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Alexander S. Preker

Bio: Alexander S. Preker is an academic researcher from World Bank. The author has contributed to research in topics: Health care & Health policy. The author has an hindex of 24, co-authored 47 publications receiving 2204 citations.

Papers
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Journal ArticleDOI
TL;DR: Reflections on the recent user fees debate are provided, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare.
Abstract: Many low- and middle-income countries continue to search for better ways of financing their health systems. Common to many of these systems are problems of inadequate resource mobilisation, as well as inefficient and inequitable use of existing resources. The poor and other vulnerable groups who need healthcare the most are also the most affected by these shortcomings. In particular, these groups have a high reliance on user fees and other out-of-pocket expenditures on health which are both impoverishing and provide a financial barrier to care. It is within this context, and in light of recent policy initiatives on user fee removal, that a debate on the role of user fees in health financing systems has recently returned. This paper provides some reflections on the recent user fees debate, drawing from the evidence presented and subsequent discussions at a recent UNICEF consultation on user fees in the health sector, and relates the debate to the wider issue of access to adequate healthcare. It is argued that, from the wealth of evidence on user fees and other health system reforms, a broad consensus is emerging. First, user fees are an important barrier to accessing health services, especially for poor people. They also negatively impact on adherence to long-term expensive treatments. However, this is offset to some extent by potentially positive impacts on quality. Secondly, user fees are not the only barrier that the poor face. As well as other cost barriers, a number of quality, information and cultural barriers must also be overcome before the poor can access adequate health services. Thirdly, initial evidence on fee abolition in Uganda suggests that this policy has improved access to outpatient services for the poor. For this to be sustainable and effective in reaching the poor, fee removal needs to be part of a broader package of reforms that includes increased budgets to offset lost fee revenue (as was the case in Uganda). Fourthly, implementation matters: if fees are to be abolished, this needs clear communication with a broad stakeholder buy-in, careful monitoring to ensure that official fees are not replaced by informal fees, and appropriate management of the alternative financing mechanisms that are replacing user fees. Fifthly, context is crucial. For instance, immediate fee removal in Cambodia would be inappropriate, given that fees replaced irregular and often high informal fees. In this context, equity funds and eventual expansion of health insurance are perhaps more viable policy options. Conversely, in countries where user fees have had significant adverse effects on access and generated only limited benefits, fee abolition is probably a more attractive policy option. Removing user fees has the potential to improve access to health services, especially for the poor, but it is not appropriate in all contexts. Analysis should move on from broad evaluations of user fees towards exploring how best to dismantle the multiple barriers to access in specific contexts.

277 citations

Journal ArticleDOI
TL;DR: Micro-level household data analysis and macro-level cross-country analysis give empirical support to the hypothesis that risk-sharing in health financing matters in terms of its impact on both the level and distribution of health, financial fairness and responsiveness indicators.
Abstract: How to finance and provide health care for the more than 1.3 billion rural poor and informal sector workers in low- and middle-income countries is one of the greatest challenges facing the international development community. This article presents the main findings from an extensive survey of the literature of community financing arrangements, and selected experiences from the Asia and Africa regions. Most community financing schemes have evolved in the context of severe economic constraints, political instability, and lack of good governance. Micro-level household data analysis indicates that community financing improves access by rural and informal sector workers to needed heath care and provides them with some financial protection against the cost of illness. Macro-level cross-country analysis gives empirical support to the hypothesis that risk-sharing in health financing matters in terms of its impact on both the level and distribution of health, financial fairness and responsiveness indicators. The background research done for this article points to five key policies available to governments to improve the effectiveness and sustainability of existing community financing schemes. This includes: (a) increased and well-targeted subsidies to pay for the premiums of low-income populations; (b) insurance to protect against expenditure fluctuations and re-insurance to enlarge the effective size of small risk pools; (c) effective prevention and case management techniques to limit expenditure fluctuations; (d) technical support to strengthen the management capacity of local schemes; and (e) establishment and strengthening of links with the formal financing and provider networks.

191 citations

BookDOI
01 Jan 2003
TL;DR: This book is an attempt to examine the design, implementation and impact of reforms that introduced market forces in the public hospital sector and provides some insights about recent trends in the reform of public hospitals, with an emphasis on organizational changes such as increased management autonomy, corporatization, and privatization.
Abstract: The question of how best to run our hospitals has been a subject of intense interest for decades with a strong focus over the past 15 years. Hospital care is the largest expenditure category in the health systems of both industrialized and developing countries. Although hospitals play a critical role in ensuring delivery of health services, less is known about how to improve the efficiency and quality of care provided. This book, a well-documented collection of case studies, is an attempt to examine the design, implementation and impact of reforms that introduced market forces in the public hospital sector; and tries to answer three questions: a) what problems did this type of reform try to address; b) what are the core elements of their design, implementation, and evaluation; and c) is there any evidence that this type of reform is successful in addressing problems for which they were intended?. It also provides some insights about recent trends in the reform of public hospitals, with an emphasis on organizational changes such as increased management autonomy, corporatization, and privatization.

