Showing papers in "International Journal of Health Planning and Management in 2003"

Analysing the primacy of distance in the utilization of health services in the Ahafo-Ano South district, Ghana

Abstract: Although the distance factor has been identified as key in the utilization of health services in rural areas of developing countries, it has been analysed without recourse to related factors of travel time and transport cost. Also, the influence of distance on vulnerable groups in utilization has not been an object of survey by researchers. This paper addresses the impact of distance on utilization, and how distance compares with travel time and transport cost that are related to it in the utilization of health services in the Ahafo-Ano South (rural) district in Ghana. The study, a cross-sectional survey, also identifies the position of distance among other important factors of utilization. A sample of 400, drawn through systematic random technique, was used for the survey. Data were analysed using the regression model and some graphic techniques. The main instruments used in data collection were formal (face-by-face) interview and a questionnaire. The survey finds that distance is the most important factor that influences the utilization of health services in the Ahafo-Ano South district. Other key factors are income, service cost and education. The effect of travel time on utilization reflects that of distance and utilization. Recommendations to reduce distance coverage, improve formal education and reduce poverty have been made.

Health workforce imbalances in times of globalization: brain drain or professional mobility?

Abstract: The health workforce is of strategic importance to the performance of national health systems as well as of international disease control initiatives. The brain drain from rural to urban areas, and from developing to industrialized countries is a long-standing phenomenon in the health professions but has in recent years taken extreme proportions, particularly in Africa. Adopting the wider perspective of health workforce balances, this paper presents an analysis of the underlying mechanisms of health professional migration and possible strategies to reduce its negative impact on health services. The opening up of international borders for goods and labour, a key strategy in the current liberal global economy, is accompanied by a linguistic shift from 'human capital flight' and 'brain drain' to 'professional mobility' or 'brain circulation'. In reality, this mobility is very asymmetrical, to the detriment of less developed countries, which lose not only much-needed human resources, but also considerable investments in education and fiscal income. It is argued that low professional satisfaction and the decreasing social valuation of the health professionals are important determinants of the decreasing attraction of the health professions, which underlies both the push from the exporting countries, as well as the pull from the recipient countries. Solutions should therefore be based on this wider perspective, interrelating health workforce imbalances between, but also within developing and developed countries.

A code of best practice for disease control programmes to avoid damaging health care services in developing countries.

Abstract: How should we implement disease control programmes so as to strengthen existing health systems? To answer this question we re-examined the integration of these programmes from a managerial perspective. Based on a literature review we concluded that integration is essential in the majority of cases. We went on to examine the mechanisms whereby the integration of disease control activities can jeopardize health care delivery resulting in low service utilization low detection and cure rates and patient delays. To do this we clustered disease control programmes into three categories and assessed the impact of each on local health care facilities. From these results we suggest a series of measures designed to help aid agencies and national governments support local health care infrastructures or as a minimum avoid damaging them. Whilst some vertical programmes should never be integrated two conditions are essential to the integration of others: (1) Disease control needs to be integrated with general health care delivery—which implies the possibility to deliver general practice/family medicine care in publicly oriented health services. (2) Integration of both operational and administrative aspects should take place simultaneously. Any health policies in developing countries tending to allocate disease control programmes to government facilities and general health care to private facilities preclude their integration. They risk unravelling the fabric on which both disease control and health care delivery depend. (authors)

District health systems in a neoliberal world: a review of five key policy areas

Abstract: District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a 'second generation' reform--to be superseded by third generation reforms with a market orientation--flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass campaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor.

Working in a decentralized system: a threat to health workers' respect and survival in Uganda.

Abstract: This article contributes to the sparse empirical material on the position of health workers within health sector reform. Using qualitative data gathered in 1999, it shows how staff at rural health units in Tororo and Busia Districts experienced the reforms during the first 5 years of decentralization in Uganda. The analysis builds on a framework proposed by Franco et al. to examine the relation between health sector reform and health worker motivation. However, it diverges from their objective description of the factors determining motivation, giving more emphasis to the subjective perspective of the health workers. The categorical distinction between organizational and cultural/community factors was less relevant for them as actors. Two themes cross-cut their lives inside and outside the health facilities: professional identity, which entailed recognition by both the organization and members of the community; and ‘survival strategies’, which were necessitated by the desire to maintain a status and lifestyle befitting a professional. Reform weakened workers' positions as professionals and hindered facility-based ‘survival strategies’ that helped them get by on poor salaries. With an overall fall in remuneration, they were more motivated than ever to establish supplementary sources of income outside the formal government health care system. Copyright © 2003 John Wiley & Sons, Ltd.

