The impacts of decentralization on health care seeking behaviors in Uganda

This paper examines the impacts of a public sector decentralization program on health care seeking behaviors in Uganda in the 1990s. Shifting priorities by local governments in Uganda's decentralized health system away from provision of primary health care, in particular the provision of public goods or goods with substantial consumption externalities, and toward provision of private health goods such as curative care are linked to shifts in individual-level care utilization behaviors. This analysis finds that, while the country has been undergoing a multitude of changes in recent years, decentralization appears to have led to increases in the use of curative services with largely private benefits, perhaps at the expense of the use of primary health care services and services with consumption externalities. A longer period of analysis is required to determine the persistence of these effects.     

Public health expenditure and spatial interactions in a decentralized national health system

One of the limitations of cross-country health expenditure analysis refers to the fact that the financing, the internal organization and political restraints of health care decision-making are country-specific and heterogeneous. Yet, a way through is to examine the influence of such effects in those countries that have undertaken decentralization processes. In such a setting, it is possible to examine potential expenditure spillovers across the geography of a country as well as the influence of the political ideology of regional incumbents and institutional factors on public health expenditure. This paper examines the determinants of public health expenditure within Spanish region-states (Autonomous Communities, ACs), most of them subject to similar financing structures although exhibiting significant heterogeneity as a result of the increasing decentralization, region-specific political factors along with different use of health care inputs, economic dimension and spatial interactions.     

Federalist flirtations: the politics and execution of health services decentralization for the uninsured population in Mexico, 1985-1995

Around the world health services delivery systems are undergoing decentralization, responding to pressure to increase equity, efficiency, participation, intersectoral collaboration and accountability. This study examines the Mexican health decentralization efforts of the past decade to discern the motivations for the reform, the context for its implementation, the politics of its downfall, and the reform's impact at subnational levels of government. Sparked by economic crisis and pressure from international creditors for fiscal reform; demands for greater democracy, equity, and quality; and technocratic impulses to rationalize health services delivery, the decentralization reform could not overcome the authoritarian centralism of the federal government and its corporatist clients. In the end, even in the most technically capable states, the reform was unable to overcome political obstacles to decentralizing fiscal power, redistributing resources in an equitable fashion, and eliminating the inefficiencies of separate but unequal health systems for social security recipients and the uninsured population.     

Continuous quality improvement in public health in Ghana: CQI as a model for primary health care management and delivery

This article describes the context and examines factors influencing the quality of primary health care delivery and management in Ghana, West Africa. It describes the potential of continuous quality improvement as a management philosophy and tool to improve the quality of primary health care delivery and management in Ghana. It compares the Ghanaian context in which the use of continuous quality improvement in health care is new and untried with the developed country context (mainly the U.S.), where continuous quality improvement has a relatively long history of use in health care and is a requirement for the accreditation of health institutions. Finally, the article discusses the steps that have to be taken to translate continuous quality improvement from a theoretical management concept to improve quality of care to an actual managerial intervention in Ghana. In conclusion, continuous quality improvement is shown to be a potential viable approach to improving quality of care in the Ghanaian context and merits further investigation.     

Neighbourhood rural medicine: an experience of rural doctors in Mali

The main constraint to improving access to health services of quality in rural areas is to attract qualified health personnel in these areas. A fifteen years experience in rural health in Mali has shown that it is possible to develop community medicine practices in an African context that do integrate individual care and public health activities. The policy of decentralization of health services encouraged local communities and municipalities to recruit rural doctors themselves. An initiative of rural doctors materialized with this event as they founded a national association and adhere to the principles of a Charter to provide quality health care at an affordable cost. A mechanism of quality improvement was established with the participation of several partners: a professional association, a funding non-governmental organization, and groups of academic staff and health managers. This paper describes the evolution of the rural doctors' experience, its philosophy, conditions that made it successful, constraints it had to overcome and the attitude of partners. It highlights the potential of health care personnel in Africa to provide primary health care well beyond traditional programs on prevalent diseases and to respond to both urgent individual needs and pressing public health requirements.     

