Centralized or decentralized? A case study of Norwegian hospital reform

In recent years, decentralization of financial and political power has been perceived as a useful means to improve outcomes of the health care sector of many European countries. Such reforms could be the result of fashionable policy trends, rather than being based on knowledge of "what works". If decentralization is the favored strategy in health care, studies of countries that go against the current trend will be of interest and importance as they provide information about the potential drawbacks of decentralization. In Norway, specialized health care has recently been recentralized. In this paper, we review some of the evidence now available on the economic effects of recentralization. Although recentralization has been associated with improvements in both cost efficiency and technical efficiency this may have been caused by the increasing role of activity-based funding methods used in the allocation of health care resources. However, recentralization was also associated with an increase in the rate of growth of real resources and the proportion of total costs being met by supplementary funding. As a result, recentralization failed to address the issues of cost containment and reductions in budget deficits.     

The cytoskeleton under external fluid mechanical forces: hemodynamic forces acting on the endothelium

The endothelium, a single layer of cells that lines all blood vessels, is the focus of intense interest in biomechanics because it is the principal recipient of hemodynamic shear stress. In arteries, shear stress has been demonstrated to regulate both acute vasoregulation and chronic adaptive vessel remodeling and is strongly implicated in the localization of atherosclerotic lesions. Thus, endothelial biomechanics and the associated mechanotransduction of shear stress are of great importance in vascular physiology and pathology. Here we discuss the important role of the cytoskeleton in a decentralization model of endothelial mechanotransduction. In particular, recent studies of four-dimensional cytoskeletal motion in living cells under external fluid mechanical forces are summarized together with new data on the spatial distribution of cytoskeletal strain. These quantitative studies strongly support the decentralized distribution of luminally imposed forces throughout the endo- thelial cell. © 2002 Biomedical Engineering Society. PAC2002: 8717-d, 8717Aa, 8719Uv     

医院管理局成立的背景与运作

香港当局委托一家咨询公司调查了80年代香港医院服务现状,建议成立一个独立的管理机构(即医院管理局)以改善服务。 尽管分权管理政策已由医院管理局落实,但医院行政总监仍需要向医院管理局行政总监直接汇报。 医院管理局在公立医院开始行使职权后,通过全体员工的不懈努力,为市民提供以为病人服务为中心的优质服务,取得了重大成效。     

社区卫生服务管理体制面临的挑战分析——基于六城区的抽样调查

目的：分析我国社区卫生服务管理体制面临的挑战。方法：运用焦点组访谈和个人深入访谈的方法收集六城区有关社区卫生服务管理体制的资料,并运用归纳总结的方法对定性资料进行分析。结果：区级政府作为举办主体理顺社区卫生服务管理体制存在困难;各级政府的事权与财力不相适应;卫生部门与其他部门的跨部门合作机制有待加强;社管中心成立的必要性与功能定位仍然悬而未决;如何管理社会资本举办的社区卫生机构有待进一步探索;缺乏居民参与管理的有效途径。建议：理顺政府相关部门之间的关系,促进财力与事权相匹配;建立有效的跨部门合作机制;制定和完善鼓励社会资本发展社区卫生的相关政策;进一步探索成立社管中心的可行性与必要性;探索和完善居民参与管理的有效途径。     

The tradeoff between centralized and decentralized health services: Evidence from rural areas in Mexico

This study investigates the effectiveness of centralized and decentralized health care providers in rural Mexico. It compares provider performance since both centralized and decentralized providers co-exist in rural areas of the country. The data are drawn from the 2003 household survey of Oportunidades, a comprehensive study of rural families from seven states in Mexico. The analyses compare out-of-pocket health care expenditures and utilization of preventive care among rural households with access to either centralized or decentralized health care providers. This study benefits from differences in timing of health care decentralization and from a quasi-random distribution of providers. Results show that overall centralized providers perform better. Households served by this organization report less regressive out-of-pocket health care expenditures (32% lower), and observe higher utilization of preventive services (3.6% more). Decentralized providers that were devolved to state governments in the early 1980s observe a slightly better performance than providers that were decentralized in the mid-1990s. These findings are robust to decentralization timing, heterogeneity in per capita government health expenditures, state and health infrastructure effects, and other confounders.     

