The Israeli health care reform: a study of an evolutionary major change

Like other advanced market economies, Israel has been engaged in a reform of its health care system, more intensely so since 1994. The first two sections describe the key features of the Israeli health care system before the reform, and their strengths and weakness. A State Commission of Inquiry, established by the government in 1988, proposed in its 1990 report two different reform strategies, respectively developed by the majority and the minority in it. The Commission diagnoses, recommendations and strategies are assessed and explained in the next sections. Legislators and policy makers opted for the incremental, evolutionary reform strategy, proposed by the minority in the Commission. The essence of the reform strategy being implemented as from 1995 is presented and examined in the penultimate section. In the concluding part, the Israeli experience with the formulation and implementation of a health care reform is discussed.     

How actors,processes, context and evidence influenced the development of Malawi's Health Sector Strategic Plan II

Health sector strategic plans are health policies outlining health service delivery in low- and middle- income countries, guiding health sectors to meet health needs while maximizing resources. However, little research has explored the formulation of these plans. This study utilized qualitative methods to explore the formulation of Malawi's Health Sector Strategic Plan II, including processes utilized, actors involved, important contextual factors and the use of evidence-based decision-making. Thirteen semi-structured key informant interviews with health policy actors were conducted to explore perceptions and experiences of formulating the policy. Data analysis used an inductive-deductive approach and interpretation of the data was guided by an adapted version of the Walt and Gilson Health Policy Triangle. Our results indicate that HSSP II formulation was complex and inclusive but that the Ministry of Health may have given up ownership of the formulation process to development partners to ensure their continued involvement. Disagreements between actors centered around inclusion of critical services in the Essential Health Package and selection of performance-based financing as purchasing strategy. Resource constraints and the Cashgate Scandal are critical contextual elements influencing the formulation and content of the policy. Evidence-based decision-making contributed to the plan's development despite respondents' divergent opinions regarding evidence availability, quality and the weight that evidence carried. The study raises questions regarding the roles of policy actors during health policy formulation, the inclusivity of health policy processes and their potential influence on government ownership of health policy, as well as the use of evidence in developing health sector strategic plans.     

中国医药卫生体制改革与中国卫生政策研究类型

中国医药卫生体制改革处于总体制度框架设计与改革发展模式选择的关键时刻，改革发展实践迫切需要卫生政策研究。卫生政策研究质量决定卫生改革的成败。卫生政策研究在医药卫生制度框架设计、发展模式选择、体制改革实践、卫生保健体系创新、医院质量管理和构建和谐医患关系等工作中扮演基础性和核心角色，发挥举足轻重的作用。本文简要论述医药卫生体制改革与卫生政策研究关系，介绍中国卫生政策研究的基本类型。     

Hospital management in the context of health sector reform: a planning model in Ethiopia

Through health sector reform in developing countries, Ministries of Health have sought to enhance health care through greater community governance and improved management effectiveness in their public hospitals. In this paper, we present a partnership-mentoring model for enhancing management capacity that has been piloted in Ethiopia and may be useful in other developing countries. The model included needs assessment and baseline evaluation using a hospital management indicator checklist, deployment of 24 Fellows (US and international hospital administrators) for 1 year to work as mentors with hospital management teams in 14 Ethiopian hospitals, continuing didactic and practical training in quality improvement methods for hospital management teams, and 24 management improvement projects to be completed during the year with plans for replication more broadly as appropriate. Surveys of Fellows and Ethiopian managers within the first quarter of onsite activity found high levels of trust in one another's abilities and intent to implement changes. The partnership-mentoring model promotes sustainability and may provide other countries with approaches for improving the quality of hospital care through improved hospital management. Copyright (c) 2007 John Wiley & Sons, Ltd.     

