Improving Maternal Survival in South Asia—What Can We Learn from Case Studies?

Technical interventions for maternal healthcare are implemented through a dynamic social process. Peoples' behaviours—whether they be planners, managers, providers, or potential users—influence the outcomes. Given the complexity and unpredictability inherent in such dynamic processes, the proposed cause-and-effect relationships in any one context cannot be directly transferred to another. While this is true of all health services, its importance is magnified in maternal healthcare because of the need to involve multiple levels of the health system, multiple types of care providers from the highly skilled specialist to community-level volunteers, and multiple technical interventions, without the ability to measure significant change in the outcome, the maternal mortality ratio. Patterns can be followed however, in terms of outcomes in response to interventions. From these case studies of implementation of maternal health programmes across five states of India, Pakistan, and Bangladesh, some patterns stand out and seem to apply virtually everywhere (e.g. failure of systems to post staff in difficult areas) while others require more data to understand the observed patterns (e.g. response to financial incentives for improving maternal health systems; instituting available accessible safe blood). The patterns formed can provide guidance to programme managers as to what aspects of the process to track and micro-manage, to policy-makers as to what features of a context may particularly influence impacts of alternative maternal health strategies, and to governments more broadly as to the factors shaping dynamic responses that might themselves warrant intervention

Global Health Initiatives and aid effectiveness: insights from a Ugandan case study

BACKGROUND: The emergence of Global Health Initiatives (GHIs) has been a major feature of the aid environment of the last decade. This paper seeks to examine in depth the behaviour of two prominent GHIs in the early stages of their operation in Uganda as well as the responses of the government. METHODS: The study adopted a qualitative and case study approach to investigate the governance of aid transactions in Uganda. Data sources included documentary review, in-depth and semi-structured interviews and observation of meetings. Agency theory guided the conceptual framework of the study. RESULTS: The Ugandan government had a stated preference for donor funding to be channelled through the general or sectoral budgets. Despite this preference, two large GHIs opted to allocate resources and deliver activities through projects with a disease-specific approach. The mixed motives of contributor country governments, recipient country governments and GHI executives produced incentive regimes in conflict between different aid mechanisms. CONCLUSION: Notwithstanding attempts to align and harmonize donor activities, the interests and motives of the various actors (GHIs and different parts of the government) undermine such efforts

The story of Primary Health Care : from Alma Ata to the present day

The idea of primary health care (PHC) emerged in the 1960s, in recognition of the shortcomings of the health systems inherited by developing countries after independence. The urban, centralised and curative-oriented health systems were poorly matched to the needs of their people.sch_iihpub374pu

Two tier issues in low income country health systems.

Two-tier situations, defined as those in which a single provider offers two services or price discriminates in selling one service are commonplace in low income countries' health systems. Examples include the provision of public and private wards in public hospitals, exemptions, and sliding scale charging systems and health facilities that negotiate separately with multiple third party payers. Analysis of these situations and their outcomes for access, quality of care and equity for health services has under emphasised the importance of the supply side incentives created. These are complex because demands for the services involved are likely to be inter-related with respect to price and quality and a provider cannot alter price or quality levels of one service without considering the implications for the other. A model (previously published) designed to better understand the implications of the offer of more than one quality level in public hospitals suggests that low quality users may not benefit, especially where there are strong inter-relationships between the demands for the two services. Only subsidy levels responding to the utilisation of the low quality service can protect low quality service users, to some extent. The model raises concerns for the implications of exemption policy, informal charging, insurance reform and pharmaceutical pricing. The incentives for providers to reduce quality of services provided to exempted patients have generally not been considered. The role of market structure in ensuring that all demands are catered for in an environment of informal pricing has not been studied. Insurance reforms have taken little account of product differentiation incentives inherent in models designed to produce universal access. Strategies that determine international differences in pharmaceutical prices may be undermined by changes in the economic conditions in high income countries. In each area a number of important areas of further research are suggested. A model of two-tier strategies operating within a public hospital environment suggested that the implications for allocation of resources between the two tiers could be regressive given levels of cross quality and price elasticity between the two services of unknown plausibility (McPake et al., 2007 ). This paper explores the broader implications of the model for the wider range of scenarios crossing public and private sectors, reviewing relevant literature for instances of analytically similar market situations, evidence of cross-price and quality elasticity and analyses of impact in terms of resource allocation. Analytically similar market situations arise in insurance, where alternative packages are offered in competition with each other by the same and competing insurance agencies. Choices made by consumers between alternative insurance packages reveal risk information (Rothschild and Stiglitz, 1976 ). They also reveal consumer preference information in ways that allow insurers to maximise producer (insurer) surplus through price discrimination. Insurers' reactions to the information revealed in both respects have implications for resource allocation and the equity of outcomes. Other analytically similar situations arise in the pricing strategies of not-for-profit providers seeking to manage exemption systems in a manner that aims to cross-subsidise from richer to poorer users and in the 'Ramsay pricing' strategy argued to be operated by the pharmaceutical industry in pricing pharmaceuticals for different national markets. Cross-price elasticities can be inferred from some studies of demand for health services and pharmaceuticals, hence can be identified at some points in relation to level of health service demanded (pharmacy shop, primary, secondary etc.); market structure (more and less competitive), and shares of public and private in total expenditure. However, implications of the pricing strategies of market players, including public sector ones for resource allocation and equity are rarely evaluated except for in the cases of a few public policy areas such as changing basic fee levels in the public sector and to a limited extent with respect to the pharmaceutical pricing debate. This paper argues that there is significant scope to gain better understanding of the scope and strategies for cross-subsidy of poorer health system users by developing better models with wider applicability of inter-dependent demand functions and focusing empirical research on the testing of these models.sch_iihpub1514pu

Health Systems Reforms in Uganda: processes and outputs.

