Health sector reform and human resources: lessons from the United Kingdom

The objective of the paper is to assess the human resource (HR) dimension of the National Health Service (NHS) reforms in the United Kingdom, and to highlight lessons for the health systems of countries undergoing reform or restructuring. Health sector reform in many countries in the 1980s and 1990s has focused on structural change, cost containment, the introduction of market mechanisms and consumer choice. This focus has inevitably challenged the ways that health professionals and other staff are employed and deployed. The methods used to manage human resources in health care may also in themselves be a major constraint or facilitator in achieving the objectives of health sector reform. The impact on the HR function of the NHS reforms is assessed in the paper by examining three central requirements of the HR function: to maintain effective staffing levels and skill mix; to establish appropriate employee relations policy and procedures; and to be involved in pay determination. The paper concludes that the most significant changes which have occurred as result of the NHS reforms have been in staffing change and organizational culture, and the individual attitudes of NHS management and staff. Attempts to alter methods of conducting employee relations and determining pay and conditions of employment have been less successful. However, an overall approach to HR management, which would have been unthinkable in the pre-reform NHS, is now accepted, albeit grudgingly by some, as the way forward. In general, the changes in the NHS HR function can be characterized as a partially successful attempt to adopt private sector HR management techniques to meet the challenges of public sector reform.     

Health sector reform: making health development sustainable

Health sector reform is underway or under consideration.in countries throughout the world and at all levels of income. This paper presents an overview of key concepts and approaches to health sector reform in developing countries. Reform implies sustained, purposeful, and fundamental changes in the health sector. While it is difficult to define precisely what constitutes a true reform, there is widespread consensus that reform is a process of change involving the what, who, and how of health sector action. Health is increasingly included as an important goal of national development. It can make development more sustainable. The paper outlines some general and specific health sector reform strategies that can contribute to sustainable development for countries at all levels of income, although the strategies will differ in content and emphasis. Health sector reform should be based on an holistic view of the health sector. The paper presents two frameworks to aid in reform design: one highlighting the linkages between different institutional actors in the health sector; the second addressing linkages across different functional areas of reform action. In order to develop and carry out reform, information and analysis is needed. A variety of practical tools now available for this purpose are discussed, encompassing all the different areas of action. While tool development should continue, reform proponents already have much to work with. Given global interest, the importance of health sector reform in development strategies, and significant existing knowledge and experience, country level analysis and action should proceed vigorously.     

The policy analysis of 'values talk': lessons from Canadian health reform

Despite widespread recognition of the importance of values, decision makers and stakeholders in health policy appear to disagree fundamentally over what 'values' essentially are. Hidden dissent about the nature of values can confuse policy deliberations. This study investigates empirically the following two questions: (1) what sorts of entities do Canadian health reformers typically call 'values'? and; (2) how do Canadian health reformers use the idea of values in health reform rhetoric? We conducted a qualitative, interpretive analysis of 36 Canadian health reform documents published during the period 1990-1999. The values raised in Canadian health reform rhetoric vary widely not only in topic (e.g. health states, health services, equity, economic viability, etc.) but also in substance (e.g. physical entities, goals, principles, attitudes, etc.). We review the diversity of concepts underlying 'values talk' in health policy, and discuss implications for policy analysis and future research.     

Good governance and corruption in the health sector: lessons from the Karnataka experience

Strengthening good governance and preventing corruption in health care are universal challenges. The Karnataka Lokayukta (KLA), a public complaints agency in Karnataka state (India), was created in 1986 but played a prominent role controlling systemic corruption only after a change of leadership in 2001 with a new Lokayukta (ombudsman) and Vigilance Director for Health (VDH). This case study of the KLA (2001-06) analysed the:Scope and level of poor governance in the health sector; KLA objectives and its strategy; Factors which affected public health sector governance and the operation of the KLA. We used a participatory and opportunistic evaluation design, examined documents about KLA activities, conducted three site visits, two key informant and 44 semi-structured interviews and used a force field model to analyse the governance findings. The Lokayukta and his VDH were both proactive and economically independent with an extended social network, technical expertise in both jurisdiction and health care, and were widely perceived to be acting for the common good. They mobilized media and the public about governance issues which were affected by factors at the individual, organizational and societal levels. Their investigations revealed systemic corruption within the public health sector at all levels as well as in public/private collaborations and the political and justice systems. However, wider contextual issues limited their effectiveness in intervening. The departure of the Lokayukta, upon completing his term, was due to a lack of continued political support for controlling corruption. Governance in the health sector is affected by positive and negative forces. A key positive factor was the combined social, cultural and symbolic capital of the two leaders which empowered them to challenge corrupt behaviour and promote good governance. Although change was possible, it was precarious and requires continuous political support to be sustained.     

