Search

Performance-based financing (PBF)—a supply-side strategy that incentivizes health providers based on predefined quality and quantity criteria—introduced an innovative approach to reaching the poor by means of using PBF equity instruments. These PBF equity instruments include paying providers more to reach out to poor women, selecting services used by the poor, subsidizing user fees to reduce out-of-pocket expenses, and adding complementary demand-side intervention. Before the implementation of the PBF equity instrument in Cameroon, there were few initiatives/schemes to enable the poor to access maternal health services. Moreover, there is a significant research gap on how the equity elements are defined and implemented across contexts. This study aims to understand (i) how health facilities define and classify the poor and vulnerable in the context of PBF, (ii) how the equity elements are implemented at the community and facility levels, and (iii) the potential impact on access to and the use of maternal health services at the facility level and challenges in the implementation process. We used key informant interviews and focus group discussions (FGDs) based on a grounded theory approach to gain an understanding of the social processes and experiences. Data were collected from three districts in the Southwest region of Cameroon from April 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. The thematic analysis approach/technique was used to analyze data. Key informant interviews and focus groups were conducted with 79 participants, including 28 health professionals and service administrators, 27 pregnant women, and 24 community health workers in three districts. Health facilities employed various subjective approaches to assess and define poor and vulnerable (PAV) persons. Home visits were reported to have an impact in reaching the poor and vulnerable to improve access to maternal services. Meanwhile, a delay in the payment of PBF incentives was reported to be the main challenge that had a negative relationship with the consistent provision of care to the poor and vulnerable, especially in private health facilities. The theory generated from our findings suggests that the impact of the PBF equity elements specific to maternal health depends on (i) a shared understanding of the definition of PAV among different stakeholders, including providers and users, as well as how the PAV is operationalized (structure), and (ii) the appropriate and timely payment of incentives to health facilities and health providers.

Introduction Health facilities assessments are an essential instrument for health system strengthening in low- and middle-income countries. These assessments are used to conduct health facility censuses to assess the capacity of the health system to deliver health care and to identify gaps in the coverage of health services. Despite the valuable role of these assessments, there are currently no minimum standards or frameworks for these tools. Methods We used a structured keyword search of the MEDLINE, EMBASE and HealthStar databases and searched the websites of the World Health Organization, the World Bank and the International Health Facilities Assessment Network to locate all available health facilities assessment tools intended for use in low- and middle-income countries. We parsed the various assessment tools to identify similarities between them, which we catalogued into a framework comprising 41 assessment domains. Results We identified 10 health facility assessment tools meeting our inclusion criteria, all of which were included in our analysis. We found substantial variation in the comprehensiveness of the included tools, with the assessments containing indicators in 13 to 33 (median: 25.5) of the 41 assessment domains included in our framework. None of the tools collected data on all 41 of the assessment domains we identified. Conclusions Not only do a large number of health facility assessment tools exist, but the data they collect and methods they employ are very different. This certainly limits the comparability of the data between different countries’ health systems and probably creates blind spots that impede efforts to strengthen those systems. Agreement is needed on the essential elements of health facility assessments to guide the development of specific indicators and for refining existing instruments.

Background Assessing the availability of health services during humanitarian emergencies is essential for understanding the capacities and weaknesses of disrupted health systems. To improve the consistency of health facilities assessments, the World Health Organization has proposed the use of the Health Resources Availability Mapping System (HeRAMS) developed in Darfur, Sudan as a standardized assessment tool for use in future acute and protracted crises. This study provides an evaluation of HeRAMS’ comprehensiveness, and investigates the methods, quality and comprehensiveness of health facilities data and tools in Haiti, where HeRAMS was not used. Methods and findings Tools and databases containing health facilities data in Haiti were collected using a snowball sampling technique, while HeRAMS was purposefully evaluated in Sudan. All collected tools were assessed for quality and comprehensiveness using a coding scheme based on the World Health Organization’s health systems building blocks, the Global Health Cluster Suggested Set of Core Indicators and Benchmarks by Category, and the Sphere Humanitarian Charter and Minimum Standards in Humanitarian Response. Eight assessments and databases were located in Haiti, and covered a median of 3.5 of the 6 health system building blocks, 4.5 of the 14 Sphere standards, and 2 of the 9 Health Cluster indicators. None of the assessments covered all of the indicators in any of the assessment criteria and many lacked basic data, limiting the detail of analysis possible for calculating standardized benchmarks and indicators. In Sudan, HeRAMS collected data on 5 of the 6 health system building blocks, 13 of the 14 Sphere Standards, and collected data to allow the calculation of 7 of the 9 Health Cluster Core Indicators and Benchmarks. Conclusions There is a need to agree upon essential health facilities data in disrupted health systems during humanitarian emergencies. Although the quality of the assessments in Haiti was generally poor, the large number of platforms and assessment tools deployed suggests that health facilities data can be collected even during acute emergencies. Further consensus is needed to establish essential criteria for data collection and to establish a core group of health systems assessment experts to be deployed during future emergencies.