Policy process for health sector reforms: a case study of Punjab Province (Pakistan)

The health sector in the Punjab (Pakistan) faces many problems, and, the government introduced reforms during 1993–2000. This paper explores the policy process for the reforms. A case study method was used and, to assist this, a conceptual framework was developed. Analysis of four initiatives indicated that there were deviations from the government guidelines and that the policy processes used were weak. The progress of different reforms was affected by a variety of factors: the immaturity of the political process and civil society, which together with innate conservatism and resistance to change on the part of the bureaucracy resulted in weak strategic sectoral leadership and a lack of clear purpose underpinning the reforms. It also resulted in weaknesses in preparation of the detail of reforms leading to poor implementation. The study suggests a need for broadening the stakeholders' base, building the capacity of policy‐makers in policy analysis and strengthening the institutional basis of policymaking bodies. Copyright © 2009 John Wiley & Sons, Ltd.     

A tool for enhancing strategic health planning: a modeled use of the International Classification of Functioning,Disability and Health

This article describes use of the International Classification of Functioning, Disability and Health (ICF) as a tool for strategic planning. The ICF is the international classification system for factors that influence health, including Body Structures, Body Functions, Activities and Participation and Environmental Factors. An overview of strategic planning and the ICF are provided. Selected ICF concepts and nomenclature are used to demonstrate its utility in helping develop a classic planning framework, objectives, measures and actions. Some issues and resolutions for applying the ICF are described. Applying the ICF for strategic health planning is an innovative approach that fosters the inclusion of social ecological health determinants and broad populations. If employed from the onset of planning, the ICF can help public health organizations systematically conceptualize, organize and communicate a strategic health plan. This article is a US Government work and is in the public domain in the USA.     

农村卫生改革与发展中的若干问题与对策

该文就中国农村卫生改革与发展中卫生服务的供给规模，服务的效率、对医疗和预防保健的投入、卫生人员的素质、医疗设备、医疗服务费用和合作医疗制度等方面的问题进行了分析，提出了精简机构增强卫生服务功能、控制规模、加强人员培训、提高服务质量、增加对预防保健服务的投入和建立合作医疗可持续发展机制的政策性建议。     

上海十年卫生改革的回顾与研究--上海卫生政策情境分析研究课题概述

该介绍了上海卫生政策情境分析研究课题的概况、主要的研究内容和研究结果。     

Decentralization and human resource management in the health sector: a case study (1996-1998) from Nampula province, Mozambique

Despite political, cultural and geographical diversity, health care reforms implemented in many developing countries share a number of common features regarding management and structural issues. Decentralization of decision-making from the central authority to local and provincial levels is generally regarded in the literature to be an important way of achieving a more equitable distribution of health care and better management practices, aligned with local priorities and needs. However, in the absence of clear guidelines, continuous monitoring and an adequate supply of financial and human resources, decentralization processes are more likely to have a low impact on the process of health care reform and can, to a certain extent, provoke inequalities between regions in the same country. This qualitative study in Nampula province, Mozambique, was conducted to assess the impact of decentralization, through an analysis of the viewpoints of provincial health managers regarding their perceptions of the process, particularly with regard to the management of basic and elementary nurses. Secondary data from Nampula provincial reports and documents from the Mozambican Health Ministry were also reviewed and comparisons made with the experiences of other developing countries.     

The management of health services in Tanzania: a plea for health sector reform

There are essentially four main approaches used in attempts to strengthen the management of health services in developing countries. These are: information system development; management training; use of planning and evaluation methodologies; and, health sector reform. As part of a collaborative research project based in Kisarawe District, Tanzania, we tested the hypothesis that a combination of the first three of these approaches would be sufficient to ensure that decisions and actions were taken to bring about major improvements in the management of health services. It was assumed that the decentralization, which took place as part of the 1982 reorganization of local government responsibilities, had provided managers with sufficient decision-making autonomy to allow them to bring about improvement in health service performance, provided that the other conditions were met. In fact, it was found that despite being presented with clear evidence of serious inefficiencies and inequities in the allocation of health resources, managers were often highly reluctant to decide upon actions which would alleviate the problems in situations where there were potential losers as well as winners, even if the benefits greatly outweighed the costs. This article argues that interventions based solely on training, information systems, or planning and evaluation protocols will make only marginal improvements to health service management, and that changes to the system as a whole are needed in order to provide managers and health professionals with incentives to rectify performance failings. Some ideas for health sector reform, to give managers power and incentives for improving efficiency and quality of care, are put forward. Since it is likely that the systemic problems of the health sector in Tanzania are shared by many other developing countries, the lessons drawn from this study probably have more general applicability.     

