Decentralization Of Health Services Research Articles

Public health information needs in districts

Public health information needs in districts

Institutions and Leakage of Public Funds in the Cameroonian Healthcare Delivery Chain

Abstract This study attempts to examine the extent of leakage in the Cameroonian health sector and identify its sources. The analyses in the study are based on the Public Expenditure Tracking Survey data collected in Cameroon in 2004. The findings reveal that 18.8% of the actual budget allocations of decentralized health services in the Ministry of Public Health do not reach them. Health centers, which are the frontline healthcare providers, receive only 26.4% of their actual budgets contained in the recurrent expenditures of the decentralized health services. We investigate the institutional factors that correlate with the leakage rates and identified the factors that affect the likelihood of health centers receiving public funds. The study finds weak compact and voice institutional links in the Cameroonian health accountability system. The need to effectively control and monitor public funds, improve the information flow mechanism and improve the wage/allowance scale is highlighted. Finally, spending rules should be strictly respected and extra-budgetary spending restricted.

A descriptive study on health workforce performance after decentralisation of health services in Uganda

BackgroundUganda, like many developing countries, is committed to achieving the Millennium Development Goals (MDGs) by 2015. However, serious challenges prove to hamper the attainment of these goals, particularly the health related MDGs. A major challenge relates to the human resources for health. The health system in Uganda was decentralised in the 1990s. Despite the health sector reforms, the services have remained significantly deficient and performance of health workers is thought to be one of the contributing factors. The purpose of this study was, therefore, to investigate the performance of health workers after decentralisation of the health services in Uganda in order to identify and suggest possible areas for improvement.MethodsA cross-sectional descriptive survey, using quantitative research methods was utilised. A structured self-administered questionnaire was used to collect quantitative data from 276 health workers in the districts of Kumi, Mbale, Sironko and Tororo in Eastern Uganda. The health workers included doctors, clinical officers, professional nurses and midwives. The sample was selected using stratified random sampling. The data was analysed using SPSS version 18.0 and included both univariate and bivariate analysis. The results were presented in tabular and text forms.ResultsThe study revealed that even though the health workers are generally responsive to the needs of their clients, the services they provide are often not timely. The health workers take initiatives to ensure that they are available for work, although low staffing levels undermine these efforts. While the study shows that the health workers are productive, over half (50.4%) of them reported that their organisations do not have indicators to measure their individual performance. The findings indicate that the health workers are skilled and competent to perform their duties. In general, the results show that health workers are proficient, adaptive, proactive and client-oriented.ConclusionAlthough Uganda is faced with a number of challenges as regards human resources for health, the findings show that the health workers that are currently working in the health facilities are enthusiastic to perform. This may serve as a motivator for the health workers to improve their performance and that of the health sector.

The response of decentralized health services to demand uncertainty and the role of political parties in the Spanish public health system

Decentralization of the public health system should lead to health resources being managed more in line with citizens’ preferences. A decentralized system is more flexible in that it can better adapt resources to local needs. Moreover, if regional political parties have responsibility for public health policies, citizens will be able to elect those parties whose positions are more in line with their preferences. However, the role of political parties in public health management has received little attention in the literature. Focusing on the decision to provide reserve service capacity to deal with demand uncertainty, we analyse whether there have been differences between central and decentralized health authorities in Spain and whether these can be explained to some extent by the way different political parties manage the trade-off between being able to cover demand and the economic costs involved. Using data on Spanish public hospitals for the period 1996–2006, we model the difference between observed and potential output using an output-oriented distance function. Reserve capacity is modelled as a function of demand uncertainty, economic costs and the political party in power. We find differences in the way resources are managed by central government and decentralized authorities, even within the same political party. We also find differences between the decentralized authorities themselves according to the political party in power. We conclude that decentralization of public health in Spain has provided regional political authorities with greater flexibility to manage reserve capacity in line with citizens’ needs and preferences.

Decentralization of health services in India: barriers and facilitating factors.

