Health sector reform and the interpretation of policy context.

Health sector reform is on the policy agenda of national governments and international agencies. This paper focuses on the policy process of health sector reform and, more specifically, the policy context. The importance of understanding policy context is emphasised and the elements of policy context are discussed. These are: demographic and epidemiological change; processes of social and economic change; economic and financial policy; politics and the political regime; ideology, public policy and the public sector. The paper then discusses the means for, and methods of, interpretation of the policy context. Particular emphasis is placed on linking policy context with an overall understanding of the policy process, the 'messiness' of policy-making, the interrelationship between the contextual factors, the contextual factors interpreted by policy actors, the use of analytical categories in the policy analysis. The paper concludes on the importance of strengthening policy analysis for effective health sector reform.     

Economic evaluation and health care decision-making

The current role of economic appraisal in health policy and medical practice is outlined, emphasizing the pharmaceutical sector where developments are most marked. General health policy in the Netherlands and pharmaceutical policy in Australia are presented as examples of how economic appraisal may diffuse further as a decision-support tool for health authorities. This can be promoted by studying how policy-makers interpret and use results of economic evaluation studies and how the international transferability of information on the cost-effectiveness profiles of health technologies can be enhanced. To be relevant for health policy, results from economic appraisal studies must be valid and reliable, relevant to the policy context and communicated to the proper decision-makers. A number of recommendations are provided for economic appraisals to meet such requirements.     

Theory and practice of the health systems reforms: the cases of Brazil and Mexico

This study focuses on the role of public health experts in the contemporary health sector reform process. The authors discuss the issue based on the case of Brazil and Mexico, where a group of public health specialists have oriented their participation to influence the conflict concerning health policy reform in the respective countries. One approach has been to develop a new cognitive framework for technical health sector reform projects viewed as policy proposals with technical content. The purpose is to demonstrate how these specialists have managed to influence the national debate over health sector reform when the technical and scientific discussion leaves the academic sphere and reaches the social and political realm. The authors contend that this occurs because such technical and scientific knowledge has been postulated (independently of its intrinsic value) as a political and ideological alternative platform for sustaining a health sector reform proposal which, once transformed into a policy project, has served to aggregate certain political and social forces.     

Political analysis of health reform in the Dominican Republic.

This article examines the major political challenges associated with the adoption of health reform proposals, through the experience of one country, the Dominican Republic. The article briefly presents the problems of the health sector in the Dominican Republic, and the health reform efforts that were initiated in 1995. The PolicyMaker method of applied political analysis is described, and the results of its application in the Dominican Republic are presented, including analysis of the policy content of the health reform, and assessment of five key groups of players (public sector, private sector, unions, political parties, and other non-governmental organizations). The PolicyMaker exercise was conducted in collaboration with the national Office of Technical Coordination (OCT) for health reform, and produced a set of 11 political strategies to promote the health reform effort in the Dominican Republic. These strategies were partially implemented by the OCT, but were insufficient to overcome political obstacles to the reform by late 1997. The conclusion presents six factors that affect the pace and political feasibility of health reform proposals, with examples from the case of the Dominican Republic.     

Bangladesh pharmaceutical policy and politics

An analysis of the politics of Bangladesh pharmaceutical policy in the 1980s shows how significant health policy reforms in developing countries depend on political conditions both inside and outside the country. Bangladesh's drug policy of 1982 illustrates that governments can sometimes change public policy in ways unfavourable to multinational corporations, while the failed health policy reform of 1990 shows that reforms unfavourable to powerful domestic interest groups can be more difficult to achieve, even contributing to a government's downfall. The case provides evidence of basic changes in how the international agenda for health policy is set, especially the growing role of non-governmental organizations in international agencies and national policy debates. Understanding the political patterns of policy reform in Bangladesh has important implications for strategies to affect health policy in developing countries.     

Health sector reform and pharmaceutical policy in Peru

This article analyzes the Shared Pharmaceutical Management Program (PACFARM) and its relationship to pharmaceutical policy in Peru within the scope of health sector reform. Implementation of various programs for essential medicines has involved an on-going effort towards improving the supply of essential drugs to the community. However, the corresponding legal framework includes random and disconnected regulations which hinder the feasibility of a consistent national drug policy. PACFARM is a decentralized system for the provision of essential medicines on a care-level basis, self-supported by revolving funds. While expanded coverage and decreased economic barriers to access to essential medicines provided the basis for a pharmaceutical policy and traits of supply management efficiency kept pace with administrative modernization as part of the reform, other aspects hindered the program's implementation and limited its effects, including deregulation and the very processes of change in the sector. The study's methodology included qualitative and quantitative techniques, prioritizing an analysis of the program's implementation.     