'Tipping the balance towards primary health care': managing change at the local level

This article addresses the problem of managing change at the local level, by focusing on the experience of the research and action project 'Tipping the Balance Towards Primary Health Care'. The experience of this project and case studies in other countries is abstracted. It includes some characteristics of the actors and forces under which local services operate, pointing to some opportunities and constraints in managing change and development, as well as organizational relationships in the field of primary health care. In this article it is argued that the ongoing structural reform is a necessary prerequisite, but it is not the unique key, for solving local health services problems. If the mission of the health sector is to satisfy the real and the perceived needs of the population, skilled professionals, appropriate technology, and enough financial resources must be allocated to the local level.     

A critical account of the rise and spread of 'leadership': the case of U.K. healthcare

This paper considers the rise of 'leadership' in discourses relating to the British health service, and the application of the term to increasingly heterogeneous actors. Analysing interviews with NHS chief executives from the late 1990s, and key policy documents published since, we highlight how leadership has become a term of choice among policymakers, with positive cultural valences which previously predominant terms such as 'management' now lack. We note in particular how leadership is increasingly conferred not only on those in positions of formal power but on frontline clinicians, patients and even the public, and how not just the implementation but the design of policy is now constructed as being led by these groups. Such constructions of the distribution of power in the health service, however, contradict the picture drawn by academic work. We suggest, therefore, that part of the purpose of leadership discourse is to align the subjectivities of health-service stakeholders with policy intentions, making their implementation not just everyone's responsibility, but part of everyone's sense of self. Given the realities of organizational life for many of the subjects of leadership discourse, however, the extent to which leadership retains its current positive associations and ubiquity remains to be seen.     

区块链技术在卫生健康领域的应用及发展

区块链作为一种去中心化、去信任、兼具信息完整透明和隐私保护的数据库技术方案,可以构建高效可靠的价值传输系统,推动互联网成为构建社会信任的网络基础设施。区块链在优化金融行业业务流程、降低运营成本、提升协同效率方面优势显著,在其他行业的应用也快速展开。着眼卫生领域,健康医疗大数据建设面临着信息安全和隐私保护的双重挑战。区块链拥有高容错性、无法篡改、隐私保护性的特点,在医疗、制药、医保、基因组学等领域均有重要的应用空间。     

Health system strengthening in Cambodia—A case study of health policy response to social transition

ObjectivesCambodia, following decades of civil conflict and social and economic transition, has in the last 10 years developed health policy innovations in the areas of health contracting, health financing and health planning. This paper aims to outline recent social, epidemiological and demographic health trends in Cambodia, and on the basis of this outline, to analyse and discuss these policy responses to social transition.MethodsSources of information included a literature review, participant observation in health planning development in Cambodia between 1993 and 2008, and comparative analysis of demographic health surveys between 2000 and 2005.ResultsIn Cambodia there have been sharp but unequal improvements in child mortality, and persisting high maternal mortality rates. Data analysis demonstrates associations between location, education level and access to facility based care, suggesting the dominant role of socio-economic factors in determining access to facility based health care. These events are taking place against a background of rapid social transition in Cambodian history, including processes of decentralization, privatization and the development of open market economic systems. Primary policy responses of the Ministry of Health to social transition and associated health inequities include the establishment of health contracting, hospital health equity funds and public–private collaborations.ConclusionsDespite the internationally recognized health policy flexibility and innovation demonstrated in Cambodia, policy response still lags well behind the reality of social transition. In order to minimize the delay between transition and response, new policy making tactics are required in order to provide more flexible and timely responses to the ongoing social transition and its impacts on population health needs in the lowest socio-economic quintiles.     

Management support for provinces: A programme for developing provincial health management capabilities in Papua New Guinea

The decentralization of key health functions in Papua New Guinea in 1983, after a lengthy period of centralized control, highlighted the need to develop and strengthen planning and management capabilities at the intermediate level. This article describes the development of an interactive management support programme, combining regular on-site consultation with in-service training, to improve health planning, supervision and information system development at the provincial level in Papua New Guinea.