Health systems can primarily improve the health of individuals and populations by delivering high-quality interventions to those who may benefit from them. We propose a concept of effective coverage as the probability that individuals will receive health gain from an intervention if they need it. Understanding the extent to which health systems are delivering key interventions to those who will benefit from them and the factors that explain gaps in delivery are a critical input to decision-making at the local, national and global levels. We develop an integrated conceptual framework for monitoring and analyzing the delivery of high-quality interventions to those who need them. This framework can help clarify the inter-relationships between notions of access, demand for care, utilization, and coverage on the one hand and highlight the requirements for health information systems that can sustain this type of analysis. We discuss measurement strategies and demonstrate the concept by means of a simple simulation model.

The World Health Report 2000 [1] sought tooutline, for the first time, a consistent frameworkfor assessing the performance of health systemsthat could be used by countries to monitor theirown progress over time, and which would helpcountries learn from each other. It was motivatedby the need to have the debate about appropriatehealth sector policies and reforms guided by thebest available evidence on outcomes. ProfessorWilliams describes Dr Gro Harlem Brundtland’sambition in undertaking this exercise as ‘a worthyone’ and calls the task undertaken by the Report‘ambitious, and potentially very rewarding’. Hismain criticisms focus on the quality of the dataused to measure outcomes. Yet his solution is notto seek better data or to develop better outcomeindicators, but to advocate that further attemptsto measure outcomes should cease forthwith.Moreover, he concludes his piece by impugningthe very integrity of the Organization in seekingto provide evidence for health policy.There is something inconsistent and disquietingin this. It is particularly disquieting whenWilliams claims (based on no evidence at all) that‘internal dissent is stifled’ in WHO and that theOrganization would benefit from more academicdebate. It is inconsistent to argue on the one handthat more academic debate should be stimulatedwithin the Organization while at the same timearguing that WHO’s attempts to focus healthpolicy on outcomes, and to measure these out-comes using the best evidence possible, should becensored. To stifle the search for evidence on thegrounds that current data are weak is totallyinconsistent with the scientific ethos which WHOis trying to pursue and which we believe is thehallmark of academia.Because of Williams’ attack on the integrity ofthe Organization and its management, it is impor-tant to respond to the individual technical pointsmade. They are dealt with in turn.OVERALL ATTAINMENTWilliams takes exception to producing an overallscore rather than confronting people with thetrade-offs between competing objectives. This issimply not relevant. The World Health Report(WHR) provides tables showing attainment on allof the individual components as well as the over-all score. We should not underestimate the intelli-gence of policy makers who, if they wish toexamine the trade-offs, can look at the individualtables as well as the overall scores.It is true that there are some statistically signif-icant differences between respondents from devel-oped countries and those from developingcountries in the weights assigned to health andto inequalities in responsiveness in constructionof the overall index. The difference between

Objective To provide insight of national activities and international assistance in PHC reform and to assess their effects on technical and allocative efficiency as well as financial sustainability of primary health care in the Republic of Serbia. Materials and methods Analytical framework of the study consisted of gathering and reviewing of relevant political documents, international assistance project documentation, and analysis of routinely collected national statistical data based on the evaluation model of three groups of criteria: allocative, technical efficiency and financial sustainability in the public sector of Serbia from 2000 to 2007. Time trends were analyzed by Poisson regression models using average annual percentage changes – AAPC, and the percent of targeted change achieved by progress quotient – PQ. Results Allocative efficiency of the PHC during period of 8 years was improved, but technical efficiency was almost unchanged for all service, except for preschool health care. Financial sustainability was also improved measured by indirect indicators of health expenditure. Conclusions Results of this study indicated that we are on the right track with PHC reform, and international support is in accordance with the reform goals. Our approach has been and will remain incremental, gradualist and multi-faceted.