Crossing the public-private sector divide with reproductive health in Cambodia: out-patient services in a local NGO and the national MCH clinic

Set within the context of recent literature on the private-public divide in the health sector of developing countries generally and Asia specifically, this study considers the major government and the major indigenous non-government clinics offering out-patient reproductive health services in Phnom Penh, Cambodia. Reproductive health is of critical importance in Cambodia, which has one of the highest levels of unmet need for family planning in the developing world and suffers from what is arguably the most severe STD and HIV/AIDS problem in Asia. The study is unusual in that it examines and compares aspects of service delivery and pricing along with the socio-economic profile and health-seeking behaviour of clients self-selecting services in the two settings. The socio-economic status of clients was much higher than the norm in Cambodia but did not differ significantly between the two clinics. A few service indicators suggested that the quality of care was better in the NGO clinic. Underlying variables--such as the broader mandate of the public sector institution and the significant discrepancy between public and private sector salaries--offer an obvious explanation for these differences. The Ministry of Health in Cambodia has been developing policies related to the NGO sector, which has expanded rapidly in Cambodia during the 1990s, and it is struggling to increase staff remuneration within the public sector.     

Role of GIS in Social Sector Planning: Can Developing Countries Benefit from the Examples of Primary Health Care (PHC) Planning in Britain?

Social sector planning requires rational approaches where community needs are identified by referring to relative deprivation among localities and resources are allocated to address inequalities. Geographical information system (GIS) has been widely argued and used as a base for rational planning for equal resource allocation in social sectors around the globe. Devolution of primary health care is global strategy that needs pains taking efforts to implement it. GIS is one of the most important tools used around the world in decentralization process of primary health care. This paper examines the scope of GIS in social sector planning by concentration on primary health care delivery system in Pakistan. The work is based on example of the UK’s decentralization process and further evidence from US. This paper argues that to achieve benefits of well informed decision making to meet the communities’ needs GIS is an essential tool to support social sector planning and can be used without any difficulty in any environment. There is increasing trend in the use of Health Management Information System (HMIS) in Pakistan with ample internet connectivity which provides well established infrastructure in Pakistan to implement GIS for health care, however there is need for change in attitude towards empowering localities especially with reference to decentralization of decision making. This paper provides GIS as a tool for primary health care planning in Pakistan as a starting point in defining localities and preparing locality profiles for need identification that could help developing countries in implementing the change.     

The organization of regional and integrated healthcare delivery systems: challenges facing Brazil's Unified Health System

This article examines the causes of the segmentation/fragmentation in the healthcare process and the benefits of the constitution of networks set up to rationalize expenditures, optimize resources and ensure care tailored to the needs of the users. Its main purpose is to analyze the current challenges facing Brazil's Unified Health System, in order to promote improved integration between services. Among the challenges, those related to the insufficiency of resources due to low public funding, the training and education processes and their effects on the availability of health professionals to work in the public health system and the difficulties in the decentralization of health services and actions in the context of the Brazilian Federation Pact should be stressed. The paper concludes that, besides the efforts to tackle these challenges, the organization of regionalized networks integrated with the Unified Health System also depends on the improvement of intergovernmental management in the health regions to bolster the agreement on responsibilities among the government areas and the qualification of primary healthcare to coordinate care and ensure its continuity at other levels of the system.     

Cost containment, solidarity and cautious experimentation: Swedish dilemmas

This paper uses secondary data analysis and a literature review to explore a "Swedish Dilemma": Can Sweden continue to provide a high level of comprehensive health services for all regardless of ability to pay--a policy emphasizing "solidarity"--or must it decide to impose increasing constraints on health services spending and service delivery--a policy emphasizing "cost containment?" It examines recent policies and longer term trends including: changes in health personnel and facilities; integration of health and social services for older persons; introduction of competition among providers; cost sharing for patients; dismantling of dental insurance; decentralization of government responsibility; priority settings for treatment; and encouragement of the private sector. It is apparent that the Swedes have had considerable success in attaining cost containment--not primarily through "market mechanisms" but through government budget controls and service reduction. Further, it appears that equal access to care, or solidarity, may be adversely affected by some of the system changes.     

