Advances in health economics and health services research最新文献

Objectives: Purchasing has been promoted as a key policy instrument to improve health system performance. Despite its widespread adoption, there is little empirical evidence on how it works, the challenges surrounding its implementation, its impact, and the preconditions for it to function effectively, particularly in low- and middle-income settings. The objective of this chapter is to analyze critically the extent to which purchasing could be, and has been used strategically in China and to identify modifications that are needed for purchasing to be effective in assuring that the government's new funding for health care will result in efficient and effective health services.

Methods: We present a conceptual framework for purchasing, which identifies three critical principal-agent relationships in purchasing. We draw on evidence from secondary data, results of other research studies, interviews, and the impact evaluation of a social experiment in rural China that explicitly used purchasing to improve quality and efficiency. This information is used to examine purchasing relationships in urban social health insurance (SHI), the rural medical insurance scheme, and purchasing of public health services.

Findings: To date, use of strategic purchasing is limited in China. Both the urban and the rural health insurance schemes act as passive third-party payers, failing to take advantage of the opportunities to strengthen incentives to improve quality and efficiency. This may be because as government agencies, the extent to which the Ministries of Health and Labor and Social Security can act independently from provider interests, or act in the best interest of the population, is unclear. Other important challenges include ensuring adequate representation of the population's views and preferences and making better use of the leverage provided by purchasing to create appropriate provider incentives, through better integration of financing and improved coordination among purchasers.

Implications for policy: In designing purchasing arrangements, attention needs to be paid to all three principal-agent relationships. Successful purchasing appears to require mechanisms to mobilize and represent community preferences and more strategic contracting with providers. More research is needed to strengthen the evidence on which purchasing arrangements work, which do not work, and under what conditions different purchasing configurations can work most effectively.

Objective: Tanzania, Mexico, and the United States are at vastly different points on the economic development scale. Yet, their health systems can be classified as "developing": they do not live up to their potential, considering the resources available to them. The three, representing many others, share a common structural deficiency: a segregated health care system that cannot achieve its basic goals, the optimal health of its people, and their possible satisfaction with the system. Segregation follows and signifies first and foremost the lack of financial integration in the system that prevents it from serving its goals through the objectives of equity, cost containment and sustainability, efficient production of care and health, and choice.

Method: The chapter contrasts the nature of the developing health care system with the common goals', objectives, and principles of the Emerging Paradigm (EP) in developed, integrated--yet decentralized--systems. In this context, the developing health care system is defined by its structural deficiencies, and reform proposals are outlined.

Findings: In spite of the vast differences amongst the three countries, their health care systems share strikingly similar features. At least 50% of their total funding sources are private. The systems comprise exclusive vertically integrated, yet segregated, "silos" that handle all systemic functions. These reflect and promote wide variations in health insurance coverage and levels of benefits--substantial portions of their populations are without adequate coverage altogether; a considerable lack of income protection from medical spending; an inability to formalize and follow a coherent health policy; a lack of financial discipline that threatens sustainability and overall efficiency; inefficient production of care and health; and an dissatisfied population. These features are often promoted by the state, using tax money, and donors.

Policy implications: The situation can be rectified by (a) "centralizing"--at any level of development and resource availability--health system finance around a set package of core medical benefits that is made available to the entire population and (b) "decentralizing" consumption and provision of care. The first serves equity and cost containment and sustainability. The second supports efficiency and client satisfaction.

Originality/value of chapter: The chapter views commonly discussed problems of the health care system--a lack of insurance coverage and income protection--as symptoms of a large problem: health system segregation.

Objective: The first wave of experiences of exemptions policies suggested that poverty-based exemptions, using individual targeting, were not effective, for practical and political economic reasons. In response, many countries have changed their approach in recent years--while maintaining user fees as a necessary source of revenue for facilities, they have been switching to categorical targeting, offering exemptions based on high-priority services or population groups. This chapter aims to examine the impact and conditions for effectiveness of this recent health finance modality.

Methodology/approach: The chapter is based on a literature review and on data from two complex evaluations of national fee exemption policies for delivery care in West Africa (Ghana and Senegal). A conceptual framework for analysing the impact of exemption policies is developed and used. Although the analysis focuses on exemption for deliveries, the framework and findings are likely to be generalisable to other service- or population-based exemptions.

Findings: The chapter presents background information on the nature of delivery exemptions, the drivers for their use, their scale and common modalities in low-income countries. It then looks at evidence of their impact, on utilisation, quality of care and equity and investigates their cost-effectiveness. The final section presents lessons on implementation and implications for policy-makers, including the acceptability and sustainability of exemptions and how they compare to other possible mechanisms.

Implications for policy: The chapter concludes that funded service- or group-based exemptions offer a simple, potentially effective route to mitigating inequity and inefficiency in the health systems of low-income countries. However, there are a number of key constraints. One is the fungibility of resources at health facility level. The second is the difficulty of sustaining a separate funding stream over the medium to long term. The third is the arbitrary basis for selecting high-priority services for exemption. The chapter therefore concludes that this financing mode is unstable and is likely to be transitional.