In India, the process of decentralization of health services started taking shape in the mid-1990s. Systemic reforms envisaged delegation of administrative and financial responsibilities at district level for management of health-care institutions in 23 states of India in 1999. Subsequently, some of these reforms became part of the National Rural Health Mission (NRHM) launched in 2005. This study aims to document the process of decentralization in health services with special reference to the barriers and facilitating factors encountered during formulation and implementation of reform policies. Secondary data were reviewed, health facilities were observed, and semi-structured interviews of the key actors involved in decentralization were carried out in Haryana (India). Political and bureaucratic commitment to reforms was found to be the most important facilitating factor. Orientation training on decentralized administrative structures and performance-based resource distribution were the other important facilitators. Structural changes in administrative procedures led to improvement in the financial management system. Significant improvement in the public health infrastructure was observed. From 2004 to 2008, the state government increased the budget of health sector by nearly 60%. Frequent changes in the top administration at the state level hampered the decentralization process. Districts having a dynamic administrative leadership implemented decentralization more effectively than the rest. Decentralization of financial resources has improved the functioning of health services to some extent. Major policy decisions on decentralization of human resource management, increase in financial allocation, and greater involvement of community in decision-making are required.

The Psychiatrist as Administrator: The Career of W. F. Theunissen in the Dutch East Indies

W. F. Theunissen (1882-1961) was a leading psychiatrist in the Dutch East Indies. He was the medical director of several large mental hospitals after which he became director of the Dutch East Indies Public Health Service. Theunissen was not known for his research into the causes of mental illness. Instead, he made his mark as an administrator greatly reducing the expenses of the Lawang mental hospital by expanding occupational therapy in new and innovative ways. His accomplishments earned him the position of director of the Indies Public Health Department, where he oversaw the decentralisation of health services and the development of public health initiatives.

The impact of decentralization of health services on health outcomes: evidence from Canada

This article contributes to the limited empirical literature on the impact of decentralization on economic welfare by investigating the hypothesis that shifts towards more fiscal decentralization in health services would be accompanied by improvements in population health. Building on a conventional public finance model applied to health care, this hypothesis is tested on a panel data of the highly decentralized Canadian provinces during the period 1979 to 1995. The results of the exploratory empirical analysis presented in this article suggest that fiscal decentralization of health services in Canada has had a positive and substantial influence on the effectiveness of public policy in improving a population's health over the period studied.

Organização de redes regionalizadas e integradas de atenção à saúde: desafios do Sistema Único de Saúde (Brasil)

This article examines the causes of the segmentation/fragmentation in the healthcare process and the benefits of the constitution of networks set up to rationalize expenditures, optimize resources and ensure care tailored to the needs of the users. Its main purpose is to analyze the current challenges facing Brazil's Unified Health System, in order to promote improved integration between services. Among the challenges, those related to the insufficiency of resources due to low public funding, the training and education processes and their effects on the availability of health professionals to work in the public health system and the difficulties in the decentralization of health services and actions in the context of the Brazilian Federation Pact should be stressed. The paper concludes that, besides the efforts to tackle these challenges, the organization of regionalized networks integrated with the Unified Health System also depends on the improvement of intergovernmental management in the health regions to bolster the agreement on responsibilities among the government areas and the qualification of primary healthcare to coordinate care and ensure its continuity at other levels of the system.

Holding health providers in developing countries accountable to consumers: a synthesis of relevant scholarship

Health care providers in low-income countries often treat consumers poorly. Many providers do not consider it their responsibility to listen carefully to consumer preferences, to facilitate access to care, to offer detailed information, or to treat patients with respect. A lack of provider accountability to health consumers may have adverse effects on the quality of health care they provide, and ultimately on health outcomes. This paper synthesizes relevant research on health provision in low-, middle- and high-income countries with the aim of identifying factors that shape health provider accountability to consumers, and discerning promising interventions to enhance responsiveness. Drawing on this scholarship, we develop a framework that classifies factors into two categories: those concerning the health system and those that pertain to social influences. Among the health systems factors that may shape provider accountability are oversight mechanisms, revenue sources, and the nature of competition in the health sector-all influences that may lead providers to be accountable to entities other than consumers, such as governments and donors. Among the social factors we explore are consumer power, especially information levels, and provider beliefs surrounding accountability. Evidence on factors and interventions shaping health provider accountability is thin. For this reason, it is not possible to draw firm conclusions on what works to enhance accountability. This being said, research does suggest four mechanisms that may improve provider responsiveness: 1. Creating official community participation mechanisms in the context of health service decentralization; 2. Enhancing the quality of health information that consumers receive; 3. Establishing community groups that empower consumers to take action; 4. Including non-governmental organizations in efforts to expand access to care. This synthesis reviews evidence on these and other interventions, and points to future research needs to build knowledge on how to enhance health provider accountability to consumers.

