Performance-based financing and changing the district health system: experience from Rwanda

Evidence from low-income Asian countries shows that performance-based financing (as a specific form of contracting) can improve health service delivery more successfully than traditional input financing mechanisms. We report a field experience from Rwanda demonstrating that performance-based financing is a feasible strategy in sub-Saharan Africa too. Performance-based financing requires at least one new actor, an independent well equipped fundholder organization in the district health system separating the purchasing, service delivery as well as regulatory roles of local health authorities from the technical role of contract negotiation and fund disbursement. In Rwanda, local community groups, through patient surveys, verified the performance of health facilities and monitored consumer satisfaction. A precondition for the success of performance-based financing is that authorities must respect the autonomous management of health facilities competing for public subsidies. These changes are an opportunity to redistribute roles within the health district in a more transparent and efficient fashion.     

The MESH approach: strengthening public health systems for the MDGs

This article addresses some of the complexities in the interactions both within the public health system and between that and civil society. It examines what needs to be done to improve the capacity of health systems, primarily through building relevant infrastructure (what is called MESH--management, economic, social and human - infrastructure) where this is lacking. This lack is most likely to occur in poorer communities and health districts. The problem of absorption and appropriate use of funds in disadvantaged areas has been highlighted as a critical bottleneck to the achievement of the millennium development goals (MDGs). MESH is defined as infrastructure which is built to improve the capacity of communities and other entities to implement health service programs efficiently. We employ this concept to determine how best to invest in health in poor areas so that they can better use any additional resources they receive. The article reviews some initial explorations of the relevance of MESH building strategies in South Africa. The research shows the usefulness of the MESH approach which requires inter alia a more developmental approach that goes beyond the vertical silos of much influential prioritization literature over the last two decades. In practice it is clear that MESH will vary from location to location which reflects the fact that investing in successful health strategies must take into account the voices of the local people with respect to what they want from their health services.     

Health systems strengthening: a common classification and framework for investment analysis

Significant scale-up of donors' investments in health systems strengthening (HSS), and the increased application of harmonization mechanisms for jointly channelling donor resources in countries, necessitate the development of a common framework for tracking donors' HSS expenditures. Such a framework would make it possible to comparatively analyse donors' contributions to strengthening specific aspects of countries' health systems in multi-donor-supported HSS environments. Four pre-requisite factors are required for developing such a framework: (i) harmonization of conceptual and operational understanding of what constitutes HSS; (ii) development of a common set of criteria to define health expenditures as contributors to HSS; (iii) development of a common HSS classification system; and (iv) harmonization of HSS programmatic and financial data to allow for inter-agency comparative analyses. Building on the analysis of these aspects, the paper proposes a framework for tracking donors' investments in HSS, as a departure point for further discussions aimed at developing a commonly agreed approach. Comparative analysis of financial allocations by the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance for HSS, as an illustrative example of applying the proposed framework in practice, is also presented.     

Overview: Health and the planning of health care systems

Implicit functions of a health care system which are often omitted or improperly emphasized are the study and promotion of individual health. This situation stems from the fact that health care systems are primarily based on the concept of disease, while the attributes of health (positive health) have not been investigated and objectively defined. However, an operational definition of the elusive concept of health appears possible today and is discussed in this paper. If the hypotheses that health can be improved and deterioration due to age can be retarded are accepted, then the consequences of these possibilities must be analyzed in relation to the planning of health care systems and to the planning of national health care programs. Thus, any attempt to describe the natural history of the health process must include the effects of interventions aimed at the promotion of health in the absence of disease. These effects must be defined so that quantitative criteria, which would serve as the basis for predictive medicine, can be established. Quantitative predictive medicine is necessary in order to evaluate the effectiveness of preventive measures. While it is widely recognized that the prevention of disease is one of the major goals of a health care delivery system, the methods presently used to evaluate alternative courses of action are notoriously limited.     

Helping public sector health systems innovate: the strategic approach to strengthening reproductive health policies and programs

Public sector health systems that provide services to poor and marginalized populations in developing countries face great challenges. Change associated with health sector reform and structural adjustment often leaves these already-strained institutions with fewer resources and insufficient capacity to relieve health burdens. The Strategic Approach to Strengthening Reproductive Health Policies and Programs is a methodological innovation developed by the World Health Organization and its partners to help countries identify and prioritize their reproductive health service needs, test appropriate interventions, and scale up successful innovations to a subnational or national level. The participatory, interdisciplinary, and country-owned process can set in motion much-needed change. We describe key features of this approach, provide illustrations from country experiences, and use insights from the diffusion of innovation literature to explain the approach's dissemination and sustainability.     

From Newborn Screening to Population Health Research: Implementation of the Michigan BioTrust for Health

In June 2009, the Michigan Department of Community Health launched the Michigan BioTrust for Health to improve preservation and utility of residual dried blood spots from newborn screening (NBS) for biomedical research while maintaining public support and integrity of NBS. In this article, we chronicle implementation of the BioTrust and document its impact on NBS. Overall, the percentage of new parents who consent to possible future research use of their children''s dried blood spots through the BioTrust has remained consistent with previous public opinion surveys. No significant increase in refusal of NBS has been observed despite increased publicity. There was, however, a slight increase in requests to destroy samples following completion of NBS, indicating readily accessible opt-out information. Given adequate training and cooperation of birthing hospital staff, as well as outreach education for parents and health-care providers, we conclude it is possible to implement a biobanking initiative without adversely impacting NBS.Newborn screening (NBS) for phenylketonuria marked the advent of a vital public health program leading to the identification and treatment of more than 4,691 Michigan newborns with serious disorders since 1965. Recently, state NBS programs have grappled with residual dried blood spot storage and research, but Michigan first began the stepwise process of examining these issues more than two decades ago (Figure 1). In 1987, the Michigan Department of Community Health (MDCH) implemented a policy of storing residual dried blood spots for 21.5 years, after receiving legal advice on appropriate retention periods. In 1999, the Governor''s Commission on Genetic Privacy and Progress recommended that residual dried blood spots be retained indefinitely because of their potential utility in health research.¹ As a result, the Michigan Legislature amended the public health code in 2000 to allow the use of residual dried blood spots during the retention period, as long as human subjects and privacy were protected.² Language directing MDCH to set the retention schedule was included in the law, and the current laboratory policy of indefinite storage was established in 2008.³Open in a separate windowFigure 1Michigan BioTrust for Health timelineMDCH = Michigan Department of Community HealthBRFS = Behavioral Risk Factor SurveyIRB = Institutional Review BoardWhile Michigan''s public health code established the foundation for storage and research use of residual dried blood spots, numerous challenges had to be addressed to ensure adequate community education and public support. Historically, parents were advised of retention practices and potential research use of residual dried blood spots through a paragraph in the Michigan NBS brochure distributed at the time of delivery. Concerns developed about whether parents read the brochure or were truly informed of options. Policy questions also arose on how best to balance individual autonomy and public benefit from dried blood spot research, particularly if demand for use increased. Therefore, MDCH undertook a process to formalize dried blood spot storage and use policies through creation of the Michigan BioTrust for Health (hereafter, BioTrust), drawing heavily from stakeholder input. The original aims of the BioTrust were to improve the preservation and utility of dried blood spots through more optimal storage conditions and to promote their use for biomedical and public health research while maintaining the public support and integrity of Michigan NBS.