Charles Collins

How does the new cooperative medical scheme influence health service utilization? A study in two provinces in rural China.

BackgroundMany countries are developing health financing mechanisms to pursue the goal of universal coverage. In China, a rural health insurance system entitled New Cooperative Medical Scheme (NCMS) is being developed since 2003. Although there is concern about whether the NCMS will influence the serious situation of inequity in health service utilization in rural China, there is only limited evidence available. This paper aims to assess the utilisation of outpatient and inpatient services among different income groups and provinces under NCMS in rural China.MethodsUsing multistage sampling processes, a cross-sectional household survey including 6,147 rural households and 22,636 individuals, was conducted in six counties in Shandong and Ningxia Provinces, China. Chi-square test, Poisson regression and log-linear regression were applied to analyze the association between NCMS and the utilization of outpatient and inpatient services and the length of stay for inpatients. Qualitative methods including individual interview and focus group discussion were applied to explain and complement the findings from the household survey.ResultsNCMS coverage was 95.9% in Shandong and 88.0% in Ningxia in 2006. NCMS membership had no significant association with outpatient service utilization regardless of income level and location.Inpatient service utilization has increased for the high income group under NCMS, but for the middle and low income, the change was not significant. Compared with non-members, NCMS members from Ningxia used inpatient services more frequently, while members from Shandong had a longer stay in hospital.High medical expenditure, low reimbursement rate and difference in NCMS policy design between regions were identified as the main reasons for the differences in health service utilization.ConclusionsOutpatient service utilization has not significantly changed under NCMS. Although utilization of inpatient service in general has increased under NCMS, people with high income tend to benefit more than the low income group. While providing financial protection against catastrophic medical expenditure is the principal focus of NCMS, this study recommends that outpatient services should be incorporated in future NCMS policy development. NCMS policy should also be more equity oriented to achieve its policy goal.

Reproductive health and health sector reform in developing countries: establishing a framework for dialogue

It is not clear how policy-making in the field of reproductive health relates to changes associated with programmes for the reform of the health sector in developing countries. There has been little communication between these two areas, yet policy on reproductive health has to be implemented in the context of structural change. This paper examines factors that limit dialogue between the two areas and proposes the following framework for encouraging it: the identification of policy groups and the development of bases for collaborative links between them; the introduction of a common understanding around relevant policy contexts; reaching agreement on compatible aims relating to reproductive health and health sector change; developing causal links between policy content in reproductive health and health sector change as a basis for evidence-based policy-making; and strengthening policy-making structures, systems, skills, and values.

Management capacity and health insurance: the case of the New Cooperative Medical Scheme in six counties in rural China

In 2003, China launched the New Cooperative Medical Scheme (NCMS) as a form of health insurance for rural areas. Counties play an important part in the management of the system, raising issues over the capacity of local government to manage complex health insurance systems. This paper examines the extent and impact of county level managerial capacity to manage the NCMS. The paper is largely based on qualitative data but supported by quantitative data. Policy makers, NCMS administrators, health providers and residents were interviewed in May 2006 in six counties in rural China. Management capacity was defined as the capability to bring together and use resources to carry out responsibilities. The results are grouped into three areas of management capacity: staff, organizational and contextual. Respondents complained about inadequate staffing, poor organizational resources and conduct of responsibilities in areas such as premium collection and remuneration. Key problems in contextual capacity included: counties are restricted in their ability to use resources for management; counties lack support from other organizations and suffer from a conflict of responsibilities. This paper underlines the importance of effective management capacity for NCMS at the decentralized level and suggests pointers for the content and process of management capacity development.

HIV/AIDS and TB: contextual issues and policy choice in programme relationships

Tuberculosis (TB) and HIV/AIDS affect each other closely. Given the rapid spread of the HIV‐driven TB epidemic worldwide, the case for establishing some form of relationship between control activities for HIV/AIDS and TB is clear. However, the question ‘how’ has not been resolved satisfactorily. TB and HIV/AIDS programmes have traditionally maintained their own management, supervision, funding flows and specialist boundaries. This article explores opportunities and challenges for collaboration between the two, through drawing on the expertise in organization and management, policy analysis and disease control of both TB and HIV/AIDS. Based on an extensive literature review, the article investigates how contextual issues affect the design of a collaboration; what the organizational options are; and what impact a collaboration would have. A universal model for organizational change is unlikely and changes may present as both solutions and contradictions. Careful planning and consultation are required before implementing the changes, in order to avoid jeopardizing the function and effectiveness of both disease control programmes and the health service system.