To decentralize or not to decentralize, is that the question? Nicaraguan health policy under structural adjustment in the 1990s.

Since 1990, health services decentralization in Nicaragua has been accompanied by structural adjustment, resulting in reduced equity and accountability. Sandinista efforts in the 1980s to extend access to primary care and reduce class and regional disparities in the delivery of health services were accompanied by modest attempts to increase local-level accountability and responsiveness. The escalation of war in the late 1980s transformed this effort into greater de facto decentralization. Over the past decade, Nicaragua has used decentralization policy to restructure the health system through health spending cuts and the favoring of curative over preventive services; privatization and the promotion of user fees; and confusion of lines of accountability. The authors analyze the 1990s' health policies in Nicaragua, paying particular attention to the blending of decentralization policy with the fiscal and administrative reforms advanced by the International Monetary Fund, World Bank, and other international agencies. They conclude that analyzing decentralization as a sector-specific reform that can be ameliorated through technocratic modifications is insufficient. A full understanding of the problems and possibilities of decentralization requires an analysis of the political and economic context that conditions these policies.     

Culturally and linguistically appropriate health care for racial or ethnic minorities: analysis of the US Office of Minority Health's recommended standards

As the demographic make-up of the United States becomes more culturally diverse, there is more emphasis on providing culturally and linguistically appropriate health care to racial or ethnic minorities. This paper examines the recommended standards for culturally and linguistically competent health care delivery released by the Office of Minority Health of the US Department of Health and Human Services in December 2000. This paper presents a discussion of the impact of these standards on health care organizations in terms of structural requirements, process requirements and outcome expectations. Although the role of the public health agency is only implied in the standards, this paper argues that the public health agency must play a pivotal role in the delivery of culturally and linguistically competent health care in the community.     

Trust relations in health care: developing a theoretical framework for the "new" NHS

PURPOSE: This paper seeks to address how and why trust relations in the NHS may be changing and presents a theoretical framework for exploring them in future empirical research. DESIGN/METHODOLOGY/APPROACH: This paper provides a conceptual analysis. It proposes that public and patient trust in health care in the U.K. appears to be shaped by a variety of factors. From a macro perspective, any changes in levels of public trust in health care institutions appear to derive partly from top-down policy initiatives that have altered the way in which health services are organised and partly from broader social and cultural processes. A variety of policy initiatives, including the introduction of clinical governance and the resulting use of performance management to scrutinise and change clinical activity, increasing patient choice and involvement in decision-making regarding their care, are examined for how they have changed the context for trust relations within the NHS. FINDINGS: It is argued that these policy initiatives have produced a new context for trust relations within the NHS, shifting the inter-dependence and distribution of power between patients, clinicians, and mangers and changing their vulnerability to each other and to health care institutions. The paper presents a theoretical framework based on current policy discourses which illustrates how new forms of trust relations may be emerging in this new context of health care delivery, reflecting a change in motivations for trust from affect based to cognition based trust as patients, clinicians and managers become more active partners in trust relations. The framework suggests that trust relations in all three types of relationship in the "new" modernised NHS might, in general, be particularly characterised by an emphasis on communication, providing information and the use of "evidence" to support decisions in a reciprocal, negotiated alliance. ORIGINALITY/VALUE: The paper examines the drivers for change in trust in health care relations in the U.K. and develops a theoretical framework for the emergence of new trust relations that can be subsequently explored through empirical research.     

Are we getting what we pay for?

The British NHS delivers health care free at the point of access to whomever needs it. It is often claimed to be the envy of the world. But does it deliver health? Or could the resource put into the health service be better spent elsewhere? In this article, we discuss the determinants of health in the United Kingdom in the past, the rise of public health and the impact medical technology has had on health. We discuss resource distribution in health care, and apply the principles of health economics to the wider context of the delivery of health, rather than health care. With a background of rising demand for health care and rationing of resources in the UK, combined with inequalities in life expectancy related to position in society, we conclude that wealth redistribution, environmental regulation, improved nutrition and better education must come first in the priorities for achieving a healthy population.     