Health care reform and equity: promise, pitfalls, and prescriptions

The United States has made little progress during the past decade in addressing health care disparities. Recent health care reforms offer an historic opportunity to create a more equitable health care system. Key elements of health care reform relevant to promoting equity include access, support for primary care, enhanced health information technology, new payment models, a national quality strategy informed by research, and federal requirements for health care disparity monitoring. With effective implementation, improved alignment of resources with patient needs, and most importantly, revitalization of primary care, these reforms could measurably improve equity.     

The insurer-provider relationship in health care: From administration to strategic management: the Dutch case

This article presents an analysis of some changes in insurer-providerrelations in The Netherlands during the last two decades, withspecial emphasis upon insurer-hospital relations. The analysistakes an insurer perspective: insurer-provider relations willbe analysed from the viewpoint of the health insurers. The argumentis that the ongoing changes in insurer-provider relations canbe conceptualized as a transition from administrationto strategicmanagement. Attention is paid to some aspects of strategic managementfor health insurers.     

Health reform in Greece: planning and implementation of a national health system

The health system in Greece has for many years been in a state of continuous crisis. The basic aspects of this crisis involve: a fragmented administrative framework; low level of public expenditure; a significant private sector; inadequate hospitals; skewed manpower; and, a low level of primary care. In 1983, the National Health System (ESY) was established, as an effort to improve the above situation. This article presents the context of the ESY and the situation of the health system prior to and after the establishment of the ESY. The conclusion drawn is that many of the goals of the ESY have not been achieved or only partly achieved, and that a number of the above serious problems still persist.     

Legacies of primary health care in an age of health sector reform: Vietnam's commune clinics in transition

Developing countries that were early, enthusiastic adopters of primary health care often developed an extensive - but eventually dilapidated and under utilized - network of public clinics at the grassroots. As paradigms and investment patterns of health sector reform have shifted, the question of what role these public clinics can meaningfully play, and how best to revitalize them, has become important in a number of countries. This paper evaluates the strategy taken by, and outcomes of, a major attempt in Vietnam to revitalize the grassroots infrastructure of primary health care against the backdrop of the country's economic transition. The project's substantial supply-side investments in infrastructure led to marginal increases in utilization and the quality of preventive health services provided by the centers. But because the project failed to take adequate stock of broader, public sector-wide trends and reforms over the transition, the investments had little impact on the incentives, accountability patterns and capacities of clinic staff and the local authorities. Such institutional factors are heavily implicated, in Vietnam as elsewhere, in the substantial and often increasing disparities in service access and quality that continue to afflict transitional health sectors.     

The challenge of measuring quality of care at health centre level in Africa: the example of Tsholotsho health district in Matabeleland North, Zimbabwe

This study is on the evaluation of quality of health care within first line health services in rural Zimbabwe. It took place between 2001 and 2002, and consisted of a cross-sectional survey designed to compare the quality of health care on offer at a newly created health centre with that provided by the district hospital's outpatient department. The hypothesis to be tested was that the health centre offered better quality of care. A comprehensive quality of care evaluation framework was designed. The concept of patient enablement was incorporated into the study's assessment of health care delivery outcomes. The results did not provide conclusive evidence that the care offered at the health centre was better than the care on offer at the hospital OPD. The reasons for these unexpected findings are discussed in depth. They are related to the limited understanding amongst local health workers of the organisational changes introduced by the District Health Executive (DHE), together with a (European) cultural bias in the quality of care model under test. An important lesson of this study is that the notion of enablement, notwithstanding the need to put into context the tools used to measure it, was considered by the DHE as relevant in the organisation and evaluation of health care.     