Balancing health and industrial policy objectives in the pharmaceutical sector: lessons from Australia

INTRODUCTION: Policy-makers worldwide struggle to balance health with industrial policy objectives in the pharmaceutical sector. Tensions arise over pricing and reimbursement in particular. What health plans view as necessary to maintain equitable access to medicines, industry views as inimical to R&D and innovation. Australia has grappled with this issue for years, even incorporating the goal of "maintaining a responsible and viable medicines industry" into its National Medicines Policy. METHODS: This case study was conducted via a narrative review that examined Australia's experiences balancing health and industrial policy objectives in the pharmaceutical sector. The review included electronic databases, grey literature and government publications for reports on relevant Australian policy published over the period 1985-2007. RESULTS: While pharmaceutical companies claim that Australia's pricing and reimbursement policies suppress drug prices and reduce profits, national policy audits indicate these claims are misguided. Australia appears to have secured relatively low prices for generics and "me-too drugs" while paying internationally competitive prices for "breakthrough" medicines. Simultaneously, Australia has focused efforts on local pharmaceutical investment through a variety of industry-targeted R&D incentive policies. DISCUSSION: Despite the fact that policy reviews suggest that Australia has achieved balance between health and industrial policy objectives, the country continues to face criticism from industry that its health goals harm innovation and R&D. Recent reforms raise the question whether Australia can sustain the apparent balance.     

Equity, governance and financing after health care reform: lessons from Mexico

To determine, from the perspective of providers, community leaders and users of health services, equity, governance and health financing outcomes of the Mexican health system reform.Cross-sectional study oriented towards the qualitative analysis of financing, governance and equity indicators for the uninsured population. Taking into account feasibility, as well as political and technical criteria, six Mexican states were selected as study populations and a qualitative research was conducted during 2004-2006. Two hundred and forty in-depth interviews were applied, in all selected states, to 60 decision-makers, including medical and administrative personnel; 60 service providers at health centres; 60 representatives of civil organizations, including municipal representatives and, finally, 60 members of health committees and users of services at second and first levels of care units. The analysis of interviews was performed using ATLAS-Ti software. An outcome mapping of health reform was developed. For political actors, Mexican health system reform has not modified dependence on the central level; ignorance about reform strategies and lack of participation in the search for financial resources to finance health systems were evidenced. Also, in all states under study, community leaders and users of services reported the need to improve an effective accountability system at both municipal and state levels. Health strategies for equity, governance and financing do not have adequate mechanisms to promote participation from all social actors. Improving this situation is a very important goal in the Mexican health democratization process, in the context of health care reform. There are relevant positive and negative effects of the reform on equity, governance and financing in health. Special emphasis is placed on the analysis of lessons learned in Mexico and the usefulness of the main strengths and weaknesses, as relevant evidences for other middle-income countries which are designing, implementing and evaluating reform strategies in order to achieve equity in resource allocation, good levels of governance and a greater financial protection in health.     

Health sector reform and public sector health worker motivation: a conceptual framework

