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Regulation is traditionally seen as the use of bureaucratic and administrative controls by government to correct market failure. Yet traditional methods such as licensing and certification frequently fail to control behaviour because of the limited resources available to government in low- and middle-income countries, and because of the powerful countervailing incentives that encourage deviant behaviour to continue. It is increasingly being realised, therefore, that goals of policy can sometimes be achieved more efficiently by involving other actors in the regulatory mechanism. In addition, a more flexible view of regulatory tools and strategies may enable governments, particularly in resource constrained environments, to utilise a much wider range of administrative controls and market enhancing incentives. The review suggests a wide range of tools that may be utilised to encourage better behaviour. These require that governments become aware of the need to reinforce controls with enabling incentives, utilise external standards where local measures are deemed inadequate and promote greater access to information on standards and services to consumers and providers.

Objective: To measure costs and willingness-to-pay for delivery care services in 8 districts of Nepal., Method: Household costs were used to estimate total resource requirements to finance: (1) the current pattern of service use; (2) all women to deliver in a health facility; (3) skilled attendance at home deliveries with timely referral of complicated cases to a facility offering comprehensive obstetric services., Results: The average cost to a household of a home delivery ranged from 410 RS (5.43 dollars) (with a friend or relative attending) to 879 RS (11.63 dollars) (with a health worker). At a facility the average fee for a normal delivery was 678 RS (8.97 dollars). When additional charges, opportunity and transport costs were added, the total amount paid exceeded 5,300 RS (70 dollars). For a caesarean section the total household cost was more than 11,400 RS (150 dollars). Based on these figures, the cost of financing current practice is 45 RS (0.60 dollar) per capita. A policy of universal institutional delivery would cost 238 RS (3.15 dollars) per capita while a policy of skilled attendance at home with early referral of cases from remote areas would cost around 117 RS (1.55 dollars) per capita. These are significant sums in the context of a health budget of about 400 RS (5 dollars) per capita. Conclusions The financial cost of developing a skilled attendance strategy in Nepal is substantial. The mechanisms to direct funding to women in need must to be improved, pricing needs to be more transparent, and payment exemptions in public facilities must be better financed if we are to overcome both supply and demand-side barriers to care seeking.

Health care can be funded in a number of ways ranging from direct user charges (out of pocket) payments to indirect methods that pool across time (prepayment) and across different risk and wealth groups (insurance and general taxation). All these methods can be used to finance maternal health services. When assessing the impact of financing mechanisms it is important to be aware of the different ways they effect service delivery patterns and utilisation. Specifically most systems have both equity and efficiency aspects that combine to impact on health service utilisation and health status. In general indirect methods that help families to pool the costs of maternal health services are preferable to direct methods of payment. It is also clear, however, that user charges may sometimes help to mitigate deficiencies in systems of pooled funding. Available literature suggests that financing mechanisms for maternal health services could be improved by systems that increase transparency, help to mitigate demand-side costs of services and provide funding for that promote transparent charging for services. While the limited experience of demand-side mechanisms for improving access to maternal health services more evaluation is required.

In order to understand the impact of specific maternal health interventions, it is necessary to understand the likely effect of the health system structure. An important aspect of this structure is the organizational culture. Many systems in low-income countries have been based on a centrally planned and financed system. In recent years a series of organizational changes have been introduced into many systems and these substantially alter the way in which the system operates and impacts on reproductive health care provision. The main changes reviewed in this paper are: (i) decentralization, (ii) privatization and (iii) integration and sector wide approaches. Each of these changes is seen to have important implications for reproductive health. In each case it is clear that the nature of the impact depends crucially on the way it is implemented. Quantifying the impact of these changes remains extremely difficult given the many different ways they can be introduced and the many confounding factors that affect the overall impact. The literature does, however, point to a number of key issues that impinge on the way in which change is likely to affect reproductive health initiatives.