Costs of maternal health care services in three anglophone African countries

Abstract: This paper is a synthesis of a case study of provider and consumer costs, along with selected quality indicators, for six maternal health services provided at one public hospital, one mission hospital, one public health centre and one mission centre, in Uganda, Malawi and Ghana. The study examines the costs of providing the services in a selected number of facilities in order to examine the reasons behind cost differences, assess the efficiency of service delivery, and determine whether management improvements might achieve cost savings without hurting quality. This assessment is important to African countries with ambitious goals for improving maternal health but scarce public health resources and limited government budgets. The study also evaluates the costs that consumers pay to use the maternal health services, along with the contribution that revenues from fees for services make to recovering health facility costs. The authors find that costs differ between hospitals and health centres as well as among mission and public facilities in the study sample. The variation is explained by differences in the role of the facility, use and availability of materials and equipment, number and level of personnel delivering services, and utilization levels of services. The report concludes with several policy implications for improvements in efficiency, financing options and consumer costs.

Prioritization of prevention activities to combat the spread of HIV/AIDS in resource constrained settings: a cost-effectiveness analysis from Chad, Central Africa.

Abstract: In Chad, as in most sub-Saharan Africa countries, HIV/AIDS poses a massive public health threat as well as an economic burden, with prevalence rates estimated at 9% of the adult population. In defining and readjusting the scope and content of the national HIV/AIDS control activities, policy makers sought to identify the most cost-effective options for HIV/AIDS control. The cost-effectiveness analysis reported in this paper uses a mixture of local and international information sources combined with appropriate assumptions to model the cost-effectiveness of feasible HIV prevention options in Chad, with estimates of the budget impact. The most cost-effective options at under US$100 per infection prevented were peer group education of sex workers and screening of blood donors to identify infected blood before transfusion. These options were followed by mass media and peer group education of high risk men and young people, at around US$500 per infection prevented. Anti-retroviral therapy for HIV infected pregnant women and voluntary counselling and testing were in the order of US$1000 per infection prevented. The paper concludes with recommendations for which activities should be given priority in the next phase of the national HIV/AIDS control programme in Chad.

Stronger health systems for more effective HIV/AIDS prevention and care

Abstract: Of the 42 million living with HIV/AIDS world-wide some 90% live in developing countries. The international community acknowledges the devastating impact of HIV/AIDS on development and over the past few years resources to control HIV/AIDS have increased considerably. We argue that strengthening of health systems is a necessary prerequisite for improving the prevention of HIV infection and the care of HIV-infected persons. Sexual behaviour change requires a multidisciplinary approach, but health services play a crucial role in detection and treatment of other sexually transmitted infections; HIV counselling and testing; prevention of mother-to-child transmission of HIV; and care of HIV-infected patients. Increasing access to antiretroviral treatment especially poses formidable challenges to health authorities in developing countries. Additional resources for the prevention of HIV-infection and the care of HIV-infected persons may not have the desired impact if health systems in developing countries are not strengthened. Further, any activity in the area of HIV/AIDS prevention and care, carried out within health services, can have a positive ripple effect on other health care activities and vice versa. This interactive effect needs to be acknowledged and built on.

Nordic privatization and private healthcare

Abstract: The role of the private sector in public healthcare systems is much debated, but there is little research to inform the debate. In the Nordic countries the extent and type of private sector involvement is largely unknown and the changes and the consequences have not been studied. This paper presents a conceptual framework and some limited data about the changing private-public mix and privatization in the Nordic countries between 1985 and 2000. The data suggest a small increase in both private financing and provision which has accelerated in recent years, especially in specific healthcare fields such as diagnostic centres, dentistry, primary medical care and care for older people. The overall increase is small, but large in certain sectors. Differences between the countries can only be understood in relation to their historical, financial, economic and political context, even though there are many commonalities. Impact also is context dependent, but the findings do show a cross-country pattern of a willingness to experiment and a change in underlying assumptions. The findings show a more extensive interpenetration of private and public than previously recognized but more research is required, especially about changes in recent years about which data are scarce. The paper considers the factors driving these trends, the likely larger changes in the next 10 years and the possible consequences for patients, professionals, managers and governments. It notes the different ways governments can control or influence finance and provision. It proposes that the Nordic and other governments improve regulation and data collection about the private sector and consider influencing private providers through partnership arrangements, rather than leaving the developments to be shaped by growing consumer demands or market logic alone.