180 citations

MonographDOI
TL;DR: The authors conclude by proposing concrete public policy measures that governments can introduce to strengthen and improve the effectiveness of community involvement in health care financing.
Abstract: Most community financing schemes have evolved in the context of severe economic constraints, political instability, and lack of good governance. Usually government taxation capacity is weak, formal mechanisms of social protection for vulnerable populations absent, and government oversight of the informal health sector lacking. In this context of extreme public sector failure, community involvement in the financing of health care provides a critical albeit insufficient first step in the long march towards improved access to health care by the poor and social protection against the cost of illness. Health Financing for Poor People stresses that community financing schemes are no panacea for the problems that low-income countries face in resource mobilization. They should be regarded as a complement to - not as a substitute for - strong government involvement in health care financing and risk management related to the cost of illness. Based on an extensive survey of the literature, the main strengths of community financing schemes are the extent of outreach penetration achieved through community participation, their contribution to financial protection against illness, and increase in access to health care by low-income rural and informal sector workers. Their main weaknesses are the low volume of revenues that can be mobilized from poor communities, the frequent exclusion of the very poorest from participation in such schemes without some form of subsidy, the small size of the risk pool, the limited management capacity that exists in rural and low-income contexts, and their isolation from the more comprehensive benefits that are often available through more formal health financing mechanisms and provider networks. The authors conclude by proposing concrete public policy measures that governments can introduce to strengthen and improve the effectiveness of community involvement in health care financing.

154 citations

Journal ArticleDOI
TL;DR: A conceptual framework in which a combination of institutional economics and organizational theory is used to examine the core production activities in the health sector concludes that most inputs for the healthsector can be efficiently produced by and bought from the private sector.
Abstract: A central theme of recent health care reforms has been a redefinition of the roles of the state and private providers. With a view to helping governments to arrive at more rational "make or buy" decisions on health care goods and services, we propose a conceptual framework in which a combination of institutional economics and organizational theory is used to examine the core production activities in the health sector. Empirical evidence from actual production modalities is also taken into consideration. We conclude that most inputs for the health sector, with the exception of human resources and knowledge, can be efficiently produced by and bought from the private sector. In the health services of low-income countries most dispersed production forms, e.g. ambulatory care, are already provided by the private sector (non-profit and for-profit). These valuable resources are often ignored by the public sector. The problems of measurability and contestability associated with expensive, complex and concentrated production forms such as hospital care require a stronger regulatory environment and skilled contracting mechanisms before governments can rely on obtaining these services from the private sector. Subsidiary activities within the production process can often be unbundled and outsourced.

128 citations


Cited by
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Journal ArticleDOI
TL;DR: This article documents disparities in access to health services in low‐ and middle‐income countries (LMICs), using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services.
Abstract: People in poor countries tend to have less access to health services than those in better-off countries, and within countries, the poor have less access to health services. This article documents disparities in access to health services in low- and middle-income countries (LMICs), using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services. Whereas the poor in LMICs are consistently at a disadvantage in each of the dimensions of access and their determinants, this need not be the case. Many different approaches are shown to improve access to the poor, using targeted or universal approaches, engaging government, nongovernmental, or commercial organizations, and pursuing a wide variety of strategies to finance and organize services. Key ingredients of success include concerted efforts to reach the poor, engaging communities and disadvantaged people, encouraging local adaptation, and careful monitoring of effects on the poor. Yet governments in LMICs rarely focus on the poor in their policies or the implementation or monitoring of health service strategies. There are also new innovations in financing, delivery, and regulation of health services that hold promise for improving access to the poor, such as the use of health equity funds, conditional cash transfers, and coproduction and regulation of health services. The challenge remains to find ways to ensure that vulnerable populations have a say in how strategies are developed, implemented, and accounted for in ways that demonstrate improvements in access by the poor.