Public sector hospitals and organizational change: an agenda for policy analysis

An important feature of health care systems in recent years is the change in the organizational position and relations of public sector hospitals. Health sector reforms have led to increasing heterogeneity in the organizational location and status of public sector hospitals and new organizational forms of public-private relations are being developed by and for hospitals. These changes can have important implications for health and health care. They raise issues around equity, control, accountability and performance of health care. Yet the policy process in practice may be failing to develop and implement appropriate forms of policy formulation on health sector reform. This paper focuses on the organizational position and relations of hospitals within public sector health services. It firstly outlines key elements of health sector reform and relates these to two dimensions of organizational change for hospitals: increasing heterogeneity and forms of public-private relations. The paper provides a descriptive format for classifying forms of hospital organizational change and proposes a framework of six questions for analysing these organizational forms. This may be used to assess the appropriateness of specific policies to particular country situations and to develop more open debate around hospital organizational forms.

Decentralization and Primary Health Care in Developing Countries: Ten Key Questions

Decentralization is an important element in the policy formulation and implementation of Primary Health Care (PHC) in developing countries. While this may well be the case, certain forms of “decentralization” policies can have negative implications for the development of PHC. It can be associated with a reduced role of the public sector, weaken the central Ministry of Health, be instrumental in producing inequity and facilitate political domination. It is necessary to examine decentralization with a view to securing its effective formulation and implementation. A set of ten questions and related issues is set out to facilitate this examination.

The Market and Health Sector Reform

A new international orthodoxy has developed on health sector reform. The dominant theme of the orthodoxy is the alleged benefits of market style reforms for health development. This is shaping changes formulated, and being implemented, in the British NHS and other European health services (including Central and Eastern Europe), Latin America and a number of developing health systems in Africa and Asia. Sets out a ten-point description of the orthodoxy. Contends that the orthodoxy is showing distinct signs of restricting the analysis and development of health management and planning. This is a matter for considerable concern as the adoption of market-style reforms can generate unforeseen and, in some cases, negative consequences. There is clearly a need for strengthening management research and development as a basis for effective health sector reform.

Public purchasers contracting external primary care providers in Central America for better responsiveness, efficiency of health care and public governance : issues and challenges

Several national health systems in Latin America initiated health reforms to counter widespread criticisms of low equity and efficiency. For public purchasing agencies, these reforms often consisted in contracting external providers for primary care provision. This paper intends to clarify both the complex and intertwined issues characterizing such contracting as well as health system performances within the context of four Central American countries. It results from a European Commission financed project lead between 2002 and 2005, involving participants from Costa Rica, Guatemala, Nicaragua, Salvador, United Kingdom, Netherlands and Belgium, whose aim was to promote exchanges between these participants. The findings presented in this paper are the results of a two stage process: (a) the design of an initial analytical framework, built upon findings from the literature, interlinking characteristics of contractual relation with health systems performances criteria and (b) the use of that framework in four case studies to identify cross-cutting issues. This paper reinforces two pivotal findings: (a) contracting requires not only technical, but also political choices and (b) it cannot be considered as a mechanical process. The unpredictability of its evolution requires a flexible and reactive approach. This should be better assimilated by national and international organizations involved in health services provision, so as to progressively come out of dogmatic approaches in deciding to initiate contractual relation with external providers for primary care provision.

Health system decentralisation in Nepal: identifying the issues

PURPOSE The purpose of this paper is to describe and discuss policy analysis in Nepal and review the wide range of choices feasible in decentralisation decision making. DESIGN/METHODOLOGY/APPROACH In this paper an iterative qualitative method was developed and used in the research, which consisted of focus group interviews, key informant interviews, document analysis, including descriptive statistics, and analysis of the policy context. Participants in the research reflected the urban/rural mix of districts and the geography of Nepal. Analysis combined transcribed interviews with findings from document searches and analysis of the policy context. Coding was pre-determined during the training workshop and further codes were generated during and after the fieldwork. FINDINGS The paper finds that Nepal is in the process of decentralising public services from the central level to the local level, particularly to local bodies: District Development Committees (DDCs), Village Development Committees (VDCs) and Municipalities. Key contextual factors referred to are the overall structure of decentralisation, the social context of poverty and the political instability leading to a fluid political situation characterised by political tension, armed conflict, controversies and agreements while carrying out the research. The key issues identified and discussed in the paper are the policy process leading to decentralisation, the organisational structure and tension in the proposed system, the systems of resource generation, allocation, planning and management and lastly the forms of accountability, participation, public-private relations and collaborative strategies. ORIGINALITY/VALUE The paper discusses the challenges faced in conducting such a policy analysis, the broad ranging and unremitting nature of the decentralisation process, and the contextual setting of the process of change.