Health policy versus industrial policy in the pharmaceutical sector: the case of Canada

This paper analyses the trade-off between health policy and industrial policy objectives in the field of pharmaceuticals in the Canadian policy setting. In Canada pharmaceutical regulation is organized in two tiers. The federal government is responsible for the conduct of industrial policy for the pharmaceutical sector, including the patenting of new molecular entities, the registration and approval of pharmaceutical products, and the pricing of new products. At the province level, policy-makers are responsible for the reimbursement of the cost of medicines; the methodologies implemented for this purpose may be geared towards meeting the objective of cost containment within tight health budgets rather than addressing industrial policy objectives and, thereby, supporting the pharmaceutical industry. The reimbursement methodologies implemented may also be related with the strength of pharmaceutical presence in each province. The paper provides evidence from two such provinces, British Columbia and Ontario, and contrasts pharmaceutical policy-making at the provincial level with that at the federal level.     

中国卫生改革的形势:问题和挑战

分析了当前中国卫生改革的形势，认为存在的主要问题是卫生系统绩效差，医院市场化、医疗费用增长、需求受抑制，城乡之间在卫生服务覆盖率、可及性和健康结果等方面的差异拉大。总结了三医联动改革的成就和今后改革的方向，认为中国需要做更多的循证政策研究来解决自身的问题并迎接挑战。     

Reforming the health sector in Thailand: the role of policy actors on the policy stage

This paper reports on exploratory research carried out into the processes of policy-making, and in particular health sector reform, in the health sector of Thailand. It is one of a set of studies examining health sector reform processes in a number of countries. Though in the period under study (1970-1996) there had been no single health sector reform package in Thailand, there was interest in a number of quarters in the development of such an initiative. It is clear, however, that despite recognition of the need for reform such a policy was far from being formulated, let alone implemented. The research, based on both documentary analysis and interviews, explores the reasons underpinning the failure of the policy process to respond to such a perceived need. The research findings suggest that the policy formation process in Thailand successfully occurs when there is a critical mass of support from strategic interest groups. The relative power of these interest groups is constantly changing. In particular the last two decades has seen a decline in the power of the bureaucratic élites (military and civilian) and a related rise in the power of the economic élites either directly or through their influence on political parties and government. Other critical groups include the media, NGOs and the professions. Informal policy groups are also significant. A number of implications for policy makers operating under such circumstances are drawn.     

The role of the World Bank in international health: renewed commitment and partnership

During the course of the past ten years, the World Bank has become the single largest external financier of health activities in low and middle income countries and an important voice in national and international debates on health policy. This article highlights the Bank's new strategic direction in the health sector aimed at: improving health, nutrition, and population outcomes of the poor; enhancing the performance of health care systems; and securing sustainable health care financing. Millions of preventable deaths and treatable illnesses, together with health systems that are inefficient, inequitable and ineffective, have motivated expanded Bank support for the health sector in many of its client countries. The new policy directions and system-wide reforms observed in these countries are the result of both demand and supply factors. It is part of a general shift in the Bank's approach to development assistance, which sees systemic reform as a way to improve the impact and sustainability of investments in health. On the demand side, the Bank is trying to adapt to ongoing political, technological, economic, demographic, epidemiological and social pressures. On the supply side, the Bank's growing international experience and substantial financial resources are used to complement the development assistance provided by other organizations and the global effort to improve health and health systems in low and middle income countries.     

世界卫生组织国家药品报告监测指标的制定和评价

1999年以来,世界卫生组织每4年开展一次全球药品部门调查,并计划改进监测指标后于2011年开展全球第4次调查,中国是全球13个试点监测国家之一。此项工作对推动我国基本药物政策的实施、做好改革的定期监测和评价工作具有深远意义,可为科学决策提供循证依据。本文主要介绍了世界卫生组织三个层次水平的监测指标、全球和欧盟国家的监测进展情况以及国家药品报告的具体做法等。     