The Effects of Health Care Reforms on Health Inequalities: A Review and Analysis of the European Evidence Base

Health care is widely considered to be an important determinant of health. The health care systems of Western Europe have recently experienced significant reforms, under pressure from economic globalization. Similarly, in Eastern Europe, health care reforms have been undertaken in response to the demands of the new market economy. Both of these changes may influence equality in health outcomes. This article aims to identify the mechanisms through which health care may affect inequalities. The authors conducted a literature review of the effects on health inequalities of European health care reforms. Particular reference was paid to interventions in the fields of financing and pooling, allocation, purchasing, and provision of services. The majority of studies were from Western Europe, and the outcomes most often examined were access to services or income distribution. Overall, the quality of research was poor, confirming the need to develop an appropriate impact assessment methodology. Few studies were related to pooling, allocation, or purchasing. For financing and purchasing, the studies showed that publicly funded universal health care reduces the impact of ill health on income distribution, while insurance systems can increase inequalities in access to care. Out-of-pocket payments increase inequalities in access to care and contribute to impoverishment. Decentralizing health services can lead to geographic inequalities in health care access. Nationalized, publicly funded health care systems are most effective at reducing inequalities in access and reducing the effects on health of income distribution.

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.

5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention: summary of key research and implications for policy and practice - operations research.

Operations research was added as a fourth scientific track to the pathogenesis conference series at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009) in recognition of the importance of this growing research field and the need for applied research to inform and evaluate the scale up of some key interventions in HIV treatment, care and prevention.Several studies demonstrated how task shifting and the decentralization of health services can leverage scarce health care resources to support scale-up efforts. For example, a Ugandan study comparing home-based and facility-based antiretroviral therapy (ART) delivery found that both delivered equivalent clinical outcomes, but home-based delivery resulted in substantial cost savings to patients; and a retrospective cohort analysis of an HIV care programme in Lesotho demonstrated that devolving routine patient management to nurses and trained counsellors resulted in impressive gains in annual enrolment, retention in care and other clinical indicators.Studies also demonstrated how the use of trained counsellors and public health advisors could effectively expand both clinical and public health capacity in low-income settings. Studies evaluating the impact of integrating HIV and TB care resulted in improved treatment outcomes in coinfected populations, the development of environmental interventions to reduce TB transmission, and uncovering of the extent of multi-drug-resistant and extremely drug-resistant tuberculosis (MDR-TB and XDR-TB) in KwaZulu-Natal, South Africa.Some mathematical modelling and cost-effectiveness studies presented at this meeting addressed interventions to increase retention in care, and strengthened the evidentiary basis for universal voluntary testing and immediate ART on reducing HIV transmission; debate continued about the relative merits of clinical versus laboratory monitoring. Finally, a provocative plenary presentation outlined the shortfalls of current prevention interventions and argued for more cost-effectiveness analyses to guide the selection of interventions for maximum benefit.