Motivation in the work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. Health sector performance is critically dependent on worker motivation, with service quality, efficiency, and equity, all directly mediated by workers' willingness to apply themselves to their tasks. Resource availability and worker competence are essential but not sufficient to ensure desired worker performance. While financial incentives may be important determinants of worker motivation, they alone cannot and have not resolved all worker motivation problems. Worker motivation is a complex process and crosses many disciplinary boundaries, including economics, psychology, organizational development, human resource management, and sociology. This paper discusses the many layers of influences upon health worker motivation: the internal individual-level determinants, determinants that operate at organizational (work context) level, and determinants stemming from interactions with the broader societal culture. Worker motivation will be affected by health sector reforms which potentially affect organizational culture, reporting structures, human resource management, channels of accountability, types of interactions with clients and communities, etc. The conceptual model described in this paper clarifies ways in which worker motivation is influenced and how health sector reform can positively affect worker motivation. Among others, health sector policy makers can better facilitate goal congruence (between workers and the organizations they work for) and improved worker motivation by considering the following in their design and implementation of health sector reforms: addressing multiple channels for worker motivation, recognizing the importance of communication and leadership for reforms, identifying organizational and cultural values that might facilitate or impede implementation of reforms, and understanding that reforms may have differential impacts on various cadres of health workers.     

Data analysis needs for health sector reform

This paper addresses the role of information in health policy reform. It recognizes that reform can be based on data, but that there are other influences on health policy. The steps involved in making policy, including problem identification, comparison of solutions, policy adoption, implementation, and amendment, all require information. When information is unavailable for any of these steps, the policy process sometimes proceeds without it. The policy makers must make difficult choices regarding the potential benefit of comprehensive information to the policy outcome versus the potential drawbacks, in terms of time and cost, of seeking the missing information. Different areas where data are needed within health policy are enumerated, as are sources of health policy data, and examples of strategies are given. Finally, three case studies are presented, highlighting the use of information in policy making. The National Epidemiology Board in Thailand commissioned studies by experts on relevant policy topics. It had a substantial impact on changing policies in the areas of AIDS control, iodine deficiency, essential drugs and vaccination. The attempt at decentralizing health administration to the province level in Papua New Guinea is the second example presented. At the time of the evaluation, this effort had not yet attained its objectives of improving the health of the people, nor had it reduced costs or lessened inequity among regions. If this reform had been tested in a pilot project, its problems may have been discovered at an earlier stage of implementation when they would have been easier to correct. The final case concerns the UNICEF child survival interventions during the 1980s. These interventions were chosen based on cost-effectiveness analysis and were successfully implemented. The use of cost-effectiveness analysis in prioritizing interventions is one example of the way in which information can improve policy and health outcomes.     

Private sector health reform in South Africa

This paper discusses some of the trends, debates and policy proposals in relation to the financing of the private health sector in South Africa. The public and private sectors in South Africa are of equivalent size in terms of overall expenditure, but cover substantially different population sizes. Within this context the government has reached the unavoidable conclusion that the private sector has to play some role in ensuring that equity, access and efficiency objectives are achieved for the health system as a whole. However, the private sector is some way off from taking on this responsibility. Substantial increases in per capita costs over the past 15 years, coupled with a degree of deregulation by the former government, have resulted in increasing instability and volatility. The development of a very competitive medical scheme (health insurance) market reinforced by intermediaries with commercial interests has accelerated trends toward excluding high health risks from cover. The approach taken by the government has been to define a new environment which leaves the market open for extensive competition, but removes from schemes the ability to compete by discriminating against high health risks. The only alternatives left to the private market, policy makers hope, will be to go out of business, or to survive through productivity improvements. © 1998 John Wiley & Sons, Ltd.     

Building institutions for an effective health system: lessons from China's experience with rural health reform

This paper is concerned with the management of health system changes aimed at substantially increasing the access to safe and effective health services. It argues that an effective health sector relies on trust-based relationships between users, providers and funders of health services, and that one of the major challenges governments face is to construct institutional arrangements within which these relationships can be embedded. It presents the case of China, which is implementing an ambitious health reform, drawing on a series of visits to rural counties by the author over a 10-year period. It illustrates how the development of reform strategies has been a response both to the challenges arising from the transition to a market economy and the result of actions by different actors, which have led to the gradual creation of increasingly complex institutions. The overall direction of change has been strongly influenced by the efforts made by the political leadership to manage a transition to a modern economy which provides at least some basic benefits to all. The paper concludes that the key lessons for other countries from China's experience with health system reform are less about the detailed design of specific interventions than about its approach to the management of institution-building in a context of complexity and rapid change.     

