Effects of decentralization on the levels of GAP-43 and p38 (synaptophysin) in sympathetic adrenergic neurons: a semi-quantitative study using immunofluorescence and confocal laser scanning microscopy

The distribution of GAP-43 in superior cervical ganglion (SCG) and iris were studied in normal animals and following decentralization using immunofluorescence and confocal laser scanning microscopy (CLSM). GAP-43-like immunoreactivity (LI) was compared with p38 (synaptophysin)-LI, and tyrosin hydroxylase (TH)-LI. In the control SCG, GAP-43-LI and p38-LI were mainly localized in nerve terminals around the principal neurons. The neuronal perikarya were negative for GAP-43, but positive for p38 in a perinuclear zone, as well as positive for TH. SIF cells (Small Intensely Fluorescent cells, ganglionic interneurons) were positive for GAP-43, TH and p38. One day after decentralization, GAP-43-LI and p38-LI in nerve terminals around principal neurons had disappeared. Some of the principal neurons showed a weak GAP-43-immunoreactivity. Three days post-decentralization, GAP-43- and p38-positive nerve terminals around the neurons had reappeared in considerable numbers and the intra-ganglionic nerve bundles were positive for both antibodies. In the control irides, GAP-43-LI and p38-LI were distributed in a varicose pattern in the nerve bundles, around blood vessels and in the network of terminals. Double labelling studies showed that GAP-43-LI was colocalized with TH-LI and p38-LI. The network of terminals in the dilator plate of the irides was quantified by measuring the fluorescence intensity of randomly selected areas, using CLSM. Three days after decentralization the intensity of GAP-43-LI and p38-LI had significantly increased. TH-LI had decreased 8 days after decentralization. The results indicate that GAP-43-LI and p38-LI are normally present in the nerve fibers and terminals of both pre- and post-ganglionic neurons in adult rats. The expression of GAP-43-LI and p38-LI in post-ganglionic neurons is preganglionically regulated, as indicated by the increased expression after decentralization. The expression of p38 in these neurons is probably regulated via mechanisms that are separate from those which regulate GAP-43, since it showed a different time course than that of GAP-43-LI.     

Decentralization of management responsibility: the case of Danish hospitals

This article examines a specific management reform at three hospitals in a Danish county. Management reform at the hospital level implies a decentralization of responsibility and power to the departmental level. Along with increased responsibility and power, departments get the message: keep your budgets and keep your output level. This preliminary analysis indicates that departmental budgets can be a way of containing costs in clinical departments. Non-staff expenditures especially are subjected to reductions. The system still seems to 'favour' doctors and nurses, but less than in a system with traditional budgetary institutions. The behaviour of the top-management teams shows that the output constraint is not seriously meant. Departments are allowed to reduce capacity, with declining output, with the knowledge of the top-management team. The declining output makes it easier to departments ceteris paribus to keep within their budgets. And that makes it easier for the top-management team to keep the overall hospital budget. The obligation to keep the overall hospital budget is thus an important criterion of success in the eyes of the political masters of hospitals.     

卫生体制改革的目标与政策选择--国际卫生体制改革的经验与教训

引入市场机制,采取分权、分级与分类管理等政策与措施是当今国际卫生体制改革中的主流特点,由于各个国家的社会经济体制与卫生保健制度不同,这些改革政策与措施所产生的影响与效果也各具特色.因此,在深化我国卫生体制改革的进程中,借鉴国际卫生体制改革的经验与教训具有一定的现实意义.     

The promises and perils of hospital autonomy: Reform by decree in Viet Nam

This article investigates impacts of hospital autonomization in Viet Nam employing a “decision-space” framework that examines how hospitals have used their increased discretion and to what effect. Analysis suggests autonomization is associated with increased revenue, increasing staff pay, and greater investment in infrastructure and equipment. But autonomization is also associated with more costly and intensive treatment methods of uncertain contribution to the Vietnamese government's stated goal of quality healthcare for all. Impacts of autonomization in district hospitals are less striking. Despite certain limitations, the analysis generates key insights into early stages of hospital autonomization in Viet Nam.     

Is decentralization good for logistics systems? Evidence on essential medicine logistics in Ghana and Guatemala

Efficient logistics systems move essential medicines down the supply chain to the service delivery point, and then to the end user. Experts on logistics systems tend to see the supply chain as requiring centralized control to be most effective. However, many health reforms have involved decentralization, which experts fear has disrupted the supply chain and made systems less effective. There is no consensus on an appropriate methodology for assessing the effectiveness of decentralization in general, and only a few studies have attempted to address decentralization of logistics systems. This paper sets out a framework and methodology of a pioneering exploratory study that examines the experiences of decentralization in two countries, Guatemala and Ghana, and presents suggestive results of how decentralization affected the performance of their logistics systems. The analytical approach assessed decentralization using the principal author's 'decision space' approach, which defines decentralization as the degree of choice that local officials have over different health system functions. In this case the approach focused on 15 different logistics functions and measured the relationship between the degree of choice and indicators of performance for each of the functions. The results of both studies indicate that less choice (i.e. more centralized) was associated with better performance for two key functions (inventory control and information systems), while more choice (i.e. more decentralized) over planning and budgeting was associated with better performance. With different systems of procurement in Ghana and Guatemala, we found that a system with some elements of procurement that are centralized (selection of firms and prices fixed by national tender) was positively related in Guatemala but negatively related in Ghana, where a system of 'cash and carry' cost recovery allowed more local choice. The authors conclude that logistics systems can be effectively decentralized for some functions while others should remain centralized. These preliminary findings, however, should be subject to alternative methodologies to confirm the findings.     