The World Bank and pharmaceuticals

Within less than a decade the World Bank has become the largest single source of finance (loans) for health in low and middle income countries as well as a major player in the field of pharmaceuticals. Often 20-50% of the recurrent government health budget in developing countries is used to procure drugs. Drugs are among the most salient and cost-effective elements of health care and often a key factor for the success of a health sector reform. However, pharmaceuticals are frequently being used irrationally, mainly due to market imperfections in health care, such as information asymmetries, leading to serious health problems and a heavy financial burden on the health system. Lending priorities set by the World Bank could be used to promote public health sector reform, leading to the rational use of affordable and available drugs of good quality in developing countries. This report provides the first analysis of World Bank activity in the pharmaceutical sector worldwide. The analysis of 77 staff appraisal reports, describing the planning phase of World Bank country projects, shows that 16% of the total World Bank health, nutrition and population budget, or approximately US$1.3 billion, has been committed to loans or credits supporting pharmaceutical activities in the programme countries between 1989-95. Roughly US$1.05 billion has been committed to procurement of drugs and medical equipment. Only 5% of the total pharmaceutical sector lending is committed to software components such as drug policy work and rational use of drugs. No more than 45% of the projects were developed in collaboration with pharmaceutical expertise. The World Bank is recommended to improve its pharmaceutical sector involvement by promoting drug policy research and development including national and international dialogue on pharmaceutical issues to ensure rational use of both drugs and loans. In this, the World Bank has an advantage given its experience from working with both the private and the public sector, its in-house expertise in health economics, and lastly its ability to be listened to by governments through its power.     

Patient mobility within national borders. Drivers and politics of cross-border healthcare agreements in the Spanish decentralized system

Cross-border patient mobility has become a topic of increasing interest for policy-makers and academic scholars. However, the focus on international dynamics hinders the fact that healthcare mobility takes place within national boundaries as well, particularly in countries characterized by decentralized health systems. This paper shifts the focus from the drivers of international patient mobility to the ones of policy-making on patient mobility within national borders, analyzing more than fifty policy arrangements adopted between Spanish Regions in the period 2000-2020. As the findings indicate, geographical/historical, economic and political factors are key to understanding the development of cross-border healthcare agreements, as well as the conflicts that may arise therefrom. Accordingly, these arrangements may become a controversial issue and a key arena for partisan competition, affecting the articulation of effective responses to patient mobility in Spain and, ultimately, patients’ rights.     

Ends and means in public health policy in developing countries

International discussions of public health policy strategies in developing countries have been characterized by strong and conflicting positions. Differences regarding the means of health sector improvement can often be traced to differences about the ends, that is, the goals of the health sector. Three types of health sector goals are reviewed: health status improvement, equity and poverty alleviation, and individual welfare (utility) improvement. The paper argues that all three must be considered in developing health sector reform strategies in all countries. Highly normative policy positions often can be attributed a unidimensional affiliation with one health sector goal and denial of the relevance of the others. The current global interest in using cost-effectiveness analysis to set national health priorities is assessed in light of this eclectic approach. Examples are provided of how a health sector strategy based on cost-effectiveness would give sub-optimal solutions. These examples include situations where a private health care sector exists and provides some degree of substitution for publicly provided services; significantly high income elasticities exist for health care such that higher income beneficiaries may differentially capture public subsidies; and market failures exist in insurance. It is argued that these conditions are virtually universal in developing countries. Thus, rational policy development should explicitly consider multiple goals for the health sector.     

An implementation model for health system reform

Health system reform in post-industrial countries has become a dominant problem facing national governments. This problem is aggravated by the pace of social and technological changes and continued economic pressures. In order to accomplish health system reform, governments must develop new policies to redirect or change the present course of the system. Health system reform involves broad based change in behaviors of consumers, providers and the government itself. The direction of the change requires nothing less than shifting the focus of the system and its actors from its predominant emphasis on sickness treatment (negative-health focus) towards an emphasis on maintaining and promoting the highest possible standards of personal health (positive-health focus). This paper introduces an implementation model for health system reform. The model was developed based on major supports and constraints presently operating in the United States health policy context. Major support is provided by the existence of both theoretical and structural frameworks upon which the policy shift can be built. The structural framework includes four laws and their associated activities which outline national health goals and objectives. A major constraint is the implementation conundrum. Policy is government's primary tool to achieve system reform. However, while government is strong in creating policies, it is extremely weak in implementing the very policies it creates. This implementation conundrum consists of three barriers. These barriers are: a universal fear of change; early stage in development of the technology of social change; and the failure of government to plan for implementation of the very policies it creates. The implementation model for health system reform is introduced to aid policy makers and analysts in overcoming this implementation conundrum. The model recognizes policy as a process of change and provides two stages for use in translating theory and aims of policy into a formula for action. Stage one is used to identify the factors of change necessary in achieving policy reform. Stage two identifies the appropriate process of change to achieve successful outcomes. The model can be used in planning for both national and local levels of health system reform by both public and private sector players in the health arena.     