Selecting medical devices and materials for development in Korea: the analytic hierarchy process approach.

Abstract: Recently, the health industry in Korea has been given greater emphasis. Amid budgetary restrictions, setting the priorities for effective and efficient investment in medical devices and materials has been a key issue in the government sector. This paper shows how the analytic hierarchy process (AHP) can be used in assessing selected medical devices and materials for grants by the Korean Ministry of Health and Welfare. The final results show that unabsorbable suture is the most attractive medical product among 88 evaluated products, followed by i.v. cannula and central venous catheter. Copyright © 2003 John Wiley & Sons, Ltd.

Quality standards for health care delivery and management in publicly oriented health services

Abstract: In 1999, the multidisciplinary Tavistock group prepared a generic statement of ethical principles to govern health care systems. This paper elaborates on these principles in two directions. First, it develops a set of quality standards, based on ethical principles, intended to regulate health care delivery and service management. Second, it focuses them on 'publicly oriented' (not necessarily governmental) as opposed to 'for profit' (not necessarily private) services. We propose ten principles or quality standards for these services, part of which relate to the individual patients, others to the community. They are political as well as technical, and can be used to inspire health policies, contracts issued by governments, and identification of partners by aid agencies. We analyse their application in key areas of health care by publicly oriented and for-profit health care organizations standards in developing countries, and conclude that the latter are unlikely to adopt the proposed standards. We further elaborate on the implications of the standards for publicly oriented services, focusing on care delivery and patient-centred care, family and community medicine, services management and disease control. Using these criteria for a renewed compact between authorities, health professionals and communities may help to motivate health professionals by bridging the gap between their professional and social-political identity.

Organizing health care within political turmoil: the Palestinian case.

Abstract: Palestinians were given control over their own health services in late 1994. Since then they have been facing the challenge of reorganizing disordered health services into a cohesive, regulated and sustainable health care system. This paper focuses on the experience of organizing health care during political instability. It considers the ways that health care is currently provided and funded in the Palestinian Territories. The patterns of accessibility to health care services in terms of insurance coverage and provision (physical allocation) of services are discussed. Finally, the major health care policy changes in this transitional period are examined. Copyright © 2003 John Wiley & Sons, Ltd.

Determinants of health status and the influence of primary health care services in Latin America, 1990-98.

Abstract: Primary health care (PHC) services have been advocated as a means by which less developed countries may improve the health of their populations even in the face of poverty, low levels of literacy, poor nutrition and other factors that negatively influence health status. Using aggregated data from the World Bank and UNICEF this study examined which factors, both within the health care system and outside of it, are associated with under-5 mortality rates in 22 countries of Latin America and the Caribbean during the 1990s. In a multivariate analysis using generalized estimating equations for repeated measures, five factors were found to be independent predictors of lower under-5 mortality rates (U5MRs). These were vaccination levels, female literacy, the use of oral rehydration therapy, access to safe water and GNP per capita. When the magnitude of these associations were assessed, higher levels of GNP per capita was found to be very weakly associated with lower U5MRs, compared with female literacy and vaccination rates. These findings suggest that government policies which focus only on promoting economic growth, while not making important investments in PHC services, female education and access to safe water are unlikely to see large improvements in health status. Copyright © 2003 John Wiley & Sons, Ltd.

The impact of financial constraints and incentives on professional autonomy.

Abstract: General practice has been the subject of extensive reforms over the 1990s in Australia as elsewhere. Reforms have attempted to improve quality and contain the overall cost of health care, and have often been seen as reducing the autonomy of medical professionals. This paper examines the impact of financial constraints and incentives introduced during the 1990s on Australian GPs' perceptions of autonomy. An existing seven component definition of autonomy and six themes that emerged from reviewing publications were used to construct focus group questions. A total of 25 GPs participated in four focus groups. Those who participated believe that their financial autonomy has been diminished by policy changes and consumer expectations. They also perceive that their ability to control clinical decisions, which they regard as the most important aspect of professional autonomy, has been reduced along with financial autonomy. Organized medicine in Australia sees financial accountability and clinical decision making as polar opposites, and has continued to argue that fee-for-service payment is the only appropriate method of remuneration, despite increasing evidence that this does not guarantee clinical autonomy. Major changes to the financing of general practice in Australia are required to address the concerns of GPs, governments and patients.

Globalization, global health, and access to healthcare.

