Private sector approach to health care reform. Interview by Thomas G. Goodwin

The Healthcare Leadership Council (HLC) was formed in 1990 by 50 CEOs of hospitals, hospital systems, pharmaceutical companies, medical device manufacturers, Insurers and medical professionals. HLC is a coalition to develop the necessary consensus to realistically influence health care reforms. HLC urges that the "U.S. public policy goal should be to seek the best mechanism for balancing quality, access and affordability." As for access for the poor, the HLC would standardize eligibility for Medicaid at the federal poverty level, establishing a minimum basic benefit and payment plan with funding to come from specific taxes. For the employed uncovered, HLC would extend the exemption from state mandates to small employers; enact appropriate market reforms and provide income-related subsidies for those near the poverty line and for small employers; encourage employer-provided coverage for all employees on a voluntary basis.... HLC also backs state subsidized uninsurable risk pools for people whose conditions would make premiums too expensive. As for affordability of health care, HLC says consumers should become involved in cost-effective health care plans, appropriate employee cost sharing, lifestyle incentives/penalties, etc. Also, legislation should be overridden that inhibits innovation, creativity (state-mandated benefits, restrictions on selective contracting, CON requirements...), and medical malpractice tort reform measures also should be enacted. What follows is an in-depth interview with HLC Chairman G. Robert O'Brien, president of CIGNA Employee Benefits Companies.     

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.     

Chile's health sector reform: lessons from four reform periods

This paper applies an interdisciplinary approach to analyze the process of health reform in four significant periods in Chilean history: (1) the consolidation of state responsibility for public health in the 1920s, (2) the creation of the state-run National Health Service in the 1950s, (3) the decentralization of primary care and privatization of health insurance in the 1980s, and (4) the strengthening of the mixed public-private market in the 1990s. Building on the authors' separate disciplines, the paper examines the epidemiological, political and economic contexts of these reforms to test simple hypotheses about how these factors shape reform adoption and implementation. The analysis underlines: (1) the importance of epidemiological data as an impetus to public policy; (2) the inhibiting role of economic recession in adoption and implementation of reforms: and (3) the importance of the congruence of reforms with underlying political ideology in civil society. The paper also tests several hypotheses about the reform processes themselves, exploring the role of antecedents, interest groups, and consensus-building in the policy process. It found that incremental processes building on antecedent trends characterize most reform efforts. However, interest group politics and consensus building were found to be complex processes that are not easily captured by the simple hypotheses that were tested. The interdisciplinary approach is found to be a promising form of analysis and suggests further theoretical and empirical issues to be explored.     

A more flexible approach to health reform

The United States spends $817 billion on health care and yet has tremendous gaps in coverage. The system must be reformed without spending increasingly huge sums of money on health care. By combining national spending limits apportioned among the states and state-devised all-payer cost containment, the U.S. can afford to expand coverage to the uninsured without a stratospheric increase in spending.     

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.     

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。     

The interface between health sector reform and human resources in health

The relationship between health sector reform and the human resources issues raised in that process has been highlighted in several studies. These studies have focused on how the new processes have modified the ways in which health workers interact with their workplace, but few of them have paid enough attention to the ways in which the workers have influenced the reforms.     

The provision of animal health care to smallholders in Africa: an analytical approach

Many of the problems associated with the delivery of quality veterinary services to smallholders in Africa are attributed to the complexity of the provision of animal health care (AHC) in sub-Saharan Africa. In this region, a holistic and analytical approach is needed to determine area-specific requirements for sustainable, and thus quality, AHC. This study examines three components of the animal health care system in sub-Saharan Africa, namely, the structure, the process and the outcomes. It focuses particularly on the factors that contribute to the quality of the structure and the process. For this purpose, two measures of quality are used, i.e. availability (in relation to the structure) and acceptability (in relation to the process). The authors identify factors that affect the availability and acceptability of AHC and suggest ways in which they, and hence the quality of AHC provided to smallholders in Africa, can be improved.     

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.     

A case study of health sector reform in Kosovo

The impact of conflict on population health and health infrastructure has been well documented; however the efforts of the international community to rebuild health systems in post-conflict periods have not been systematically examined. Based on a review of relevant literature, this paper develops a framework for analyzing health reform in post-conflict settings, and applies this framework to the case study of health system reform in post-conflict Kosovo. The paper examines two questions: first, the selection of health reform measures; and second, the outcome of the reform process. It measures the success of reforms by the extent to which reform achieved its objectives. Through an examination of primary documents and interviews with key stakeholders, the paper demonstrates that the external nature of the reform process, the compressed time period for reform, and weak state capacity undermined the ability of the success of the reform program.     

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.     

Toward a more unified approach to community-based mental health services

Conclusion Mental health administrators are always facing challenges and turning them into opportunities; this article has introduced an additional and possibly more complex opportunity. With an internal environment that deals with reduced resources and consumer activism, the manager may temporarily lose sight of the changing, shifting external scene. The manager should access the local scene and make it work for the benefit of the people we serve and the organizations we help direct.     

The implications of health sector reform for human resources development

The authors argue that "health for all" is not achievable in most countries without health sector reform that incorporates a process of coordinated health and human resources development. They examine the situation in countries in the Eastern Mediterranean Region of the World Health Organization. Though advances have been made, further progress is inhibited by the limited adaptation of traditional health service structures and processes in many of these countries. National reform strategies are needed. These require the active participation of health professional associations and academic training institutions as well as health service managers. The paper indicates some of the initiatives required and suggests that the starting point for many countries should be a rigorous appraisal of the current state of human resources development in health.