Zambia: the role of aid management in sustaining visionary reform.
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As part of its ongoing reform of the health sector, Zambia has developed a number of systems and structures to coordinate and manage external resources. With increasing attention being given to the potential for sector-wide approaches (SWAps) to enhance the efficiency and effectiveness of health systems in low-income countries, Zambia provides an interesting case study of how this is emerging in practice over time. The paper outlines the different coordination mechanisms and assesses them in terms of selected criteria of effectiveness, finding that the potential to meet reform objectives is currently not being met. Factors influencing the effectiveness of these mechanisms are identified as falling into categories around personalities and human interaction, the nature of reform processes, and the impact of broader context. The need to maintain dialogue in the face of external constraints and uncertainties is stressed. (+info)
Small fish in a big pond? External aid and the health sector in South Africa.
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Since a new government was elected in 1994, South Africa has become a favoured nation for the many bilateral and multi-lateral agencies providing aid to developing countries. Despite several relatively large pledges of 'transition support', however, external resources constitute less than 2% of the annual government budget. This non-dependence has established a degree of equilibrium in a relationship normally regarded as highly unequal in other African countries. Although international donors funded the antiapartheid movement in South Africa prior to 1994, the new government inherited a chaotic administration that had little institutional experience of conventional development aid. Many of the new cadres entering government had not been exposed to the workings of government, let alone donor, bureaucratic processes. It is not surprising, therefore, that in the first few years after 1994, the aid relationship was characterized by low disbursements, unrealistic expectations and a degree of conflict. Since 1997, however, aid supported projects have started to become more visible. Within the broad objective of supporting transformation of the health system, one of the key areas of donor support is managerial capacity development, particularly of district, hospital and provincial health structures. These initiatives tend to be poorly coordinated, a problem compounded by a quasi-federal system in which provinces have large amounts of autonomy. The contribution of donor aid to strengthening the health system could be enhanced by the establishment of a clear national framework to guide the many externally supported projects building managerial skills and systems. (+info)
Managing external resources in the health sector: are there lessons for SWAps (sector-wide approaches)?
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Drawing on the case studies presented in this issue, from Bangladesh, Cambodia, Mozambique, Zambia and South Africa, and examples from other countries, this paper asks what general conclusions can be drawn about the management of external resources, and specifically what lessons could inform the future implementation of sector-wide approaches (SWAps) in the health sector. Factors constraining the management of aid by ministries of health are grouped under three themes: context and timing, institutional capacities and the interplay of power and influence in negotiations over aid. Two factors, often underplayed, were found to be important in facilitating management of resources: the inter-relationship of formal and informal relationships, and the extent to which incremental changes are tolerated. The main conclusion is that coordination and management of external resources is inherently unstable, involving a changing group of actors, many of whom enjoy considerable autonomy, but who need each other to materialize their often somewhat different goals. Managing aid is not a linear process, but is subject to set-backs and crises, although it can also produce positive spin-offs unexpectedly. It is highly dependent on institutional and systemic issues within both donor and recipient environments. In promoting sector-wide approaches the key will be to recognize context-specific conditions in each country, to find ways of building capacity in ministries of health to develop and own the future vision of the health sector, and to negotiate a realistic package that is explicit in its agreed objectives. The paper ends with identifying crucial actions that will enable ministries of health to take the lead role in developing and implementing SWAps. (+info)
Changes in patient satisfaction and experience in primary and secondary care: the effect of general practice fundholding.
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BACKGROUND: The contributions of patients' opinions to the evaluation of health care is widely acknowledged. This study investigates whether the patients of a fundholding practice perceived any changes in the services offered. AIM: To examine the effect of general practice fundholding on patient satisfaction with both primary and secondary care services. METHOD: In April 1992, questionnaires were sent to 180 patients in each of four second-wave fundholding practices and four non-fundholding practices in the former South East Thames region. This took place before any changes were made in the practices as a result of fundholding. Repeat questionnaires were sent 30 months later. RESULTS: The overall response rate was 70% in 1992 and 66% in 1994/1995. Satisfaction levels were generally high for primary care services and changed little over time. There was no evidence to suggest that fundholding GPs were less inclined to prescribe or refer to secondary care services. Waiting times for the first appointment with a consultant in secondary care had reduced between 1992 and 1994 for patients referred from the fundholding practices. However, there were no differences in the time patients had to wait for subsequent treatments or further investigations. One-fifth of the fundholding patients referred to secondary care were seen by the specialist in their doctor's surgery, and those seen in this setting preferred it. CONCLUSION: Patients perceived no major differences in primary care services over the period between the two surveys. There was some evidence of preferential treatment for patients of fundholding practices, but only in waiting times for the first appointment with the secondary care specialist. (+info)
New Zealand: long-term care in a decade of change.