Abstract: It is now commonly realized that the globalization of the world economy is shaping the patterns of global health, and that associated morbidity and mortality is affecting countries' ability to achieve economic growth. The globalization of public health has important implications for access to essential healthcare. The rise of inequalities among and within countries negatively affects access to healthcare. Poor people use healthcare services less frequently when sick than do the rich. The negative impact of globalization on access to healthcare is particularly well demonstrated in countries of transitional economies. No longer protected by a centralized health sector that provided free universal access to services for everyone, large segments of the populations in the transition period found themselves denied even the most basic medical services. Only countries where regulatory institutions are strong, domestic markets are competitive and social safety nets are in place, have a good chance to enjoy the health benefits of globalization.

Health systems in developing countries: public sector managers and the management of contradictions and change.

Abstract: Health sector reform in the past decade has tended to focus on remodelling institutional relations and changing methods of health system financing. Little attention has been paid to human resources. This paper focuses on one category of health sector staff, health managers and planners, and the tensions they face in carrying out their roles. An understanding of these tensions has been neglected in the policy-making process. The paper is divided into two parts. Firstly, it will set out the nature of three tensions that public sector health managers and planners face: changes in the health care system; the contradictions between public interest and private gain; and changes in the forms of accountability. Secondly, it will suggest ways forward in relation to these problems, paying particular attention to the role of international agencies.

Strong general health care systems: a prerequisite to reach global tuberculosis control targets.

Abstract: We argue that tuberculosis control cannot reach its proposed global targets without investment in an adequate network of accessible, effective and comprehensive health services. Lessons from the past are reviewed. They underscore that passive case-detection and adequate case management is the central technical strategy for tuberculosis control. There is no compelling evidence to support active case-detection in the general population. We elaborate on why a strong health care system is a prerequisite in the framework of case-detection and treatment. The necessity to improve quality and accessibility of general health services for ensuring early detection and subsequent cure is demonstrated. It is argued why the need for strong public health care system becomes even more eminent in the light of the tuberculosis/HIV dual epidemics and of the rapid growth of unregulated private-for-profit services. We finally examine the financial gaps for tuberculosis control and discuss the need for allocating more resources to the strengthening of general health care systems. Copyright © 2003 John Wiley & Sons, Ltd.

Effective community health participation strategies: a Cuban example.

Abstract: Since the decade of the 1970s health promotion has been an integral part of most primary health care strategies. This article examines some community participation strategies adopted in the health promotion in Cuba and the policies which enable such strategies. This is done in the context of health promotion theory and also examines the concept of direct involvement by the political directorate in health promotion. The article is written from a reflexive perspective following the author's visit to Cuba as member of a health study tour in March 2002. Copyright © 2003 John Wiley & Sons, Ltd.

Understanding referral from primary care clinics in rural Kenya: using health information systems to prioritize health services

Abstract: This study analyses the referral patterns of patients, over time, from primary care to secondary or tertiary level facilities in rural Africa. The data come from a health information system of a non-governmental organization with a decade of experience in health services delivery in Samburu District, Kenya. The differential referral patterns from two communities are examined in some detail to shed more light on the meaning of a 'referral rate' in this context. First, referral rates over time for two clinics are calculated and compared. These quantitative data, obtained from monthly reports from 1989 to 1997, are interpreted in the light of qualitative data obtained from interviews with community health workers, nurses and members of the communities. The main differences in referral between these ostensibly similar communities are for malaria, trauma and anaemia. Social, environmental and specific health services factors are used to explain these differences. We demonstrate that basic information from health information systems, which tell us little on their own because referral in this context is a rare event, can be combined with local knowledge from the community to provide evidence for health managers to set priorities for public health and clinical interventions.

The importance of quality, access and price to health care consumers in Bulgaria: a self‐explicated approach

Abstract: One approach to the problem of low patient satisfaction in Bulgaria is to identify attributes of health care services that the consumers value most and to focus on their improvement. Based on data from a household survey, this paper examines the importance that health care consumers attach to quality, access and price. The survey was conducted in 2000 among the population of the region of Varna (the third largest city in Bulgaria). The elicitation of attribute importance was based on a self-explicated method. To analyse the data, an ordered logit regression was performed. The analysis shows that clinical quality is the most valued characteristic by Bulgarian health care consumers compared with social quality, access and price. Given the poor quality of health care provision in Bulgaria, the allocation of revenues to its improvement appears to be essential in order to raise patient satisfaction and to enhance social efficienc

Governance in a period of strategic change in U.S. healthcare.