At the beginning of the 21st century, health systems in both industrialized and developing countries are becoming increasingly pluralistic, with diversified public, private, non-governmental organizations, community, and home provision of care leading to greater complexity of health service organization. At the same time, political stewardship is often weak and challenged by strong interest groups. To manage the challenge of HIV better, countries need to strengthen various aspects of their health systems. Specific investments in strengthening health systems may improve the capacity of the system to plan and deliver services. Reforms at the sector level may strengthen incentives for efficiency; these include, for example, introduction of contractual relationships, decentralization of decision making, increased autonomy for health providers and integration of services. Also training capacity must be sufficient to respond to train appropriate healthcare personnel. Combating HIV calls for innovative, socially responsible and flexible approaches to human resources development and use.

HIV/AIDS, Cluster ofHIV/AIDS, Tuberculosis and Malaria, World Health Organization, Geneva, SwitzerlandIn the context of the Millennium Development Goals, human resources represent the most criticalconstraint in achieving the targets. Therefore, it is important for health planners and decision-makersto identify what are the human resources required to meet those targets. Planning the humanresources for health is a complex process. It needs to consider both the technical aspects related toestimating the number, skills and distribution of health personnel for meeting population healthneeds, and the political implications, values and choices that health policy- and decision-makers needto make within given resources limitations. After presenting an overview of the various methods forplanning human resources for health, with their advantages and limitations, this paper proposes amethodological approach to estimating the requirements of human resources to achieve the goals setforth by the Millennium Declaration. The method builds on the service-target approach and functionaljob analysis.Key words: health planning, human resources for health, health interventions, tuberculosis, maternal health,child health,malaria, HIV/AIDS

are taking place in a context in which the global public-health workforce is unprepared to confront these challenges. This lack of preparation is partly because the challenges are large and complex, 3 the public-health workforce and infrastructure have been neglected, and training programmes are inadequate. These problems are exacerbated by the concentration of funding on biomedical research and the failure to confront and work with vested interests, which promote and sustain unhealthy behaviour patterns. If public-health practitioners are to address national and global health challenges effectively, the way they work and make their work relevant to these challenges 4 will require a major reorientation. A clear vision of what public health is, and what it can offer, is required. To be achievable, the vision must then be communicated not only to its practitioners, but also to the wider policy community, whose actions are necessary to improve the health of the public. Here, we propose a reformulation of public health appropriate for the global and national health challenges in this new era. The practice of public health Approaches to the practice of public health are contingent on time and place. They are distinguished mainly by the amount of authority vested in the state and their main disciplinary base. In terms of state involvement and responsibility, there are two extreme approaches: the state medicine model and the market model. The practice of public health in the USA is an example of the market approach. The aim of this model is to limit government responsibility for public health and to encourage individual responsibility for health improvement, on the assumption that the market will respond to individuals’ demands for goods that promote health. 5 The state medicine model, by contrast, envisages a strong role for the state, encroaching in many areas that some might consider private life. A particular version was transposed to the Soviet Union, where public health became a central part of state policy, summarised by Lenin’s comment that “if communism does not destroy the louse, the louse will destroy communism”. 6

The global community is in the midst of a growing response to health crises in developing countries, which is focused on mobilising financial resources and increasing access to essential medicines. However, the response has yet to tackle the most important aspect of health-care systems--the people that make them work. Human resources for health--the personnel that deliver public-health, clinical, and environmental services--are in disarray and decline in much of the developing world, particularly in sub-Saharan Africa. The reasons behind this disorder are complex. For decades, efforts have focused on building training institutions. What is becoming increasingly clear, however, is that issues of supply, demand, and mobility (transnational, regional, and local) are central to the human-resource problem. Without substantial improvements in workforces, newly mobilised funds and commodities will not deliver on their promise. The global community needs to engage in four core strategies: raise the profile of the issue of human resources; improve the conceptual base and statistical evidence available to decision makers; collect, share, and learn from country experiences; and begin to formulate and enact policies at the country level that affect all aspects of the crisis.