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Long-term care in New Zealand incorporates a mix of public and private funding and provision. After a decade of structural change, the purchasing of almost all publicly funded health and social care is now the responsibility of one central agency. Services for older persons are poorly integrated, and there are problems of access to and quality of some services. Efforts are being made to address these problems. The challenge now is to ensure that this groundwork is not lost amid the turmoil of yet another round of restructuring by an enthusiastic, newly elected government. (+info)
Adoption of alternative financing strategies to increase the diffusion of picture archiving and communication systems into the radiology marketplace.
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The objective of the study was to evaluate current marketplace conditions and strategies employed by major picture archiving and communication systems (PACS) vendors in the creation of alternative financing strategies, to enhance the diffusion of filmless imaging. Data were collected from the major PACS vendors in the forms of survey questionnaires and review of existing leases. Topics evaluated in the survey included current financing options available, foreseeable changes in PACS financing, role of third-party financiers, and creation of risk-sharing arrangements. Generic leases were also reviewed evaluating the presence or absence of several key variables including technology obsolescence protection, hardware/software upgrades, end-of-term options, determination of fair market value, functionality/acceptance testing, uptime guarantees, and workflow management consulting. Eight of the 10 PACS vendors surveyed participated in the data collection. The vast majority of current PACS implementations (60% to 90%) occur through direct purchase, with conventional leasing (operating or capital) accounting for only 5% to 30% of PACS installations. The majority of respondents view fee-for-lease arrangements and other forms of risk sharing as increasing importance for future PACS financing. The specific targets for such risk-sharing arrangements consist of small hospital and privately owned imaging centers. Leases currently offered range in duration from 3 to 5 years and frequently offer technology obsolescence protection with upgrades, multiple end-of-term options, and some form of acceptance testing. A number of important variables frequently omitted from leases include uptime guarantees, flexibility in changing financing or vendors, and incorporation of expected productivity/operational efficiency gains. As vendors strive to increase the penetration of PACS into the radiology marketplace, there will be a shift from conventional financing (loan or purchase) to leasing. Fee-for-use leasing and other forms of risk sharing have the greatest potential in smaller hospitals, which do not have the financial resources to pursue conventional financing options. Potential PACS customers must be cautious when entering into these alternative financing strategies, to ensure that appropriate safeguards are incorporated, in order to minimize downside risk. (+info)
The Kaiser Family Foundation Community Health Promotion Grants Program: findings from an outcome evaluation.
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OBJECTIVES: To present results from an outcome evaluation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grants Program (CHPGP) in the West, which represented a major community-based initiative designed to promote improved health by changing community norms, environmental conditions, and individual behavior in 11 western communities. METHODS: The evaluation design: 14 randomly assigned intervention and control communities, 4 intervention communities selected on special merit, and 4 matched controls. Data for the outcome evaluation were obtained from surveys, administered every two years at three points in time, of community leaders and representative adults and adolescents, and from specially designed surveys of grocery stores. Outcomes for each of the 11 intervention communities were compared with outcomes in control communities. RESULTS: With the exception of two intervention communities-a largely Hispanic community and a Native American reservation-we found little evidence of positive changes in the outcomes targeted by the 11 intervention communities. The programs that demonstrated positive outcomes targeted dietary behavior and adolescent substance abuse. CONCLUSIONS: Improvement of health through community-based interventions remains a critical public health challenge. The CHPGP, like other prominent community-based initiatives, generally failed to produce measurable changes in the targeted health outcomes. Efforts should focus on developing theories and methods that can improve the design and evaluation of community-based interventions. (+info)
HMOs and health education.
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HMOs, by their stated purpose and nature, have a necessary and central involvement with health education. The specific characteristics of any HMO determine the extent and quality of health education. An HMO has the responsibility to identify its educational objectives, as well as the educational components of any of its other objectives. The more professional the educational guidance, the better it is integrated into the organization, and the greater its financial and administrative support, the more likely will be the success in achieving objectives. In brief, every HMO has the need and potential for a health education effort. The extent and quality of that effort will reflect the mix of administrative philosophy, organizational characteristics, the degree to which professional educators are involved, and the amount and stability of financial support. (+info)