Health care reform: lessons from Canada

Although Canadian health care seems to be perennially in crisis, access, quality, and satisfaction in Canada are relatively high, and spending is relatively well controlled. The Canadian model is built on a recognition of the limits of markets in distributing medically necessary care. Current issues in financing and delivering health care in Canada deserve attention. Key dilemmas include intergovernmental disputes between the federal and provincial levels of government and determining how to organize care, what to pay for (comprehensiveness), and what incentive structures to put in place for payment. Lessons for the United States include the importance of universal coverage, the advantages of a single payer, and the fact that systems can be organized on a subnational basis.     

Winning policy change to promote community health workers: lessons from massachusetts in the health reform era

There is a national movement among community health workers (CHWs) to improve compensation, working conditions, and recognition for the workforce through organizing for policy change. As some of the key advocates involved, we describe the development in Massachusetts of an authentic collaboration between strong CHW leaders of a growing statewide CHW association and their public health allies. Collaborators worked toward CHW workforce and public health objectives through alliance building and organizing, legislative advocacy, and education in the context of opportunities afforded by health care reform. This narrative of the path to policy achievements can inform other collaborative efforts attempting to promote a policy agenda for the CHW workforce across the nation.     

After Chile's health reform: increase in coverage and access, decline in hospitalization and death rates

In 2005 the government of Chile passed comprehensive health reform. The law mandated coverage by public and private health insurers for selected medical interventions related to fifty-six priority diseases and conditions. This paper presents previously unpublished evidence on various consequences of the reform. It also presents a first, partial evaluation of the reform's impact on access to care, treatment outcomes, hospitalization rates, and medical leave rates for six chronic diseases. For some of those diseases, such as hypertension, types 1 and 2 diabetes, and depression, we find that the reform was linked to growing access to services and increased coverage. For those diseases and for childhood epilepsy and HIV/AIDS, the hospital case-fatality rate dropped.     

Family planning and sexual health organizations: management lessons for health system reform

Advocates of health system reform are calling for, among other things, decentralized, autonomous managerial and financial control, use of contracting and incentives, and a greater reliance on market mechanisms in the delivery of health services. The family planning and sexual health (FP&SH) sector already has experience of these. In this paper, we set forth three typical means of service provision within the FP&SH sector since the mid-1900s: independent not-for-profit providers, vertical government programmes and social marketing programmes. In each case, we present the context within which the service delivery mechanism evolved, the management techniques that characterize it and the lessons learned in FP&SH that are applicable to the wider debate about improving health sector management. We conclude that the FP&SH sector can provide both positive and negative lessons in the areas of autonomous management, use of incentives to providers and acceptors, balancing of centralization against decentralization, and employing private sector marketing and distribution techniques for delivering health services. This experience has not been adequately acknowledged in the debates about how to improve the quality and quantity of health services for the poor in developing countries. Health sector reform advocates and FP&SH advocates should collaborate within countries and regions to apply these management lessons.     

深化上海卫生改革的政策思考

上海卫生改军面临三方面的深层次问题，一是卫生领域中政府与市场的关系尚未理清，二是多元化办医的环境有待优化，三是公立医院的体制、机制仍不健全，该文针对上述问题，提出了下一步深化上海卫生改革的思路和政策建议。     

Toward an analytical approach to health sector reform

An analytical approach to health sector reform requires definition of the objectives of the health sector. Although a multiplicity of objectives may be appealing, there are compelling analytical reasons for simplicity. It is argued that a health status maximization objective is a widely acceptable choice, which captures most of the important aspects of utility maximization of relevance for health sector reform. Equity can be addressed in the process of aggregating individual outcomes. The widely recognized need for health sector reform in developing countries constitutes, in itself, evidence of the market failures in the health sector. If the market worked, why would we need reform? Given an objective and a justification for reform, analysis should proceed to address measurement questions and intervention strategies. The disability-adjusted life year lost is proposed as a consistent and feasible measure of health. Based on an optimization model of health sector performance in Africa, the paper discusses interventions to improve allocative and technical efficiency. These are broadly characterized as interventions dealing with lack of knowledge and interventions dealing with institutional shortcomings. They lead to different approaches to health sector reform. The paper concludes that we now have a systematic analytical approach to reform, in which tools and methods for addressing information gaps are well developed and need to be more widely applied, while those addressing institutional failures still need further development and application.