The Vicissitudes of Public Health Policy in the Americas

The Vicissitudes of Public Health Policy in the Americas Amy Whitfield (bio) and Howard Waitzkin (bio) Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico. By Anne-Emanuelle Birn. Rochester, NY: University of Rochester Press, 2006. Pp. 434. $95.00 cloth. Cold War, Deadly Fevers: Malaria Eradication in Mexico, 1955–1975. By Marcos Cueto. Baltimore: Johns Hopkins University Press, 2007. Pp. 264. $45.00 cloth. The Value of Health: History of the Pan American Health Organization. By Marcos Cueto. Rochester, NY: University of Rochester Press, 2007. Pp. 252. $29.95 cloth. Decentralizing Health Services in Mexico: A Case Study in State Reform. Edited by Núria Homedes and Antonio Ugalde. La Jolla, CA: Center for U.S.-Mexican Studies, University of California, San Diego, 2006. Pp. 332. $24.95 paper, $56.95 cloth. Fit to Be Citizens? Public Health and Race in Los Angeles, 1879–1939. By Natalia Molina. Berkeley: University of California Press, 2006. Pp. 279. $21.95 paper, $55.00 cloth. Historically, public health policies in the Americas have emerged as a result of political and economic forces rather than a narrow concern for the objective improvement of public health and the prevention of illness. Specifically, public health policies have interconnected with the needs of business and foreign policy as formulated during different historical periods. The four books reviewed here show an awareness of the nonautonomous nature of public health policies in the Americas. On the basis of these excellent books, we assess the origins and impacts of public health policies in furthering economic and political goals. Economic Impacts of Public Health Policies Public health policies in the Americas have focused on the economic benefits of preventing and eradicating disease. International health agencies [End Page 216] originated in large part from the need to create a system to stop the spread of disease, which was hindering trade. Marcos Cueto's The Value of Health provides a detailed history of the creation and continuation of the Pan American Health Organization (PAHO) and its role in the use of health policies to advance trade and economic benefits. Cueto provides a nonjudgmental look at this history that historians, Latin Americanists, and health-policy professionals can enjoy. The book is easy to read and does not require previous knowledge of Latin America or public health. Cueto uses varied resources in compiling a chronicle of the international organization, separating its history into the eras of PAHO's directors. Each director's background, including education, other organizational affiliations, and personal passions, is included as a significant part of the story. This information provides a look not only at policy directives but also at the factors contributing to the organization's choices in health-policy decisions. Cueto provides details concerning the forces that initiated the organization, specifically the system of quarantining ships to block the spread of disease that, as stated previously, limited trade and created a loss of materials. Different countries were blamed for spreading disease because of the deficient cleanliness of their ports. Medical posts, set up at ports, checked ships and immigrants, and single companies established processes to sanction and authorize ships entering these ports so as to minimize trade difficulties. Walter Wyman, the first Director of PAHO, known then as the Pan American Sanitary Board, focused on the creation of public health policies that would exert minimal adverse impacts on commerce. The policies eventually moved away from concentrating only on port activities as diseases such as bubonic plague, hookworm, and yellow fever spread throughout nations, but they still focused on the economic benefits of preventing and curing diseases. The prioritization of diseases that had to be controlled resulted from considerations of commerce. Cueto's clarification of PAHO's creation based on trade provides some background for looking at the economically motivated health policies portrayed in Natalia Molina's Fit to Be Citizens? Public Health and Race in Los Angeles, 1879–1939. Public health professionals will benefit from Molina's historical look at the treatment of Chinese, Japanese, and Mexican immigrants in Los Angeles under evolving public health policies. The book provides an outstanding historical account, which historians, particularly those focused on medical or public health history, will enjoy. Much like Cueto...

Essential health information available for India in the public domain on the internet

BackgroundHealth information and statistics are important for planning, monitoring and improvement of the health of populations. However, the availability of health information in developing countries is often inadequate. This paper reviews the essential health information available readily in the public domain on the internet for India in order to broadly assess its adequacy and inform further development.MethodsThe essential sources of health-related information for India were reviewed. An extensive search of relevant websites and the PubMed literature database was conducted to identify the sources. For each essential source the periodicity of the data collection, the information it generates, the geographical level at which information is reported, and its availability in the public domain on the internet were assessed.ResultsThe available information related to non-communicable diseases and injuries was poor. This is a significant gap as India is undergoing an epidemiological transition with these diseases/conditions accounting for a major proportion of disease burden. Information on infrastructure and human resources was primarily available for the public health sector, with almost none for the private sector which provides a large proportion of the health services in India. Majority of the information was available at the state level with almost negligible at the district level, which is a limitation for the practical implementation of health programmes at the district level under the proposed decentralisation of health services in India.ConclusionThis broad review of the essential health information readily available in the public domain on the internet for India highlights that the significant gaps related to non-communicable diseases and injuries, private health sector and district level information need to be addressed to further develop an effective health information system in India.

Implementing decentralised management in Ghana

PurposeThe purpose of this paper is to examine the barriers to the implementation of management decentralisation of health services and programmes at district level in Ghana.Design/methodology/approachData for the study were collected through a qualitative technique in the Sekyere West district.FindingsThe findings are: transfer of authority for management decision making and planning was rarely operational at district level; and control over financial and personnel decisions remained centralised. The paper identified lack of staff capacity, lack of commitment and inter‐organisational conflict between health managers and local government officials as factors obstructing the implementation of management decentralisation in the district.Originality/valueThe lesson from the study is that the implementation of health care management decentralisation at district level has stalled because of the combined effect of internal and external constraints. The paper suggests that given the enormity of the problem of paucity of capacity to undertake new service management responsibilities, the process of transferring responsibilities, resources and control to lower level health managements should be gradual and incremental; the sequencing of reform too should be such that district health officers and stakeholders are given adequate training prior to the inauguration of new management reform.

La descentralización de los servicios de salud: de la teoría a la práctica

The current promoters of the decentralization of health services affirm that its implementation will improve the quality, equity and efficiency of health systems and at the same time will increase users' satisfaction. Additionally, those who advocate decentralization believe that it will facilitate community participation in health decisionmaking, and as a result it will strengthen the democratic process. In this study we discuss first the lack of consensus regarding the meaning of decentralization and the difficulties of measuring the degree of decentralization of a health system. We also identify the actors who have formulated the above hypotheses, examine the reasons behind its formulation, and analyze if the outcome of the decentralization of the Latin American health services confirm the hypotheses.