Analysis of rulings by the Brazilian Ministry of Health and reflections on national health policy management

Ministry of Health rulings and provisions are important policy regulation tools that aim to orient the enforcement of health-related laws passed by the Legislative Branch, under the terms of the 1988 Federal Constitution. Such provisions have played a major role in the health sector, due not only to the number of documents submitted since the late 1990s, but mainly because of this tool's persuasive power in defining health sector policy. The current article aims to foster reflection on both national health policy management in Brazil and the main obstacles to the implementation of health reform operational aspects. The article classified and analyzed Ministry of Health rulings issued from 1990 to 2002. The study highlights the Ministry's centralizing approach and the use of financial and political persuasion tools that subject State and Municipal governments to the system's rules without creating a negotiated and sustained health policy that the country's institutional realities ratify and support.     

The role of health insurance in the growth of the private health sector in Korea

The Korean health care system has been recognized by other countries for its rapid expansion of national health insurance. The government's policy of promoting the private sector, relying on market forces for various allocation decisions, and using the fee-for-service payment system has created a number of challenges for the Korean health system. Among these are rapid growth of health care expenditure, proliferation and duplication of medical technology, and lack of access for low-income groups due to high out-of-pocket payments for services covered by insurance. A number of recommendations are made concerning national health policy, modifying health insurance, and developing political consensus for bringing about health reform.     

Indonesian heath care and the economic crisis: is managed care the needed reform?

The ramifications of the current economic crisis are being felt throughout Asia, but problems are particularly acute in Indonesia; in the midst of high inflation and unemployment the government is considering expanding managed care reform. In this paper, we discuss the impact of the recent economic crisis on the health sector in Indonesia, and analyze the potential for implementing effective reform following the managed care model. The health sector is discussed, highlighting pre-existing problems in the health care supply environment. The determinants of the economic crisis are summarized, and the broad impacts of the crisis to date on the health sector are assessed. Next the prospects for success of current managed-care reform proposals are examined in some detail: viability of expanded managed care reform measures are assessed in light of the continuing crisis and its likely impacts on the consumers and suppliers of health care. Analysis of the potential impact of the continuing crisis focuses on key participants in health care reform: households, the government, and private health care providers. In conclusion the potential viability of managed care appears poor, given the current economic, political, and institutional conditions and likely future impacts, and suggest some alternative reform measures.     

Expanded, but not regulated: ambiguity in home-care policy in Ireland

This article argues that home-care policy in Ireland was ambiguous throughout the first decade of the 21st century: policy-makers expanded home care, but failed to develop policies to govern this expanded provision. As a result, home care became more widely available in the absence of a framework to govern access to services and to regulate care providers. We analysed official policy documents, statistics and policy critiques published between 2000 and 2010 in order to understand this incongruity between the expansion of home-care services and the failure to develop policies to govern access to and quality of services. The key factors that motivated home-care expansion in the Irish case were: (1) problems in the acute hospital sector and the perception of home care as a partial solution to these (political blame avoidance) and (2) significant GDP growth (until 2007) that provided politicians with the means to fund expansion in home-care services (political credit claiming). The key factors that inhibited the development of a policy framework to govern home-care services were: (1) weak governance structures in health services and decision-making at national level based on short-term political gain; (2) Ireland's adherence to the liberal welfare state model and concern about uncontrollable care costs in the face of population ageing; (3) until 2010, paucity of attention to home-care issues in the Irish media and (4) weak provider interest representation. The recent budgetary cutbacks in Ireland bring into sharp relief the political expediency of an unregulated domiciliary care sector and absence of entitlements to home care. We conclude that the forces that drive expanded provision are different from drivers of policy to govern home care and that weakness of governance structures and political advantages of the absence of regulation are the main reasons for the lack of standards and entitlement rules.     

Leapfrog diagnostics: Demonstration of a broad spectrum pathogen identification platform in a resource-limited setting

Background

Purpose of the study was to test a theoretical model to assess and develop policies for the promotion of physical activity among older people as part of an international intervention study.

Methods

248 semi-standardized interviews with policy-makers were conducted in 15 European nations. The questionnaire assessed policy-makers' perceptions of organizational goals, resources, obligations, as well as organizational, political and public opportunities in the area of physical activity promotion among older people. In order to develop policies, workshops with policy-makers were conducted. Workshop outputs and outcomes were assessed for four nations nine months after the workshops.

Results

Policy assessment: Results of the policy assessment were diverse across nations and policy sectors. For example, organizational goals regarding actions for physical activity promotion were perceived as being most favorably by the sports sector. Organizational obligations for the development of such policies were perceived as being most favorably by the health sector. Policy development: The workshops resulted in different outputs: a national intersectoral action plan (United Kingdom), a national alliance (Sweden), an integrated policy (the Netherlands), and a continuing dialogue (Germany).

Conclusions

Theory-driven policy assessment and policy-maker workshops might be an important means of scientific engagement in policy development for health promotion.