Search

When countries introduce programme budgets, they develop a performance framework to support performance monitoring. In theory, a performance framework establishes a chain of accountability for the budget and results all the way from Parliament to executive agents. For a performance framework to contribute effectively, performance information cannot only be generated and reported. Performance needs to be assessed systematically. The results of this analysis need to be part of a performance dialogue that affects decision-making within ministries and agencies. Incorporating performance information into budgeting is a long-term endeavour that takes persistent effort and attention. Some monitoring challenges have to be overcome to realize the potential of programme budgeting especially in LMICs. OECD countries struggle to meet expectations with their programme budgeting and performance frameworks. LMICs encounter other challenges in applying performance frameworks in the health sector. The aim of this chapter is to identify some common challenges, particularly in the health sector in LMICs, and to offer some strategies to overcome these challenges.

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage. This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries.

The First Year of Life' 4th edition. By H. B. Valman. Pp. vi + 106. Illustrated. £14. London: BMJ. 1995. ISBN 0-7279-0897-9.Health-care Options for South Africa: Lessons from the UK and the USA By W. Ouncan Reekie. Pp. x + 116. R34.95. Sandton: The Free Market Foundation of Southern Africa. 1995. ISBN 1-874930-08-2.Manual of Diagnostic Ultrasound* Edited by P. E. S. Palm"'. xvi + 323. Illustrated. Sw.fT.65! USS58.50. Geneva: WHO. 1995. ISBN 92 4 154461 9. National Cancer Control Programmes. Policies and Managerial Guidelines" WHO. Pp. xviii + 134. Sw.fr.321USS28.80. Geneva: WHO. 1995. iSBN 92-4-154474-0.An Introduction to Medical Statistics" 2nd edition. By Martin Bland. Pp. xiv + 396. Illustrated. New York: Oxford University Press. 1995. ISBN 0-19-262428-8Ear, Nose, and Throat Diseases. A Pocket Reference" 2nd revised edition. By Waiter Beeker, Hans Heinz Naumann and CarI Rudon Pfaltz. Edrted by Richard A Buckingham. Pp xiv + 583. Illustrated. DM48. Stuttgart: Georg Thieme Verlag. 1994. ISBN 3-13-671201-1.

Objectives. To analyse the financial basis for downsizing of a provincial health department and suggest implications for fiscal policy.Design. Analysis of relevant departmental, provincial and national financing and expenditure trends from 1995/96 to 2002/03.Setting. Western Cape (WC) Department of Health (DOH).Results. Downsizing involving 9 282 health workers (27.9%) and closure of 3 601 hospital beds (24.4%) over 5 years. Total aggregate provincial transfers (all provinces) remained fairly constant in real terms. The WC's share decreased from 11.8% in 1996/97 to 9.8% in 2002/03. This was offset by the DOH's share of the WC budget increasing from 25.6% to 29.6%, mainly because of an increase in national health conditional grants. The net effect of financing changes was that the DOH's allocation in real terms was similar in 2002/03 and 1995/96, which suggests that financing changes are not the major cause of downsizing. Expenditure analysis revealed a 39.7% real rise in the average cost of health personnel. Substantial interprovincial inequities remain.Conclusion. The major cause of downsizing was wage growth, particularly following the 1996 wage agreement. Disjointed fiscal and wage policy has affected health services. Simultaneous application of policies of fiscal constraint, redistribution and substantial real wage growth has resulted in substantial downsizing with limited inroads into inequities. Inequities will continue to call for further redistribution, reduction in conditional grants and downsizing, much of which could have been avoided if fiscal and wage policy choices had been optimal.

Includes bibliographical references (p. 269-299), This thesis examines the "supply" and "demand" for health care expenditure in South Africa's public sector health care services. In this context supply refers to the availability of funding and demand to the requirement for funding. The literature review focuses on the health sector planning and its application to inform sector funding. A quantitative health sector planning model is developed and applied to inform the requirement for funding public sector health services. Uses of the model include simulation, forecasting and scenario planning.

Objective: The objectives of the study were to determine General Practitioners' attitudes to National Health Insurance (NHI) and to capitation as a mechanism of reimbursement. The study also aimed to explore determinants of these attitudes. Design: The methodology utilised a cross-sectional survey using telephone interviews and four focus group discussions. Setting: The study area was the Cape Peninsula area in the Western Cape Province of South Africa. Participants: 174 general practitioners (GPs) were randomly sampled from a total population of 874 GPs in the Cape Peninsula area. Main outcome measures: The main outcome measures were GPs' acceptance of NHI and of capitation as a method of reimbursement. Main results: Sixty three percent of GPs (63,3%) approved of NHI. More than 81 % approved of NHI if GPs were to maintain their independent status, for example their own premises and working hours. Eighty two percent (82,3%) said NHI would be a more equitable system of health care than the system that existed at that time, 88% approved of the fact that NHI would make care by GPs more accessible and 73% said they had the capacity to treat more patients. However, 61,3% of GPs disapproved of capitation as a form of reimbursement. The most common conditions cited by GPs for support of NHI were retention of professional autonomy, fee for service reimbursement and adequate levels of reimbursement. Conclusions: Most GPs in the Cape Peninsula were amenable to some form of NHI. However, approval of NHI is to some extent conditional to details of the NHI system, such as payment mechanisms, workload, income and effects on professional autonomy. The implications of GPs' preferences concerning the reimbursement mechanism for the feasibility of implementing a NHI in South Africa requires serious consideration by policy makers. While this research demonstrates broad ideological and conceptual support for some form of NHI or SHI, further research is required to provide more detailed quantitative information on the trade-offs that GPs would be prepared to make for them to support the introduction of a new socially based insurance system. A national survey of medical practitioners is recommended.

This descriptive study aimed to determine the knowledge, attitudes and practices about AIDS among Sexually Transmitted Disease (STD} clinic attenders in the Cape Peninsula. A questionnaire containing open and closed questions in the appropriate language (English, Afrikaans or Xhosa) was administered by trained clinic staff to 306 patients in 9 of the 29 STD Clinics in the region. The study was requested by the local authorities to initiate and improve AIDS education programmes within the STD clinics. 306 patients were interviewed in 9 clinics. The median age of attenders was 25 years. The median period of residence in the peninsula was 7 years. Knowledge of AIDS is reasonably good when tested by true/false questions but much worse when tested by open questions. Knowledge bears little relationship to practice. There is inadequate awareness of the asymptomatic carrier state, the incurability of AIDS and ways to prevent AIDS. Sexual practice is high risk. Condom use is extremely low especially in the African areas where only 9,6% used a condom in the past year. Prostitution is perceived to be a common occurrence in attenders' communities. There is a low perception of risk to self. The most important beliefs militating against condom use are that they are unacceptable to partners and peer group. More information about AIDS was requested by 90% of patients and a strong preference was expressed for programmes to be conducted in the patient's home language. This study supports the urgent need for an AIDS education and counselling programmes for patients with STD's in the region. Recommendations include the need to address the emotions, attitudes and beliefs that affect behaviour as well as to convey knowledge. Condom acceptability poses a major problem that will need to be addressed. Patients with STDs represent an extremely important core group for HIV transmission to others in the community and need specific attention and resources.