What role for state health care in Asian transition economies?

The main findings of a study of the impact of changes to communism on health care in Asian transition economies are summarized. © 1997 John Wiley & Sons, Ltd.     

Preventive health care in six countries: models for reform?

International systems are frequently offered as models for health care reform. This study, focusing on preventive services for children and pregnant women in six industrialized countries, finds that a broad range of preventive services can be provided through health care systems with divergent financing and cost containment, utilizing multiple entry points into the health care system, and employing targeted programs for high-risk patients. Despite variability in form and financing, health outcomes are not compromised, suggesting that health care reformers in this country need not be restricted to any single model to strengthen preventive health care for children and pregnant women.     

What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?

This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households. There is growing evidence of households being pushed into poverty or forced into deeper poverty when faced with substantial medical expenses, particularly when combined with a loss of household income due to ill-health. Health sector reforms in LMICs since the late 1980s have particularly focused on promoting user fees for public sector health services and increasing the role of the private for-profit sector in health care provision. This has increasingly placed the burden of paying for health care on individuals experiencing poor health. This trend seems to continue even though some countries and international organisations are considering a shift away from their previous pro-user fee agenda. Research into alternative health care financing strategies and related mechanisms for coping with the direct and indirect costs of illness is urgently required to inform the development of appropriate social policies to improve access to essential health services and break the vicious cycle between illness and poverty.     

A role for conjoint analysis in technology assessment in health care?

The aim of this paper is to demonstrate the use of conjoint analysis (CA) in health services research. Conjoint analysis is first explained, with emphasis on the history of the technique, followed by an explanation of how to carry out such a study and how the results from such a study can be used. The technique is demonstrated with reference to a study that looks at the benefits of in vitro fertilization. It is shown how CA can be used to estimate the relative importance of attributes, the trade-offs individuals make between these attributes, willingness to pay if cost is included as an attribute, and utility or benefit scores for different ways of providing a service. The paper then considers the potential advantages of CA over other, more commonly used benefit assessment instruments. Finally, there is discussion of the issues raised in the design and analysis of CA studies. It is concluded that these issues must be addressed before the technique becomes an established instrument for technology assessment.     

What can global health institutions do to help strengthen health systems in low income countries?

Weaknesses in health systems contribute to a failure to improve health outcomes in developing countries, despite increased official development assistance. Changes in the demands on health systems, as well as their scope to respond, mean that the situation is likely to become more problematic in the future. Diverse global initiatives seek to strengthen health systems, but progress will require better coordination between them, use of strategies based on the best available evidence obtained especially from evaluation of large scale programs, and improved global aid architecture that supports these processes. This paper sets out the case for global leadership to support health systems investments and help ensure the synergies between vertical and horizontal programs that are essential for effective functioning of health systems. At national level, it is essential to increase capacity to manage and deliver services, situate interventions firmly within national strategies, ensure effective implementation, and co-ordinate external support with local resources. Health systems performance should be monitored, with clear lines of accountability, and reforms should build on evidence of what works in what circumstances.     

Can interventions improve health services from informal private providers in low and middle-income countries?: a comprehensive review of the literature

BACKGROUND There is a growing interest in the role of private health providers in low- and middle-income countries (LMICs). Informal private providers (IPPs) provide a significant portion of health care in many LMICs, but they have not received training in allopathic medicine. Interventions have been developed to take advantage of their potential to expand access to essential health services, although their success is not well measured. This paper addresses this information gap through a review of interventions designed to improve the quality, coverage, or costs of health services provided by IPPs in LMICs. METHODS A search for published literature in the last 15 years for any intervention dealing with IPPs in a LMIC, where at least one outcome was measured, was conducted through electronic databases PubMed and Global Health, as well as Google for grey literature from the Internet. RESULTS A total of 1272 articles were retrieved, of which 70 separate studies met inclusion criteria. The majority (70%) of outcomes measured proximate indicators such as provider knowledge (61% were positive) and behaviour (56% positive). Training IPPs was the most common intervention tested (77% of studies), but the more effective strategies did not involve training alone. Interventions that changed the institutional relationships and contributed to changing the incentives and accountability environment were most successful, and often required combinations of interventions. CONCLUSION Although there are documented interventions among IPPs, there are few good quality studies. Strategies that change the market conditions for IPPs-by changing incentives and accountability-appear more likely to succeed than those that depend on building individual capacities of IPPs. Understanding the effectiveness of these and other strategies will also require more rigorous research designs that assess contextual factors and document outcomes over longer periods.     