1,130 citations

01 Jan 1997
TL;DR: Heskett, Sasser, and Schlesinger as mentioned in this paper show how managers at American Express, Southwest Airlines, Banc One, Waste Management, USAA, MBNA, Intuit, British Airways, Taco Bell, Fairfield Inns, Ritz-Carlton Hotel, and the Merry Maids subsidiary of ServiceMaster employ a quantifiable set of relationships that directly link profit and growth to not only customer loyalty and satisfaction, but to employee loyalty, satisfaction, and productivity.
Abstract: Why are a select few service firms better at what they do - year in and year out - than their competitors? For most senior managers, the profusion of anecdotal "service excellence" books fails to address this key question. In this pathbreaking book, world-renowned Harvard Business School service firm experts James L. Heskett, W. Earl Sasser, Jr. and Leonard A. Schlesinger reveal that leading companies stay on top by managing the service profit chain. Based on five years of painstaking research, the authors show how managers at American Express, Southwest Airlines, Banc One, Waste Management, USAA, MBNA, Intuit, British Airways, Taco Bell, Fairfield Inns, Ritz-Carlton Hotel, and the Merry Maids subsidiary of ServiceMaster employ a quantifiable set of relationships that directly links profit and growth to not only customer loyalty and satisfaction, but to employee loyalty, satisfaction, and productivity. The strongest relationships the authors discovered are those between (1) profit and customer loyalty; (2) employee loyalty and customer loyalty; and (3) employee satisfaction and customer satisfaction. Moreover, these relationships are mutually reinforcing; that is, satisfied customers contribute to employee satisfaction and vice versa. Here, finally, is the foundation for a powerful strategic service vision, a model on which any manager can build more focused operations and marketing capabilities. For example, the authors demonstrate how, in Banc One's operating divisions, a direct relationship between customer loyalty measured by the "depth" of a relationship, the number of banking services a customer utilizes, and profitability led the bank to encourage existing customers to further extend the bank services they use. Taco Bell has found that their stores in the top quadrant of customer satisfaction ratings outperform their other stores on all measures. At American Express Travel Services, offices that ticket quickly and accurately are more profitable than those which don't. With hundreds of examples like these, the authors show how to manage the customer-employee "satisfaction mirror" and the customer value equation to achieve a "customer's eye view" of goods and services. They describe how companies in any service industry can (1) measure service profit chain relationships across operating units; (2) communicate the resulting self-appraisal; (3) develop a "balanced scorecard" of performance; (4) develop a recognitions and rewards system tied to established measures; (5) communicate results company-wide; (6) develop an internal "best practice" information exchange; and (7) improve overall service profit chain performance. What difference can service profit chain management make? A lot. Between 1986 and 1995, the common stock prices of the companies studied by the authors increased 147%, nearly twice as fast as the price of the stocks of their closest competitors. The proven success and high-yielding results from these high-achieving companies will make The Service Profit Chain required reading for senior, division, and business unit managers in all service companies, as well as for students of service management.

862 citations

Journal ArticleDOI
TL;DR: It is suggested that 150 million people globally suffer financial catastrophe annually because they pay for health services, and there is no strong evidence that social health insurance systems offer better or worse protection than tax-based systems do.
Abstract: Many countries rely heavily on patients’ out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe a...

819 citations

Journal ArticleDOI
TL;DR: In 2018, Kohler Riessman et al. as discussed by the authors proposed a solution manual for Statistical Theory Solution Manual for Environmental Engineering andStructural And Stress Analysis Solution Manual with C G Jung.
Abstract: Basic Electrical And Electronics Engineering Bhatacharya S KOtis 4000 Otis Worldwide HomeVisual Diagnosis And Treatment In Pediatrics 3rd EditionThe Two Mountains An Aztec LegendLippincott Manual Of Nursing Practice 10th EditionFoxfire Confessions Of A Girl GangNeedle Roller Bearings SkfIntroduction To Statistical Theory Solution ManualChemistry For Environmental Engineering AndStructural And Stress Analysis Solution ManualMemories Dreams Reflections By C G Jung Goodreads2018 19 Sat Act TestYanmar Diesel Engine 4jh3 Te Hte Dte Service ManualDelivery System Handbook For Personal Care And Cosmetic Products Technology Applications And Formulations Personal Care And Cosmetic TechnologyCambridge English Prepare Level 6 Students Book By James StyringSar Dr Mission Aircrew Refresher Ser Fl051 Fl051 Flwg UsLivre Math 3eme Hachette Collection PhareLeadership Secrets Of Jesus By Mike Murdock 1997Bashan 250 Service ManualElements Of Modern AlgebraLibro Gratis Las Cuatro Estaciones I Primavera Y VeranoGrade11 Economics Scope For Paper 1The Wes Anderson Collection Matt Zoller SeitzExtending The Laws Of Exponents Key412 Exporting Spot Color Separations From PhotoshopReview Catherine Kohler Riessman 2008 NarrativeBiochemistry Garrett 1st Canadian EditionMicrobiology An Introduction 11th Edition PowerpointThe Hit Will Robie 2 David BaldacciBetrayal In The City Summary

560 citations

Journal ArticleDOI
Björn Ekman1
TL;DR: The main policy implication of the review is that these types of community financing arrangements are, at best, complementary to other more effective systems of health financing.
Abstract: Health policy makers are faced with competing alternatives, and for systems of health care financing. The choice of financing method should mobilize resources for health care and provide financial protection. This review systematically assesses the evidence of the extent to which community-based health insurance is a viable option for low-income countries in mobilizing resources and providing financial protection. The review contributes to the literature on health financing by extending and qualifying existing knowledge. Overall, the evidence base is limited in scope and questionable in quality. There is strong evidence that community-based health insurance provides some financial protection by reducing out-of-pocket spending. There is evidence of moderate strength that such schemes improve cost-recovery. There is weak or no evidence that schemes have an effect on the quality of care or the efficiency with which care is produced. In absolute terms, the effects are small and schemes serve only a limited section of the population. The main policy implication of the review is that these types of community financing arrangements are, at best, complementary to other more effective systems of health financing. To improve reliability and validity of the evidence base, analysts should agree on a more coherent set of outcome indicators and a more consistent assessment of these indicators. Policy makers need to be better informed as to both the costs and the benefits of implementing various financing options. The current evidence base on community-based health insurance is mute on this point.

486 citations