Decentralization and health care in the former Yugoslav Republic of Macedonia

Since its independence in 1991, the Republic of Macedonia became a highly centralized state, with most relevant decisions taken at the central level in Skopje, resembling the highly centralized system, which once characterized Former Yugoslavia. As agreed in the Framework Agreement, which ended six months of internal conflict, the Macedonian Government will decentralize public services delivery, including social protection, health, education, and infrastructure over the course of the next few years. Within health care, it is argued that by placing policy-making authority and operating control closer to the client, decentralization will reduce some of the inequities in service provision and inefficiencies present within the current centrally controlled system. In principle, local voters will have more information on the price and quality of services, thereby increasing competition in the sector and strengthening the private sector. The emphasis on market incentives resulting in greater efficiency and better management of health care institutions is viewed as one of the benefits of privatization. Critics of decentralization and the subsequent privatization of public services fear it may result in an erosion of quality and consistency across regions, leaving some regions, cities, villages and potentially vulnerable groups worse off than others. The paper argues that if the institutional weaknesses in Macedonia have not been addressed, decentralisation could result in further excluding the rural population from health care provision. Similarly, the need for a clear delineation of responsibilities and functions among different levels and institutions is outlined.     

Canada Deserves a National Health System

A defining — some would say peculiar — feature about Canada and Canadians is the strong position that we give social programs within our national identity. FORUM presents an essay by Dr. Thomas Noseworthy based on an address to the annual meeting of the Association of Canadian Medical Colleges in April 1996. In it, Dr. Noseworthy calls for a national health system. He sees the federal government retaining an important role in preserving medicare and, in fact, strengthening its powers in maintaining national consistency and standards. Dr. Noseworthy's views are contrary to the governmental decentralization and devolution of powers occurring across the country. In a “point/counterpoint” exchange on this issue, we have invited commentaries from three experts. Raisa Deber leads off by noting that while a national health system may be desirable, constitutional provisions would be an obstacle. Governments, says Deber, have an inherent conflict of interest between their responsibility for maintaining the health care system and their desire to shift costs. Michael Rachlis reminds us that medicare fulfills important economic as well as social objectives. It helps to support Canada's business competitiveness among other nations. The problem, says Rachlis, is that public financing of health care does not ensure an efficient delivery system. Michael Walker offers some reality orientation. He observes that Canada's health care system is based upon ten public insurance schemes with widely different attributes. While he supports a minimum standard of health care across the country, citizens should be able to purchase private medical insurance and have access to a parallel private health care delivery system. Ultimately, this debate is about who should control social programs: the provinces or the federal government?We'll let you, the readers, decide. — RRS     

Decentralization and central and regional coordination of health services: the case of Switzerland

As part of reforms in the health care delivery sector, decentralization is currently promoted in many countries as a means to improve performance and outcomes of national health care systems. Switzerland is an example of a country with a long-standing tradition of decentralized organization for many purposes, including health care delivery. Apart from the few aspects where the responsibility is at the federal level, it is the task of the 26 cantons to organize the provision of health services for the population of around 7 million people. This permits the system to be responsive to local priorities and interest as well as to new developments in medical and public health know-how. However, the increasing and complex difficulties of most health care delivery systems raise questions about the need for mechanisms for coordination at federal level, as well as about the equity and the effectiveness of the decentralized approach. The Swiss case shows that in a strongly decentralized system, health policy and strategy elaboration, as well as coordination mechanisms among the regional components of the system, are very hard to establish. This situation may lead to strong regional inequities in the financing of health care as well as to differences in the distribution of financial, human and material inputs into the health system. The study of the Swiss health system reveals also that, within a decentralized framework, the promotion of cost-effective interventions through a well-balanced approach towards promotional, preventive and curative services, or towards ambulatory and hospital care, is difficult to achieve, as agreements between relatively autonomous regions are difficult to obtain. Therefore, a decentralized system is not necessarily the most equitable and cost-effective way to deliver health care.     