Redesigning health information systems in developing countries: the need for local flexibility and distributed control

AbstractDespite widespread aims to strengthen the Health Information System (HIS) as a tool for decentralised health care, there is a strong tendency in most developing countries that the HIS continues to reflect the central level's needs and requirements. The traditional design approach with little or no end user involvement results in a centralised HIS with an extensive, somewhat inappropriate, but also inflexible set of standards. Consequently, the HIS is not very useful for the wished‐for decentralisation of health services, and there is an urgent need to redesign the existing HIS in order to make it locally relevant and appropriately decentralised. Based on a comparative case analysis of the HIS in Tanzania and Ethiopia, we offer practical recommendations on the way to achieve this redesign. A central design goal should be to achieve a balance between centralised control and local autonomy. Some degree of control over a decentralised HIS, including budgets and the use of resources, should be delegated to the district administration. In order to achieve the aim of a locally relevant, well‐working HIS, it is necessary that appropriate authority, capacity and decentralised allocation of resources for HIS will be developed at the district and sub‐district levels. Copyright © 2008 John Wiley & Sons, Ltd.

Decentralizing Health Services in Mexico: A Case Study in State Reform. Edited by Núria Homedes and Antonio Ugalde. La Jolla: Center for U.S.-Mexican Studies/University of California, San Diego, 2006. Pp. xx, 332. Tables. Figures. Notes. Appendix. Index. $24.95 paper.

Decentralization: Theory and History. Decentralization: The Long Road from Theory to Practice - the Editors. Decentralization of Health Services in Mexico: A Historical Review - the Editors. The First Attempt, 1983-1988. Decentralizing Health Services: Formulation, Implementaion, and Results - M. Gonzalez-Block, R. Leyva, O. Zapta, R. Loewe, and J. Alagon. Federalist Flirtations: The Politics and Execution of Health Services Decentralization for the Uninsured in Mexico, 1985-1995 - A.-E. Birn. Trying Again, 1994-2004: Case Studies from Five States. Decentralized in Quotes: Baja California Sur, 1996-2000 - L. Olvera Santana. The Slow and Difficult Institutionalization of Health Care Reform in Sonora: 1982-2000 - R. Abrantes Pego. Guanajuato: Invisible Results - S. Arjonilla Alday. Nuevo Leon and Tamaulipas: Opening and Closing a Window of Opportunity - the Editors. Decentralization at the Health District Level in Nuevo Leon - the Editors. Conclusions - the Editors.

Análise preliminar do Sistema de Informação do Programa de Controle da Esquistossomose no período de 1999 a 2003

This study provides a preliminary analysis of the Information System in the Schistosomiasis Control Program (SISPCE) in the States of Bahia, Sergipe, Alagoas, and Pernambuco, Brazil, from 1999 to 2003. The data analysis suggests a sharp decline in data entry in the system during the transition period involving health services decentralization, followed by a gradual increase. Major under-recording was observed in Pernambuco. SISPCE-DATASUS and IBGE (National Census Bureau) data are insufficient to construct a surveillance index for serious forms of the endemic disease and other aspects that could relate sanitary conditions to schistosomiasis. Reformulation of the SISPCE is key for schistosomiasis control measures, given the new reality in the Brazilian health system. The data system should be redesigned in order to integrate the health policies with the Unified National Health System's guidelines, using a systematic data collection methodology in keeping with local specificities and allowing prospective comparisons and evaluations, in addition to constructing new indicators with an emphasis on morbidity and determinants of the endemic and the adoption of analytical of the that express the real situation of the schistosomiasis in the States.

Maternal Health Policy and the Politics of Scale in Mexico

Since 1987, international organizations have accorded greater attention to the problem of maternal mortality, particularly with the inclusion of its reduction in the Millennium Development Goals. This article examines maternal health policies in Mexico, focusing on interactions between the international, national, and local scales and considering the case of local projects in two states, Chiapas and Guerrero. Although the discourse of maternal health expressed at the international level has facilitated the creation of networks dedicated to maternal health, the restructuring of health services in Mexico and the rescaling of their provision have often conflicted with the realization of this goal. The impact of decentralizing health services has differed according to (a) the timing and nature of decentralization; (b) the number and expertise of nongovernmental organizations (NGOs) working on maternal health issues, and the connections between these NGOs and international networks; and (c) the responsiveness of the state governments to maternal health issues.