There is increasing awareness that supply subsidies for health and education services often fail to benefit those that are most vulnerable in a community. This recognition has led to a growing interest in and experimentation with, consumer-led demand side financing systems (CL-DSF). These mechanisms place purchasing power in the hands of consumers to spend on specific services at accredited facilities. International evidence in education and health sectors suggest a limited success of CL-DSF in raising the consumption of key services amongst priority groups. There is also some evidence that vouchers can be used to improve targeting of vulnerable groups. There is very little positive evidence on the effect of CL-DSF on service quality as a consequence of greater competition. Location of services relative to population means that areas with more provider choice, particularly in the private sector, tend to be dominated by higher and middle-income households. Extending CL-DSF in low-income countries requires the development of capacity in administering these financing schemes and also accrediting providers. Schemes could focus primarily on fixed packages of key services aimed at easily identifiable groups. Piloting and robust evaluation is required to fill the evidence gap on the impact of these mechanisms. Extending demand financing to less predictable services, such as hospital coverage for the population, is likely to require the development of a voucher scheme to purchase insurance. This suggests an already developed insurance market and is unlikely to be appropriate in most low-income countries for some time.

There is considerable evidence that unofficial payments are deeply embedded in the markets for health care in transition countries. Numerous surveys indicate that these payments provide a significant but possibly distorting contribution to health care financing. Unofficial payments can be characterised into three groups: cost contributions, including supplies and salaries, misuse of market position and payments for additional services. There is evidence from across the region on the presence of payment in each category although it is often difficult to distinguish between payment types. Regulatory policy must address a number of issues. Imposing penalties may help to reduce some payments but if the system is simply unable to provide services, such sanctions will drive workers into the private sector. There appears to be some support for formalising payments in order to reduce unofficial charges although the impact must be monitored and the danger is that formal fees add to the burden of payment. Regulation might also attempt to increase the amount of competition, provide information on good performing facilities and develop the legal basis of patient rights. Ultimately, unless governments address the endemic nature of payments across all sectors, policy interventions are unlikely to be fully effective.

Utilizing a study of the costs of providing essential services in rural areas in Bangladesh projections of the cost of expanding services to the entire rural population are derived. These estimates are based on the current system of primary care, the demographic structure of the population and normatives for desired utilization. Scenarios make use of known demographic characteristics of average rural areas together with information on disease prevalence. The estimates highlight a number of difficulties involved in deriving costs and in comparing the cost-effectiveness of service provision. The integrated nature of much primary care, both in terms of the technical exploitation of joint costs and clinical diagnostic and treatment protocols, means that treating services in isolation is likely to lead to inexact estimates of service cost. The context of any costs derived is required in order to make comparisons.

After undergoing many changes, the financing of health care in countries of the former Soviet Union is now showing signs of maturing. Soon after the political transition in these countries, the development of insurance systems and fee-for-service payment systems dominated the discussions on health reform. At present there is increasing emphasis on case mix adjusted payments in larger hospitals and on global budgets in smaller district hospitals. The problem is that such systems are often mistrusted for not providing sufficient financial control. At the same time, unless further planned restructuring is introduced, payment systems cannot on their own induce the fundamental change required in the health care system. As described in this article, in Tejen etrap (district), Turkmenistan, prospective business plans, which link planned objectives and activities with financial allocations, provide a framework for setting and monitoring budget expenditure. Plans can be linked to the overall objectives of the restructuring system and can be used to ensure sound financial management. The process of business planning, which calls for a major change in the way health facilities examine their activities, can be used as a vehicle to increase awareness of management issues. It also provides a way of satisfying the requirement for a rigorous, bottom-up planning of financial resources.

The Soviet health care system placed great emphasis on specialist hospitalization. Primary care, in contrast, was viewed primarily as prophylactic and also identified patients for admission to hospital. This led to long lengths of stays, since patients were provided with outpatient type care in hospital, and unnecessary admissions. The reduction in funding for the health system has exacerbated the top heavy nature of the system and made restructuring of the sector essential. Rural areas in Kazakstan follow a similar structure to other parts of the former Soviet Union. In 1996 a project was undertaken to review the provision of hospital services in one rural rayon (district) just outside Almaty. The approach taken was to emphasize the relationship between activity and financial data. It did this by analysing the link between clinical decisions taken to reduce lengths of stay, management decisions to modify staffing and costs of care. It was shown that substantial savings could be made together with improvements in the quality of care, through a programme of planned restructuring. Some success in inducing change is reported but without a major change in approach to local level management. In order to achieve changes it is important that short and long term alternatives to hospitalization are developed.