Practitioner opinions on health promotion interventions that work: opening the 'black box' of a linear evidence-based approach

While attempts are being made to improve health promotion by following a linear Evidence-Based (EB) approach, the actors involved are aware that the quality of health promotion is not just a matter of supplying 'evidence-based' interventions to local practitioners, but the result of a situated coproduction process that depends on many factors. This paper explores what constitutes an intervention that works from the perspective of health promotion professionals (HPP), and how, according to them, the development and implementation of interventions should be improved. We interviewed 81 HPPs about the use of 10 health promotion interventions at 30 Municipality Health Services in The Netherlands. The HPPs described an intervention that works as something that produces its intended effects after being realized in a local situation. Interventions are realized by combining elements of a supplied intervention (e.g. a theory, artefacts) with elements that are situated in the local context (e.g. funding, local network). Interventions that are transferred contain implicit assumptions about local contexts, but it is often unclear what precisely constitutes an intervention and what is assumed of local contexts. An intervention that works is a situated configuration of aligned elements. A linear EB approach depends on the realization of the local circumstances in which 'evidence based' interventions can work. Various strategies are possible for approximating such circumstances, but the core assumption that the configuration that is realized in practice is similar to the 'evidence based' intervention seems unrealistic for most health promotion in The Netherlands. Under such circumstances, attention should shift from central quality assurance to the system of actors and the distributed actions and heterogeneous learning processes that together add up to interventions that work.     

Health sector decentralization and local decision-making: Decision space, institutional capacities and accountability in Pakistan

Health sector decentralization has been widely adopted to improve delivery of health services. While many argue that institutional capacities and mechanisms of accountability required to transform decentralized decision-making into improvements in local health systems are lacking, few empirical studies exist which measure or relate together these concepts. Based on research instruments administered to a sample of 91 health sector decision-makers in 17 districts of Pakistan, this study analyzes relationships between three dimensions of decentralization: decentralized authority (referred to as "decision space"), institutional capacities, and accountability to local officials. Composite quantitative indicators of these three dimensions were constructed within four broad health functions (strategic and operational planning, budgeting, human resources management, and service organization/delivery) and on an overall/cross-function basis. Three main findings emerged. First, district-level respondents report varying degrees of each dimension despite being under a single decentralization regime and facing similar rules across provinces. Second, within dimensions of decentralization-particularly decision space and capacities-synergies exist between levels reported by respondents in one function and those reported in other functions (statistically significant coefficients of correlation ranging from ρ=0.22 to ρ=0.43). Third, synergies exist across dimensions of decentralization, particularly in terms of an overall indicator of institutional capacities (significantly correlated with both overall decision space (ρ=0.39) and accountability (ρ=0.23)). This study demonstrates that decentralization is a varied experience-with some district-level officials making greater use of decision space than others and that those who do so also tend to have more capacity to make decisions and are held more accountable to elected local officials for such choices. These findings suggest that Pakistan's decentralization policy should focus on synergies among dimensions of decentralization to encouraging more use of de jure decision space, work toward more uniform institutional capacity, and encourage greater accountability to local elected officials.     

Resource mobilization for health advocacy: Afro-Brazilian religious organizations and HIV prevention and control

Brazil’s national response to AIDS has been tied to the ability to mobilize resources from the World Bank, the World Health Organization, and a variety of donor agencies. The combination of favorable political economic opportunities and the bottom-up demands from civil society make Brazil a particularly interesting case. Despite the stabilization of the AIDS epidemic within the general Brazilian population, it continues to grow in pockets of poverty, especially among women and blacks. We use resource mobilization theories to examine the role of Afro-Brazilian religious organizations in reaching these marginalized populations. From December 2006 through November 2008, we conducted ethnographic research, including participant observation and oral histories with religious leaders (N = 18), officials from the National AIDS Program (N = 12), public health workers from Rio de Janeiro (N = 5), and non-governmental organization (NGO) activists who have worked with Afro-Brazilian religions (N = 5). The mobilization of resources from international donors, political opportunities (i.e., decentralization of the National AIDS Program), and cultural framings enabled local Afro-Brazilian religious groups to forge a national network. On the micro-level, in Rio de Janeiro, we observed how macro-level structures led to the proliferation of capacity-building and peer educator projects among these religious groups. We found that beyond funding assistance, the interrelation of religious ideologies, leadership, and networks linked to HIV can affect mobilization.     

Reimbursement systems and quality of hospital care: An empirical analysis for Italy

There is an ongoing debate about the effect of different reimbursement systems on hospital performance and quality of care. The present paper aims at contributing to this literature by analysing the impact of different hospital payment schemes on patients’ outcomes in Italy.     

The implementation of environmental health policies in health care facilities: The case of Malawi

Establishing and maintaining safe and sufficient environmental health (EH) conditions in health care facilities (HCFs) is important to prevent and control infections. In 2018, the Government of Malawi finalized an environmental health policy that defines specific targets and programs for EH in healthcare settings. This and other related policies have been used since 2010 as a guide for EH practice in HCFs, but the implementation of these policies has been incomplete to-date. This study qualitatively examines the successes and shortcomings of implementing these policies in Malawi's public HCFs. Thematic analysis of interviews with 53 respondents from all levels of government was used to identify the successes of the policies and the barriers to effective implementation using Contextual Interaction Theory. The greatest identified strength lies in the design of the EH department and its ability to connect individual HCFs and EH actors directly to the policy-making level of government. Identified barriers to implementation include: insufficient financial support; lack of human resources; incomplete reporting; poor stakeholder coordination; and insufficient training of EH actors. We recommend refresher trainings for all EH actors, the establishment of a directorate level EH position, and strengthened coordination to improve the collection, analysis, and reporting of monitoring data to enable EH actors to advocate for the additional funding needed to develop programs for EH personnel and to apply effective EH interventions.