Public expenditure and healthcare utilization: the case of reproductive health care in India

An important reason for public intervention in health in developing countries is to address the issue of accessibility. However, numerous studies have found inconclusive evidence of the effect of public expenditure on health outcomes. Here, I revisit the debate by examining the effect of public expenditure on the use of health services, which is an important link between expenditure and outcomes. I use data from two recent waves of the National Family Health Survey of India to study the role of public expenditure on the use of healthcare services during pregnancy and childbirth. India has high state-level variations in the use of prenatal care and delivery by skilled personnel as well as levels of public expenditure. I exploit the variation in public expenditure to identify its effect on the use of healthcare services, controlling for other confounding factors. The results show a significant effect of public expenditure at the state level on the use of both prenatal and delivery care at the individual level. Also, there is no evidence of public expenditure crowding out private expenditure. Further, there is strong evidence that public expenditure reaches the desired targets. The results highlight the positive implications of raising public expenditure for healthcare use of pregnancy and childbirth services in the Indian context.     

Service accountability and community participation in the context of health sector reforms in Asia: implications for sexual and reproductive health services

This paper examines the concept and practice of community participation in World Bank-supported health sector reforms in Asia, and how far such participation has strengthened accountability with regard to provision of sexual and reproductive health (SRH) services. It argues that the envisaged scope of community participation within a majority of reforms in Asia has been limited to programme management and service delivery, and it is occurring within the boundaries of priorities that are defined through non-participatory processes. Setting up of community health structures, decentralization and community financing are three important strategies used for promoting participation and accountability within reforms. The scant evidence on the impact of these strategies suggests that marginalized groups and sexual and reproductive rights based groups are poorly represented in the forums for participation, and that hierarchies of power between and amongst health personnel and the public play out in these forums. Community financing has not lead to enhanced service accountability. As a result of the above limitations, community participation in health sector reforms has rarely strengthened accountability with respect to provision of comprehensive SRH services. In this context, rights (including sexual and reproductive) based groups and researchers need to engage with design, monitoring and evaluation of health sector reforms, both from inside as participants and outside as pressure groups. Participation contracts enhancing powers of civil society representatives, quotas for participation (for women, other marginalized groups and rights-based organizations), and investment in capacity building of these stakeholders on leadership and sexual reproductive rights and health are pre-requisites if participation is to lead to health and SRH service accountability. Community participation and service accountability hence requires more and not less investment of resources by the state.     

Interpretative views on Hispanics' perinatal problems of low birth weight and prenatal care

From a public health perspective, there is a need to recognize that Hispanics, and in particular Mexican Americans, are a very heterogeneous group. They represent all shades of acculturation, education, income, and citizenship status. As this minority group continues to increase in numbers, pertinent information about their perinatal health problems in the context of their sociocultural characteristics will be required. This review examines critically the recent literature related to low birth weight and prenatal care and suggests alternative ways to address these perinatal health issues. Low birth weight is examined in the context of the problem of intrauterine growth retardation and the potential mechanisms and consequences of different types of growth limitation in utero which have not been studied in this population. The use of prenatal care by Mexican American women and its association with birth weight is examined as an indication of maternal behavior or as a health care intervention. The implications for public health policy are discussed in relation to the identification, interpretation, and evaluation of these perinatal health issues in this minority population.     

The Computer's Potential Role in Health Education

Computer-based technology can provide effective health education — including health information, instruction, and advice — to the general public. This article describes several successful health education programs (some computer based and some not) that have been evaluated in research studies and considers how they supplement health promotion efforts and clinical care. It discusses communication and learning theories that could be applied to future health education projects. It also examines the capabilities and limitations of computer-based media, including their current status and long-term prospects for the delivery of health education.