Publications
NGO Facilitation of a Government Community-Based Maternal and Neonatal Health Programme in Rural India: Improvements in EquityBaqui A, Rosecrans A, Williams E, Agrawal P, et. al. Health Policy and Planning 2008 23: 234 – 43.
Baqui et al use a quasi-experimental design with one intervention and one control district to evaluate the neonatal component of a governmental program for integrated nutrition and health in Uttar Pradesh India after a private NGO, CARE-India, was engaged to aid in planning, training, and logistic support of government provided infrastructure, health workers, and supplies. The district with government services supported by the NGO showed improvements in coverage and equity for all health measures. Improvements were attributed to NGO-provided additional training, planning, supervision and monitoring of community health workers. Despite the relative gains. overall equity, use of facilities, and quality remained low. The authors recommend ongoing collaborations between government and NGOs to increase utilization and decrease barriers to equity.
Strengthening Health Systems in Poor Countries: A Code of Conduct for Nongovernmental OrganizationsPfeiffer J, Johnson W, Fort M, Shakow A, Hagopian A, Gloyd S, Gimbel-Sherr K. American Journal of Public Health, 2008. 98(12): 2134 – 38
Pfeiffer et al. argue that inordinate distribution of international aid through NGOs, rather than local ministries of health, can undermine public systems of care by fragmenting services, promoting a brain drain from the public sector, fostering unsustainable and limited health projects, and increasing administrative burden of local health officials. The authors believe that a code of conduct for NGOs could “help strengthen health systems by promoting a more constructive role for NGOs” with the public sector in aid delivery. The code of conduct would restrain NGOs from hiring from the public health system and require them to pay salaries commensurate with the public sector, support the development of local health professionals, plan services with local ministries of health and adhere to ministerial norms in terms of administration and personnel.
Medicine Prices, Availability, and Affordability in 36 Developing and Middle-Income Countries: A Secondary AnalysisCameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. The Lancet. Published online December 1, 2008. DOI: 10.1016/S0140-6736(08)61345-8
In a recent study, WHO and Health Action International researchers report that common essential prescription drugs remain unavailable and unaffordable to the majority of people in thirty-six middle and low-income countries but that availability was consistently higher in the private sector than public sector. The authors ascribe this to “inadequate funding, lack of incentives for maintaining stocks, inefficient distribution systems, or leakage of medicines for private resale” in the public sector as well as the common public sector practice of marking up drug prices to cross-subsidize other components of the health system. Cameron et al also contend that generics were more available than costlier originator brands in the private sector in survey countries. The authors believe that drug availability could be increased by “improving procurement efficiency” through national pooled purchasing, procuring drugs by generic name, and making medicines available in the private sector at subsidized prices. The authors also contend that affordability could be increased by regulating mark-ups, increasing the use of generic medicines through “ensuring the quality of generic products, encouraging price competition,” and increasing the confidence of health professionals in the quality of generic medicines.
Pragmatism about the Private Sector: A debate in PLoSHanson K, Gilson L, Goodman C, Mills A, Smith R, Feachem R, Sekhri-Feachem N, Koehlmoos TP, Kinlaw H. PLoS 2008. Blog review by April Harding, Center for Global Development.
Discussions of the private health sector in developing countries have long been dominated by dogmatism on both sides. For public-sector-purists, the existence and rapid growth of the private sector in the 80s and 90s was a symptom of what was wrong with developing country health systems, and good policies were those that would strengthen the public sector in such a way as to lead to the fading away of the private sector. For the private-sector-believers, the growing private sector revealed the unfixable problems of the public sector, and made it clear that to achieve sectoral goals you’d have to engage the private sector. The public-sector-purists thought the private-sector believers were anti-poor, since they believed only the public sector could look after their interests. The believers though the purists were in denial about the fixable-ness (and pro-poorness) of the public sector. For years, this, rather sterile, debate raged - with relatively little benefit. In the past 2 years, this debate has moved on. Both the purists and the believers have shifted to the middle, with growing consensus on the need to work with the private sector (broadly defined), if not where this ranks in the long list of health policy priorities for developing countries.
Contracting for Health Services: Effects of Utilization and Quality on the Costs of the Basic Package of Health Services in AfghanistanAmeli O, Newbrander W. Bulletin of the World Health Organization 2008: 86
Following the fall of the Taliban in 2001, the Afghanistan Ministry of Public Health developed a basic set of health services to prioritize the most-pressing public health problems. Supporting this, the US Agency for International Development took responsibility for funding services in several provinces, contracting with national and international nongovernmental organizations to provide primary health access. On reviewing the contracting experience, Ameli et al. found that the majority of program expenses were from fixed costs not related to the security situation or remoteness of covered regions. The authors recommend that standardizing fixed cost elements would reduce the contracting organization’s management and monitoring needs. A secondary finding was that the use of female health workers alongside other health personnel increased both patient satisfaction and utilization of health services.
