Decentralization of HIV care in Cameroon: Increased access to antiretroviral treatment and associated persistent barriers

ContextThe national antiretroviral treatment (ART) program in Cameroon has reached one of the highest rate of coverage in Western and Central Africa (58% of the estimated eligible HIV-infected population in June 2008).ObjectivesTo assess the extent to which decentralized delivery of HIV care at the district level has contributed to increased access to ART.MethodsComparison of ART-treated and non-ART-treated in the sub-sample of medically eligible HIV-positive patients (n = 2566) in the cross-sectional ANRS-EVAL survey was carried out among patients seeking HIV care in 14 hospitals at central level (Yaoundé, Douala and capitals of 8 provinces) and 13 at district levels. Logistic regressions and multivariate analysis were carried out to identify factors related to non-access to ART at both levels of care.ResultsOnly 7% of eligible patients did not have access to ART. After adjustment for time since initial HIV diagnosis and CD4 counts (at initiation of treatment for those ART-treated and at time of survey for those who were not), younger and male patients, as well as those who only had a primary level education were less likely to be ART-treated at central but not at district level, whereas those who were unemployed were less likely to be treated at both levels. Patients were less likely to be treated in central hospitals with higher workload per medical staff member and absence of task shifting policy, and in district hospitals with non-availability of equipment for CD4 counts and larger size (150 beds or more).ConclusionMain persisting barriers in access to ART in Cameroon are rather due to insufficient access to HIV testing and difficulties in patients’ referral to ART delivery centers after HIV diagnosis, since the overwhelming majority of eligible patients already seeking HIV care had effective access. However, health systems strengthening (HSS) is still needed to overcome some remaining barriers in access to ART and to guarantee its long-term sustainability.     

Poland—an “experimental range” for health care system changes. Two reforms: decentralization and centralization and their consequences

Background In Poland, the new regulations establishing a decentralized system based on the regional sickness funds were implemented in 1999. However, the inconsequence of central government policy in Poland caused a significant reorganization of the model in 2001 towards the opposite direction. Aim The objectives of this article are to analyze the organizational shape of the health care system in Poland after its reforms, separate the consequences of both reforms, and provide a possible generalization of the findings. Methodology The authors applied a modified decision space map based on a model by T. Bossert. The types of decentralization are according to Rondelli et al. Assumptions of both reforms, and their consequences, are based on political documents and reports and articles published in international and Polish scientific journals. Results The comparison of reforms shows that in 2001 the main changes referred to the institution of payer and financial matters. In both cases incorrect preparation of the political process and legislative faultiness were noted. Decentralization in 1999 was not followed by instruments needed for increasing the efficacy of the system; in the second case reorganization of the payer appears to be missing the expectations of health system participants. Conclusions The comparison of reforms may suggest that decentralization is a better solution in the context of increasing organizational and financial efficacy of the health system, but because of numerous additional factors and specifics of political conditions in Poland generalizations are not possible.     

Social health insurance in a developing country: the case of the Philippines

Very little is known about the Philippine health care system, and in particular its experience with social health insurance (SHI). Having initiated an SHI programme 35 years ago, the Philippines hold many lessons for the development of such schemes in other low and middle-income countries. We analyse the challenges currently facing PhilHealth, the national health insurer. PhilHealth was formed in 1995 as a successor to the Medicare programme and was given a mandate to achieve universal coverage by 2010. To date, PhilHealth has been quite successful in some areas (e.g. enrollment), but lags behind in others (e.g. quality and price control). We conclude that SHI in the Philippines has been a success story so far and provides lessons for countries in a similar situation. For example: (i) SHI is based on value decisions and the clear statement of societal goals can give guidance in the technical execution, (ii) SHI is a financing institution and needs to be treated accordingly, (iii) SHI can be implemented independently of the current economic situation and might actually contribute to economic development, (iv) community-based health care financing schemes should be merged with the national SHI in the long run, and (v) there is a strong need to push for high quality care and improved physical access. No clear suggestions can be given with respect to the benefit catalogue and the balance between economies of scale and decentralisation. Although riddled with many inadequacies, PhilHealth was set up as a strong and largely politically independent institution for the development of SHI. SHI can act as a stabilizing institution in a politically and economically volatile environment.     