Dilemmas and paradoxes in providing and changing antenatal care: a study of nurses and midwives in rural Zimbabwe

This paper describes the experiences of caregivers in a rural district in Zimbabwe, in caring for pregnant women within a context of changing antenatal care routines. Data were generated using individual interviews with 18 nurses and midwives. The caregivers experienced their working situation as stressful and frustrating due to high staff turnover, inconsistent policies, parallel programmes and limited resources, including time. They also faced difficulties when implementing some of the proposed changes. Furthermore, the caregivers had to deal with the pressure and resistance from the pregnant women, whose reasoning and rationale for using care appeared different from those of the health professionals. In light of the above, we stress the necessity for reflecting on and including the experiences and perspectives of caregivers and the users of care, as well as their contexts and realities, when implementing change.     

Actor management in the development of health financing reform: health insurance in South Africa, 1994-1999

Health reform is inherently political. Sound technical analysis is never enough to guarantee the adoption of policy. Financing reforms aimed at promoting equity are especially likely to challenge vested interests and produce opposition. This article reviews the Health Insurance policy development in South Africa between 1994 and 1999. Despite more than 10 years of debate, analysis and design, no set of social health insurance (SHI) proposals had, by 1999, secured adequate support to become the basis for an implementation plan. In contrast, proposals to re-regulate the health insurance industry were speedily developed and implemented at the end of this period. The processes of actor engagement and management, set against policy goals and design details, were central to this experience. Adopting a grounded approach to analysis of primary interview data and a range of documentary material, this paper explores the dynamics between reform drivers engaged in directing policy change and a range of other actors. It describes the processes by which actors were drawn into health insurance policy development, the details of their engagement with each other, and it identifies where deliberate strategies of actor management were attempted and the results for the reform process. The primary drivers of this process were the Minister of Health and the unit responsible for health financing and economics in the national Department of Health Directorate of Health Financing and Economics, with support from members of the South African academic community. These actors worked within and through a series of four ad hoc policy advisory committees which were the main fora for health insurance policy development and the regulation of private health insurance. The different experiences in each committee are reviewed and contrasted through the lens of actor management. Differences between these drivers and opposition from other actors ultimately derailed efforts to establish adequate support for any form of SHI, even as regulatory proposals received sufficient support to be enacted in legislation. Drawing on this South African experience together with a simple analytical framework, the authors highlight five potential strategies by which reform drivers of any policy process could create alliances of support sufficient to overcome potential opposition to proposed policy changes. As little is currently known on how to manage the process of engaging actors in reform processes, these findings provide a foundation for further analysis of this issue.     

The role of public health services in prevention

Huge population migration, increasing unemployment and poverty and unhealthy lifestyles (stress, smoking, alcohol consumption, etc), among the population in Serbia, are some of the consequences of the political and economic instability in the Balkan region over the last decade (especially in countries of the former Yugoslavia). Data available reveal that, in Serbia, chronic noncommunicable diseases are the dominant cause of death. The National Burden of Disease and Injury Study, done in 2003, showed that cardiovascular diseases, cancers and injuries are responsible for 80% of the total mortality burden in both males and females. The health-care system of Serbia is excessively centralized. The public health services are based on the traditional hygiene and clinical approach and are predominantly organized through a network of Institutes of Public Health which puts insufficient emphasis on analytical and planning tasks and on health promotion (including the prevention of chronic noncommunicable diseases), and too much emphasis on routine reporting and on activities of a technical and laboratory nature in the field of communicable diseases. Today, with the aid of the EU, UNICEF, the World Bank and NGOs, the Ministry of Health is in the process of expanding the capacities and skills of the public health workforce in order to achieve the New Public Health. Although progress has been made on several important fronts in achieving the transition to the New Public Health, this does not yet extend to the wider community. Policy documents and legislative instruments have been drafted to guide the reorganization and reorientation of the public health services, especially the network of Institutes of Public Health, and the creation of the Centre School of Public Health has secured the future of professional public health training. The authors argue that the reform of the health sector should be placed within the context of the overall reform of public administration in the country. In this respect, much of the journey still lies ahead, but experience within public health can be used to stimulate, motivate and encourage professionals throughout the civil service to grasp the opportunities for positive change with both hands.