求尚有差距,且存在地区差别。建议加大政府财政支持力度,加强健康管理人员培训,增加乡镇卫生院中全科医生配置比例,建立绩效考核机制,提升农村基层卫生人员工作积极性,提高健康管理服务质量。