Effect of decentralization and glucose withdrawal on the potassium-induced cAMP increase in the rabbit superior cervical ganglion.

The concentration of cAMP in the isolated rabbit superior cervical ganglion (SCG) increases when the tissue is exposed to high potassium media for short periods. The increase was found not to be affected by agents that are known to potentiate or to antagonize the postsynaptic effects of acetylcholine. Pretreatment of the rabbits with various sympaticolytic substances did not appear to affect the cAMP increase in the isolated SCG. It was found that the K+-induced cAMP synthesis occurred neither in ganglia which had been decentralized 3 days before isolation nor in intact ganglia preincubated in a glucose-free medium. Under both these conditions the effect of potassium declines with a time course which is characteristic for the degeneration of the presynaptic terminals. These terminals therefore, appear to be the most likely site for the cAMP increase.     

Allocation of authority in European health policy

Although many study the effects of different allocations of health policy authority, few ask why countries assign responsibility over different policies as they do. We test two broad theories: fiscal federalism, which predicts rational governments will concentrate information-intensive operations at lower levels, and redistributive and regulatory functions at higher levels; and "politicized federalism", which suggests a combination of systematic and historically idiosyncratic political variables interfere with efficient allocation of authority. Drawing on the WHO Health in Transition country profiles, we present new data on the allocation of responsibility for key health care policy tasks (implementation, provision, finance, regulation, and framework legislation) and policy areas (primary, secondary and tertiary care, public health and pharmaceuticals) in the 27 EU member states and Switzerland. We use a Bayesian multinomial mixed logit model to analyze how different countries arrive at different allocations of authority over each task and area of health policy, and find the allocation of powers broadly follows fiscal federalism. Responsibility for pharmaceuticals, framework legislation, and most finance lodges at the highest levels of government, acute and primary care in the regions, and provision at the local and regional levels. Where allocation does not follow fiscal federalism, it appears to reflect ethnic divisions, the population of states and regions, the presence of mountainous terrain, and the timing of region creation.     

权力下放对乡镇卫生院卫生人力资源管理的影响研究

该文旨在了解卫生管理权力下放对乡镇卫生院卫生人力资源管理的影响。采用定性与定量相结合的方法在福建省某地区的两个县开展研究。结果表明 :实施卫生管理权力下放后 ,乡镇卫生院在人员录用、解聘及调动等方面拥有了更大的自主权 ;卫技人员参加在职培训的机会增多 ,但对预防保健人员的培训有所忽略 ;另外 ,新的薪酬制度虽然提高了卫生人员的积极性和收入 ,但在医疗费用和服务质量等方面出现了一些负面效应     

Institutionalization of the NACP and Way Ahead

In India, HIV prevention and control activities started way before the reporting of the first case of HIV infection. On reporting of evidences of HIV infection from different parts of the country and varied groups, Government launched the National AIDS Control Program (NACP). The program was launched on the foundation of early interventions and Mid-Term Plan, which evolved in three phases over the period of eighteen years. With progression of time, epidemiological situation changed and knowledge/capacity to tackle HIV improved. In the course of the evolution, NACP has moved from the centrally controlled program to district driven. Also different strategies were inducted/refined and many important institutes like Task Force, a high-powered National AIDS Committee, National AIDS Control Board, National AIDS Control Organization, State AIDS Control Societies, Project Support Units/Project Management Units, National Council on AIDS, Department of AIDS Control, Technical Support Unit, District AIDS Prevention and Control Unit (DAPCU) were created. Currently program is implemented vertically with good impetus and is able to contain the spread of HIV in India. For enhancing the effectiveness and sustainability, future of the NACP is strongly linked with the well-performing DAPCU and good synergy/integration with General Health System. HIV/AIDS epidemic in India has entered into the third decade. Evidences show that this epidemic in India is of concentrated type and characterized by the heterogeneity, following the type 4 pattern, where the epidemic shifts from the most vulnerable populations [such as female sex workers, men who have sex with men, injecting drug users to bridge populations (clients of sex workers, sexually transmitted infection patients, partners of drug users, long route truck drivers, short stay cyclical single male migrants], then to the general population and from urban centers to rural areas (ruralization of epidemic) with increasing involvement of youth and women (feminization of epidemic).