Economic evaluation in health care: is there a role for cost-benefit analysis?

This paper is devoted to the contingent valuation (CV) method and its possible area of application in health economics. With the CV method willingness to pay or willingness to accept is measured with survey methods. The CV method has been developed in environmental economics and is now the most commonly used method of measuring environmental benefits. The method has, however, seldom been used in economic evaluations of health care. The development of economic evaluation in the health care area is reviewed, and the existing methods (the human capital approach, cost-effectiveness analysis and cost-utility analysis) are compared with cost-benefit analysis using the CV method. It is shown that existing methods have several weak points, this makes the CV method an appealing alternative and/or complement to existing methods. From the empirical applications of the CV method in economic evaluations of health care it is evident that it is possible to achieve acceptable response rates. The methodological problems encountered when measuring willingness to pay with survey methods are shown to be similar to the problems encountered when measuring utility and quality of life in cost-utility analysis. Further studies with the CV method are necessary to further explore questions concerning the reliability and validity of the method.     

Information and access to health care: is there a role for trust?

In many countries health policy has been guided by a focus on the supply side factors of access to health care, a lot of attention being directed at the availability of services. This paper concentrates on the demand side of access and investigates relational factors that may limit people's subjective choice sets or their freedom to utilise health services, emphasising that relations between service providers and individuals are based on an interchange of information. It develops an argument for health communication strategies based on an interactive exchange of information as a means of improving access and is intended as a conceptual basis for further debate. Trust assumes a key position within this transactional process of information exchange or communicative interaction. Information may enlarge individual choice sets and increase the freedom to use health care; it serves as a stimulus for access. The paper argues that trust plays a role in the utilisation of provided information. Trust emerges as a prerequisite of the effectiveness of information with regard to access. A discussion of the origins of trust shows that, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place. Culturally diverse societies are often low-trust environments. The paper analyses the driving forces of trust and distrust in health care within these societies and delineates barriers for the individual and the community to the transfer of information. Specific characteristics of health communication turn out to be key determinants of access. In conclusion, principles for health policy on equity and information are derived which are rooted in a distinctive notion of democratic societal structure.     

Communication in health care delivery in developing countries: which way out?

Most governments in developing countries have adopted frameworks for health development which stressed community based initiatives and intervention at all levels of the health pyramid (WHO, 1992). But even today, most of the rural communities in these countries are still not developed in terms of available health facilities. What then is/are responsible for these failures? Various authors have come up with various reasons, principal amongst which are inadequate resources, lack of planning, insincerity/non-commitment of the governments, lack of modern information technology, etc. This paper examines some of these factors in relation to how they accentuate or hamper healthcare delivery in developing countries, using African rural communities as a study field. The resultant suggestions are a consortium of varying factors, some of which are economic in nature, policy changes, human resources development, and re-orientation of social and government attitudes towards achieving meaningful results in healthcare delivery, particularly in the rural communities.     

The health professions and the performance of future health systems in low-income countries: Support or obstacle?

This paper discusses the present and future role of the health professions in health services delivery systems in low-income countries. Unlike richer countries, most low-income countries do not have a tradition of labour market regulation and the capacity of the professions themselves to regulate the provision of health services by their members tends to be weak. The paper looks at the impact of professional monopolies on the performance of health services delivery systems, e.g. equity of access, effectiveness of services, efficiency in the use of scarce resources, responsiveness to users' needs, including protection against the financial impact of utilising health services. It identifies issues which policy-makers face in relation to opening the health labour market while guaranteeing the safety and security of services provided by professionals. The suggestion is made that a "social contract", granting privileges of practice in exchange of a commitment to actively maintain and enhance the quality of their services, may be a viable course of action. This would require that the actors in the policy process collaborate in strengthening the capacity of regulatory agencies to perform their role.     

Managing for health: why health care?

Health and health care are increasingly big business. The challenge is to apply our knowledge and skills to meet people's needs, if not their demands as efficiently, effectively and beneficially as possible. Value for money is the slogan. For those who deliver the goods as required, the converse, money for value should equally apply, and not only in a market driven system. This paper offers a very personal view of these issues in the light of recent UK policy developments.