An additional commentary by B Loevinsohn about the contracting experience in Afghanistan.
Medicines Coverage and Community-Based Health Insurance in Low-Income Countries.Vialle-Valentin C, Ross-Degnan D, Ntaganira J, Wagner A. Health Research and Policy Systems 2008, 6:11
Among the highlighted community-based health insurance (CHI) plans are two in Rwanda (Gibumbi and CUSP), where the government is supporting CHI as part of a move towards universal health insurance. The authors note the success of the Gibumbi plan in increasing access and use of medicine among the poor. This is the result of Gibumbi’s ‘family enrollment’ policy and cross-subsidy program to allow free enrollment of the poor, viable in part because out-patient drug coverage is restricted within the plan. The competing CUSP plan does not include subsidized members and uses a fixed co-payment with no drug restrictions. The poor are less represented among CUSP members than among Gibumbi, though benefits to members are higher.
The review also examines the emerging national CHI project in Lao PDR, noting challenges with the program’s voluntary membership and it’s difficulty reaching the poorest populations. CHI plans need to improve revenue collection and strategic purchasing, specifically in negotiating supplier payments and designing incentives for recommended medicines. There are few tools to assist CHI managers in designing and managing benefit packages adapted to low-income environments and a little support for managers to analyze dispensing data in order to improve use of medicines.
The Effectiveness of Contracting-out Primary Health Care Services in Developing Countries: A Review of the Evidence.Liu X, Hotchkiss DR, Bose S. Health Policy and Planning 2008; 23:1–13
Contracting between governments and non-governmental primary health providers has grown in recent years due to a surge in international health initiatives, frustration over the efficacy and quality of public services, shortages of personnel, and public preference for private care. However, there is a dearth of evidence on whether government contracting out of primary health care services improves the effectiveness and performance of health programs and systems. Reviewing thirteen contracting case studies, the authors see mixed overall performance.
The authors argue that contracting improves access to health services and equity if “services that most benefit the poor are targeted” but does not necessarily improve equity more than public providers, has mixed results in boosting efficiency, and has unclear results in increasing quality. The authors note that variations in contracting success depend heavily on the specific context of implementation and on the specific design features of intervention. In addition, the authors note that there is “relatively little understanding… of how contracting-out primary health care services influences the broader health system” and that further research is greatly needed.
Women's Social Position and Health-Seeking Behaviors: Is the Health Care System Accessible and Responsive in Pakistan?Shaikh B, Haran D, Hatcher J - Health Care for Women International 29:8 (2008) 945 — 959
This survey of women’s health-seeking behaviors in rural northern Pakistan highlights the success of the private non-profit Aga Khan Health Services (AKHSP) in promoting access to services by facilitating culturally appropriate treatment. Survey participants noted the presence of female staff, positive staff attitudes, and high quality services and medicines at AKHSP. Surveyed women visited AKHSP more frequently than other health services despite increased costs and inconvenient access, stating that the presence of female staff was their main reason for visiting AKHSP over government-run services. To increase women’s use of health services, Shaikh et al recommend social marketing with community health workers and mass-level health education campaigns to inform and empower women, as well as increased communication and coordination between the private and public health services.
Choice of healthcare provider following reform in VietnamT Nguyen, C Lofgren, L Lindholm, T Nguyen, C Kim - BMC Health Services Research 8: 162 (2008)
Nguyen et al argue that changes in Vietnam’s health care system have paralleled the country’s transition to a market economy: since 1989, the Vietnamese government has transformed the country’s health system by introducing user fees and health insurance and by deregulating pharmaceuticals. These changes aimed to increase quality but have also led to increased out-of-pocket costs leaving many individuals unable to afford care. Nguyen et al surveyed households in rural Northern Vietnam to determine factors influencing health care provider choice.
Rural Vietnamese households overwhelmingly used private providers (60%), followed by self-treatment (23%), then public providers (10%). People with higher education levels and larger families were more likely to seek routine treatment from private providers, while the poorest were more likely to use self-treatment for routine conditions. All rural individuals tended to use public health systems for the most costly treatments. Nguyen et al argue that recent changes in the Vietnamese health care system have given more affluent individuals increased access to private health care, while the increased availability of medicines has led poorer individuals to self-treat rather than pay low quality public providers. The authors bring new information to this issue, highlighting that private providers are often considered better and cheaper than the nominally free government services.