Kazakstan, as in other former communist countries, is currently replacing the soviet system of health care financing for a model based on medical insurance. The main initial purpose has been to generate additional revenue for a sector suffering considerably from reductions in state funding induced by economic transition. Two key issues need to be addressed if the new system is to produce genuine reform. First, the rural areas have suffered disproportionately from the changes. There is an urgent need to adapt the existing system so that adequate funding goes to redress this imbalance. Second, although the fund has concentrated on raising revenue, it will only induce real reform if it begins to exercise its role as an independent purchaser of health care. There is a need for the future roles of both health ministry and insurance fund to be clearly defined to ensure that wide access to medical care is preserved.

In common with many developing countries, Vietnam has begun to introduce user fees at community and district level. This is part response to the transformation of the economy, economic recession, and the growing acceptability of alternative forms of health finance. This article examines the impact of these charges on the rural poor. Results from a 1995 survey in North Vietnam suggest that the poor generally delay treatment, make less use of government health facilities, and pay more for each episode of illness than the rich. There is evidence that the poor are forced to reduce consumption of essential goods or to borrow to meet these charges. A significant minority are deterred from using facilities. The current system of exemptions fails to provide adequate protection to the poor and a completely new system is required. The results suggest that it is the poor in poorer communes that are most affected by high user fees and it is to these areas that any assistance from government or donors should be targeted.

Background: Despite the growth of managed care in the United States, there is little information about the arrangements managed-care plans make with physicians., Methods: In 1994 we surveyed by telephone 138 managed-care plans that were selected from 20 metropolitan areas nationwide. Of the 108 plans that responded, 29 were group-model or staff-model health maintenance organizations (HMOs), 50 were network or independent-practice-association (IPA) HMOs, and 29 were preferred-provider organizations (PPOs)., Results: Respondents from all three types of plan said they emphasized careful selection of physicians, although the group or staff HMOs tended to have more demanding requirements, such as board certification or eligibility. Sixty-one percent of the plans responded that physicians' previous patterns of costs or utilization of resources had little influence on their selection; 26 percent said these factors had a moderate influence; and 13 percent said they had a large influence. Some risk sharing with physicians was typical in the HMOs but rare in the PPOs. Fifty-six percent of the network or IPA HMOs used capitation as the predominant method of paying primary care physicians, as compared with 34 percent of the group or staff HMOs and 7 percent of the PPOs. More than half the HMOs reported adjusting payments according to utilization or cost patterns, patient complaints, and measures of the quality of care. Ninety-two percent of the network or IPA HMOs and 61 percent of the group or staff HMOs required their patients to select a primary care physician, who was responsible for most referrals to specialists. About three quarters of the HMOs and 31 percent of the PPOs reported using studies of the outcomes of medical care as part of their quality-improvement programs., Conclusions: Managed-care plans, particularly HMOs, have complex systems for selecting, paying, and monitoring their physicians. Hybrid forms are common, and the differences between group or staff HMOs and network or IPA HMOs are less extensive than is commonly assumed.

Like many other countries Vietnam is trying to reform its health care system through the introduction of social insurance. The small size of the formal sector means that the scope for compulsory payroll insurance is limited and provinces are beginning to experiment with ways of encouraging people to buy voluntary insurance. Methods of contracting between hospitals and insurance centres are being devised. These vary in complexity and there is a danger that those based on fee for service will encourage excessive treatment for those insured. It is important that the national and provincial government continue to maintain firm control over funding while also ensuring that a substantial and targeted general budget subsidy is provided for those unable to make contributions.

Similarities in the trends of the number of offences and the level of alcohol consumption are often used as evidence as a link between alcohol and many forms of criminal activity. However, such crude correlations may be misleading as they neither take account of other factors that might be important, not assist the understanding of the causal links between alcohol and crime. In this paper, the role that economic models may play in furthering the understanding of the potential links between alcohol and crime are explored. A complete model is presented which allows for complex interactions between alcohol, crime and the criminal justice system. Results from testing this model with time series data (1960-88) for England and Wales for different types of crime are discussed in detail. Data defined by standard regions and for the years 1980 to 1988 were also compiled and a summary of the results discussed. The argument that alcohol consumption may be one of the determinants of a wide range of crimes receives some support and is also found that alcohol consumption may affect the probability of detection for some types of crime.