Abstract: The increased enrollment in managed care plans, merger mania and the development of politically and financially powerful integrated delivery systems have significantly complicated the governance of U.S. healthcare organizations. These modifications in fiscal incentives and the corporate restructuring undertaken by American health organizations has resulted in limited fiscal savings or improvements in access to care. As a result, trustees are now faced with divesting their losers, and shuttering facilities and services to reduce fixed costs. Decision-making by trustees will be further thwarted in the future by: their institutions being forced to deliver more care without a proportional increase in revenues; physicians seeking to obtain more ambulatory revenues at a hospital's expense; the inability to adequately finance mental health and long-term care services except among the wealthy; the number of divestitures increasing so that eventually the organizational focus for most IDSs will once again be on regionally oriented hospital systems; and much more difficulty being experienced in attracting sufficiently qualified personnel to deliver high quality health services. Finally, many of these findings relevant to the United States also are being shared by governing boards in Canada, Germany, The Netherlands and the United Kingdom. Copyright © 2003 John Wiley & Sons, Ltd.

The impact of self-assessment on provider performance in Mali.

Abstract: Improving the quality of clinical care in developing country settings is a difficult task, both in public sector settings where supervision is infrequent and in private sector settings where supervision and certification are non-existent. This study tested a low-cost method, self-assessment, for improving the quality of care that providers offer in a peri-urban area in Mali. The study was a cross-sectional, case-control study on the impact of self-assessment on compliance with the quality of care standards. The two indicators of interest were the compliance with fever care standards and the compliance with structural quality standards. Both standards were derived from the Ministry of Health of Mali's standards for health care delivery. The study examined 36 providers, 12 of whom were part of the intervention and 24 of whom were part of the control group over a 3 month period from May to July 2001. Overall, the research team found a significant difference between the intervention and control groups in terms of overall compliance (p < 0.001) and in terms of assessment of fever (p < 0.005). The total costs for the intervention for 36 providers was less than US$250, which translated to approximately $6 per provider. The data appear to suggest that self-assessment, when used in a regular fashion, can have a significant effect on compliance with standards. However, it is clear that self-assessment is not a resource-neutral intervention. All of the individuals from the intervention pool interviewed cited the extra work that they had to do to comply with the intervention protocol as a burden. In particular, study participants put an emphasis on the 'long duration' of the study that 'discouraged' the study participants. Future research on self-assessment should include a larger sample of providers and should examine the impact of self-assessment over time.

Emerging crisis of continuing professional education: becoming a dead letter between external pressure and personal incentive?

Abstract: Csontinuing professional education (CPE) has been recognized as an effective tool for equipping health professionals with updated knowledge and skills for improving health services quality. However, there is globally increasing skepticism concerning the effectiveness of CPE. In developed countries, the major reasons for participation in CPE include compliance with employers' requirements and renewal of specialist qualifications and licences. In developing countries, CPE, frequently supported by development agencies, often provides subsistence support to participants and is possibly perceived as an extra income opportunity or tool for promotion among health professionals. The knowledge and skills learned are insufficiently applied in daily practice. This carrot-and-stick approach should be reduced and efforts should be made to increase the level of application of what has been learned. To deliver more effective and efficient CPE, it is critical to study this issue in more depth. Copyright © 2003 John Wiley & Sons, Ltd.

Privatization and the allure of franchising: a Zambian feasibility study.

Abstract: Efforts to privatize portions of the health sector have proven more difficult to implement than had been anticipated previously One common bottleneck encountered has been the traditional organizational structure of the private sector, with its plethora of independent, single physician practices The atomistic nature of the sector has rendered many privatization efforts difficult, slow and costly—in terms of both organizational development and administration In many parts of Africa, in particular, the shortages of human and social capital, and the fragile nature of legal institutions, undermine the appeal of privatization The private sector is left with inefficiencies, high prices and costs, and a reduced effective demand The result is the simultaneous existence of excess capacity and unmet need One potential method to improve the efficiency of the private sector, and thereby enhance the likelihood of successful privatization, is to transfer managerial technology—via franchising—from models that have proven successful elsewhere This paper presents a feasibility analysis of franchizing the successful Bolivian PROSALUD system's management package to Zambia The assessment, based on PROSALUD's financial model, demonstrates that technology transfer requires careful adaptation to local conditions and, in this instance, would still require significant external assistance Copyright © 2003 John Wiley & Sons, Ltd

Projecting the cost of essential services in Bangladesh.