Social Franchising to Improve Quality and Access in Private Health Care in Developing CountriesD Bishai, N Shah, D Walker, W Brieger, D Peters – Harvard Health Policy Review, 2008
An economic overview of the fundamentals of public-private healthcare system interests, and presentation of a case study of a social franchise in Pakistan to demonstrate the success of healthcare franchising in increasing quality and access to care.
Bishai et. al. use the case study of the Green Star private social healthcare franchise in Pakistan to reveal that healthcare franchises can be used as an effective mechanism to increase quality of care, access to care among poor clients, and efficiency of services. The paper identifies social franchises, like Green Star, can increase quality of care and access to services to the whole population in parallel to government and non-governmental health systems. The authors additionally provide an “economic model of public private interests in healthcare” centered around the concepts of “quality of service provision and access to care by disenfranchised groups” – concepts that cannot be ensured by complete free market mechanisms. The paper as well notes predictions regarding alternative business models of health care provisions, including vouchers, contract systems, and incentive payment systems.
Public Purchasers Contracting External Primary Care Providers in Central America for Better Responsiveness, Efficiency of Health Care, and Public Governance: Issues and ChallengesJ Macq, P Martiny, L Villalobos, A Solis, J Miranda, H Mendez, C Collins – Health Policy 87 (2008) 377 – 388
A comparative case study of four Central American countries’ experience with limited contracting between public purchasing agencies and external health care providers using an analytical framework based on equity and efficiency.
Contracting between non-governmental primary care providers and a public purchasing agencies has occurred recently in several Latin America countries as a way to increase efficiency, quality, sustainability and accessibility. Macq et. al. identify that the performance of contracted parties are influenced by three factors: 1) “core descriptive elements of the contractual relation” (including the selection process, definition of benefits packages, management of resources, and quality management), 2) external factors (such as health related technical issues, as well as economic, political, social, and financial beliefs of the contracting agency), and 3) the relationship between the contracting agency and key stakeholders in the larger health system. Upon review of the contracting experiences, the authors conclude that the complexity of contracting requires making clear technical and value-based choices during the nascent stages and adopting flexible behaviors to cope with unexpected planning development and to manage contracting external providers.
Speciality Care Systems: A Pioneering Vision For Global HealthA Bhandari, S Dratler, K Raube, R.D. Thulasiraj – Health Affairs 27, no. 4 (2008): 964 – 976
An overview of successful core elements of private specialty care system models using the case study of Aravind Eye Care System in India.
Bhandari et. al, consider the specialty care model of medical service, one that focuses on a particular medical condition or disease area, has potential for “greater patient volume, better outcomes, improved quality of care, and lower costs” over traditional models when implemented successfully. The authors note that thriving specialty care businesses include: 1) a standardized and continuously improving management system with local ownership, 2) development of a specialized workforce, 3) access to low-cost technology, and 4) high patient volume. The authors consider Aravind Eye Care System an exemplar of these criteria. It employs a “serial production” model for medical operations to maximize efficiency and quality, and uses a semi-autonomous systems management agency to “improve the planning, efficiency, and effectiveness of all eye hospitals in India.” Aravind creates its specialized workforce though technical and value-based training programs of paramedical and medical staff. The program also focuses on technological development by building and operating a manufacturing plant for specialty lenses that has increased financial autonomy and reduced overall costs. Aravind in addition builds patient volume though a hub-and-spoke model which uses aggressive community outreach screening and then sending evaluated patient to its centralized surgery centers. The authors note that generalisability of this model is limited by the availability of a specialized workforce, density of the population, patient cultural norms, and the availability of low-cost technology.
Impact of Mutual Health Organizations: Evidence from West AfricaS Chankova, S Sulzbach, F Diop – Health Policy and Planning 23 (2008): 264 – 276
An analysis of Mutual Health Organizations’ effects on decreasing out-of-pocket health expenditures and increasing health care access in three West African Countries.
Mutual Health Organizations (MHOs) are health insurance providing voluntary membership organizations that are typically designed, owned, and managed by the communities they serve. MHOs have spread in the developing world in recent years. They are believed to increase use of health services and decrease out-of-pocket payments for users. Chankova et. al., surveying MHOs in Ghana, Mali, and Senegal, have found that MHO enrollment is highest in households that are headed by women and older individuals, more educated, and more affluent. Chankova et al. further note that in Ghana and Mali enrollments in MHOs have increased patient access to modern health care providers and patient hospitalization levels while significantly decreasing hospitalization-related expenditures. Enrollments have had an inconclusive effect on out-of-pocket health care due to their high cost sharing rates. To improve enrollment and social inclusion, the authors suggest that MHO managers should market to individuals with low educational levels, collect premiums on a monthly rather than yearly basis, alter service packages to increase outpatient care coverage and lower co-payments, and target populations close to health care facilities.