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The evolving two tier systems in Malawi.

Malawi is one of a few countries experiencing extreme crises of both human resources and HIV/AIDS, all of them in sub-Saharan Africa (McCoy et al., 2008). Overall expenditure on the health system has been rising, supported by a growing public sector in turn supported by growing external assistance (WHOSIS). This has implications for the nature and shape of the public health system. It is highly stressed, in particular in relation to human resource availability. In principle it is focused on the provision of an essential health package (EHP), focused on mainly infectious diseases that account for the greatest burden of disease which is the priority of external funding channelled through the national sector wide approach process. Although only recently included in the EHP, much external assistance has been channelled to an antiretroviral treatment programme which has been considered an 'island of excellence' in an otherwise very basic public health system (McCoy et al., 2008 ). For relatively wealthy Malawians who are not HIV positive or currently eligible for antiretroviral treatment, the public health system is likely to offer little. WHOSIS data also indicate stagnation of private expenditure on health in international (purchasing power parity) dollar terms while other data indicate a growing private health care sector in Malawi. The number of private health services providers as recorded by the business registrar has increased from 40 in 1995 to 78 by the end of 2007. Similarly, a physical count of private health providers shows that the number of private providers has increased from 65 in 1995 to 138 by end of 2007(Business Registrar report,2007). This combination of observations is likely to imply a struggling private sector with providers moving in and out of the sector as they initially invest and often then fail to remain solvent, such as has been described in Tanzania (Tibandebage and Mackintosh, 2002 ). The implications of this category of private sector for the nature of two-tier provision are likely to differ from the implications of a more thriving and stable private sector. This paper will present evidence of the characteristics of private sector development and their consequences for the nature of two tier provision using available data concerned with: - Human resource distribution across the health system and implications for retention and motivation - Factor prices - Distribution of users of the tiers of the system in relation to income or wealth quintiles and disease profile - Distribution of benefit incidence across user groups comparing these, where internationally comparable data are available, with data from countries in which there appears a more thriving and stable private sector. The paper will inform the development of a research proposal focused on the implications of two tier provision for equitable access to health care in different types of settings.sch_iihpub1511pu

‘They say we are money minded’ exploring experiences of formal private for-profit health providers towards contribution to pro-poor access in post conflict Northern Uganda

From Crossref journal articles via Jisc Publications RouterSuzanne Fustukian - ORCID: 0000-0002-4570-5800 https://orcid.org/0000-0002-4570-5800Background: The perception within literature and populace is that the private for-profit sector is for the rich only, and this characteristic results in behaviours that hinder advancement of Universal health coverage (UHC) goals. The context of Northern Uganda presents an opportunity for understanding how the private sector continues to thrive in settings with high poverty levels and history of conflict.Objective: The study aimed at understanding access mechanisms employed by the formal private for-profit providers (FPFPs) to enable pro-poor access to health services in post conflict Northern Uganda.Methods: Data collection was conducted in Gulu municipality in 2015 using Organisational survey of 45 registered formal private for-profit providers (FPFPs),10 life histories, and 13 key informant interviews. Descriptive statistics were generated for the quantitative findings whereas qualitative findings were analysed thematically.Results: FPFPs pragmatically employed various access mechanisms and these included fee exemptions and provision of free services, fee reductions, use of loan books, breaking down doses and partial payments. Most mechanisms were preceded by managers’ subjective identification of the poor, while operationalisation heavily depended on the managers’ availability and trust between the provider and the customer. For a few FPFPs, partnerships with Non-governmental organisations (NGOs) and government enabled provision of free, albeit mainly preventive services, including immunisation, consultations, screening for blood pressure and family planning. Challenges such as quality issues, information asymmetry and standardisation of charges arose during implementation of the mechanisms.Conclusion: The identification of the poor by the FPFPs was subjective and unsystematic. FPFPs implemented various innovations to ensure pro-poor access to health services. However, they face a continuous dilemma of balancing the profit maximization and altruism objectives. Implementation of some pro-poor mechanisms raises concerns included those related to quality and standardisation of pricing.The publication of this work has also been funded as part of a supplement under SPEED project [HUM/2014/341-585], funding code is ZGHA-2020-C4168..pubpu

Trace amounts? Assessing hospital costs in Zimbabwe

Hospital costs are difficult to measure when there is limited or poor quality data. Current accounting methods may miss key aspects of inefficiency. Researchers from the London School of Hygiene and Tropical Medicine find that using 'tracer' illnesses is a more effective way to assess costs in Zimbabwe's hospitals.sch_iihpub379pu

Paying their way: health financing mechanisms in Zambia

Health services in many low-income countries charge user fees. These payments may deter the poorest people from seeking treatment. Zambia has tried two alternatives to user fees: prepayment and discount cards. How do these schemes affect equity in the use of health services?sch_iihpub375pu

Policymakers in rich countries drive the health migration crisis

The shortage of human resources in developing countries has reached crisis point, particularly in sub-Saharan Africa. One cause is increasing rates of migration by qualified doctors and nurses to higher-income countries. So what is driving this growing demand for health staff, and what are health labour market conditions like in the destination countries?sch_iihpub377pu