Abstract: Utilizing a study of the costs of providing essential services in rural areas in Bangladesh projections of the cost of expanding services to the entire rural population are derived. These estimates are based on the current system of primary care, the demographic structure of the population and normatives for desired utilization. Scenarios make use of known demographic characteristics of average rural areas together with information on disease prevalence. The estimates highlight a number of difficulties involved in deriving costs and in comparing the cost-effectiveness of service provision. The integrated nature of much primary care, both in terms of the technical exploitation of joint costs and clinical diagnostic and treatment protocols, means that treating services in isolation is likely to lead to inexact estimates of service cost. The context of any costs derived is required in order to make comparisons. Copyright © 2003 John Wiley & Sons, Ltd.

Health policy and its implementation in small island developing states in the British West Indies.

Abstract: SUMMARY Health policy and its implementation in small island developing states (SIDS) is a neglected area of study, and, seemingly, of little interest. The existing literature is generally characterized by descriptions of failure or incompetence, with little attempt to understand the nature and workings of the policy process in these small, yet complex, societies. The research undertaken in this article was carried out over 6 years in Anguilla (pop. 9000) and the British Virgin Islands (pop. 20 000), two British Overseas Territories in the North East Caribbean. The purpose of the research was to determine to what extent policy theory and the tools of policy analysis could be used to explain the nature and the outcomes of the health policy and implementation process. In trying to analyse and understand the policy process in these small islands it was necessary to understand their socio-politic character. In addition, the development of a model of the public policy and public administration system in the English-speaking Caribbean was an essential part of this process. It was found that the conduct and outcome of the policy and implementation process in these islands varied significantly. It is postulated that the variations are anchored in the nature of the local context, the working practices and ideologies of politicians, senior public servants and the local policy elite. Copyright # 2003 John Wiley & Sons, Ltd.

Using financing to motivate a for-profit health care provider to deliver family planning services: is it a cost-effective intervention? A study of AAR health services in Kenya.

Abstract: Despite much discussion of the role of private health care providers, there are no tried and tested models for supporting for-profit providers in ways that produce cost-effective public health outcomes. This paper examines the cost effectiveness of using a loan mechanism to motivate a for-profit provider to deliver family planning services. The intervention examined directly resulted in a private provider delivering family planning services, however, it did not create a long-term financial incentive for the private provider to promote the use of family planning. The cost effectiveness of this intervention is analysed using a methodology that captures long term sustainability of the intervention within a traditional family planning outcome measure, such as couple years protection (CYP), by discounting future expected CYPs. Depending on the method for analysing costs and assumptions regarding future CYPs, this intervention produced family planning outcomes at no or very low cost ($0–$4.11 per CYP). The analysis demonstrates that innovative family planning interventions with private providers should be considered as they can be more cost effective than traditional programmes. Copyright © 2003 John Wiley & Sons, Ltd.

Disease coding errors by health care organizations: effects of a government quality intervention.

Abstract: SUMMARY Disease coding errors in claims data can cause serious problems for financing, reimbursement systems, public health surveillance and health research. This study analysed a government intervention to improve coding accuracy of health care organizations in South Korea. The intervention was implemented in 1997 by 226 organizations that had submitted erroneous claims in 1996 for five selected diseases. In 1998, 94% of these organizations eliminated coding errors for these diseases. Those organizations least responsive to the intervention were tertiary hospitals, those publicly owned, and those with other complex organizational characteristics. Overall, this simple intervention appeared extremely effective, and wider adoption of such techniques should be explored. Copyright # 2003 John Wiley & Sons, Ltd.

Cost analysis of pneumonia treatment in the Philippines.

Abstract: The objectives of this study were to describe the cost distribution of pneumonia treatment in tertiary hospitals in the National Capital Region (NCR) and to identify variations in costs in order to provide basic information to the Philippine Health Insurance Corporation (PHIC) for quality assurance and policy development. This study focuses on 3861 reimbursement claims, which come from 22 government and 38 private tertiary hospitals. Wide variations of cost existed among the hospitals and among the inpatients. Medicine was the leading expenditure in total costs (38%), second was examinations (27%), third was beds (22%) and the last was doctors fees (13%). The same ranking ocurred for reimbursement by PHIC. The private hospitals were more expensive than the government hospitals, but also more efficient in the length of hospitalization. The member patients spent more and were reimbursed more for clinical practice than the dependent patients. However, there was no difference in the length of hospitalization between member and dependent patients. There was no difference in the length of hospitalization and expenditure between Government Service Insurance System (GSIS) in 1997 and Social Security System (SSS) patients. Clinical guidelines should be effectively implemented and PHIC should contribute more to reduce existing variations, improve cost-effectiveness and the quality of clinical practices.