In the face of diverse contexts in the world's regions and countries, decentralization and increasing autonomy of hospitals are an important trend in hospital sector development. Substantial gains in institutional performance can be achieved through better internal hospital management. The article examines hospital managers' functions and practices and outlines a framework for assessing their management education needs. We argue that training is most appropriate if targeted at improving managerial competence within a specific health system development context.

It is estimated that in 2000 almost 175 million people, or 2.9% of the world's population, were living outside their country of birth, compared to 100 million, or 1.8% of the total population, in 1995. As the global labour market strengthens, it is increasingly highly skilled professionals who are migrating. Medical practitioners and nurses represent a small proportion of highly skilled workers who migrate, but the loss of health human resources for developing countries can mean that the capacity of the health system to deliver health care equitably is compromised. However, data to support claims on both the extent and the impact of migration in developing countries is patchy and often anecdotal, based on limited databases with highly inconsistent categories of education and skills. The aim of this paper is to examine some key issues related to the international migration of health workers in order to better understand its impact and to find entry points to developing policy options with which migration can be managed. The paper is divided into six sections. In the first, the different types of migration are reviewed. Some global trends are depicted in the second section. Scarcity of data on health worker migration is one major challenge and this is addressed in section three, which reviews and discusses different data sources. The consequences of health worker migration and the financial flows associated with it are presented in section four and five, respectively. To illustrate the main issues addressed in the previous sections, a case study based mainly on the United Kingdom is presented in section six. This section includes a discussion on policies and ends by addressing the policy options from a broader perspective.

Imbalance in the health workforce is a major concern in both developed and developing countries. It is a complex issue that encompasses a wide range of possible situations. This paper aims to contribute not only to a better understanding of the issues related to imbalance through a critical review of its definition and nature, but also to the development of an analytical framework. The framework emphasizes the number and types of factors affecting health workforce imbalances, and facilitates the development of policy tools and their assessment. Moreover, to facilitate comparisons between health workforce imbalances, a typology of imbalances is proposed that differentiates between profession/specialty imbalances, geographical imbalances, institutional and services imbalances and gender imbalances.

Foreword 1. Health Care in the Canadian Community(Robert G. Evans) 2. A Comparison of Our Two Systems(The Honorable Perrin Beatty) 3. From Inside the System: A Physician, Hospital Administrator, and Business Executive Talk About Their Work in Canada(Jerry Estill) 4. Voices from the Polls: Consensus and Satisfaction from Canadian Patients and Taxpayers(Ian McKinnon) 5. The Political Perspective: Planning and Implementing the Canadian System(The Honorable Allan Blakeney) 6. Delivering and Financing Long-Term Care in Canada's Ten Provinces(Rosalie Kane) 7. Serving Elderly Patients: The Benefits of Integrated Long-Term Care in British Columbia(Paul Pallan) 8. Understanding the Health Care System That Works(Orvill Adams) 9. Eleven Lessons from Canada's Health Care System(Ron Pollack).

Background Recent economic growth in Kazakhstan has been accompanied by slower improvements in population health and this has renewed impetus for health system reform. Strengthening strategic planning and policy-making capacity in the Ministry of Health has been identified as an important priority, particularly as the Ministry of Health is leading the health system reform process. Case description The intervention was informed by the United Nations Development Programme (UNDP) framework for capacity building which views capacity building as an ongoing process embedded in local institutions and practices. In response to local needs extra elements were included in the framework to tailor the capacity building programme according to the existing policy and budget cycles and respective competence requirements, and link it with transparent career development structures of the Ministry of Health. This aspect of the programme was informed by the institutional capability assessment model used by the United Kingdom National Health Service (NHS) which was adapted to examine the specific organizational and individual competences of the Ministry of Health in Kazakhstan. Discussion and evaluation There were clear successes in building capacity for policy making and strategic planning within the Ministry of Health in Kazakhstan, including better planned, more timely and in-depth responses to policy assignments. Embedding career development as a part of this process was more challenging. This case study highlights the importance of strong political will and high level support for capacity building in ensuring the sustainability of programmes. It also shows that capacity-building programmes need to ensure full engagement with all local stakeholders, or where this is not possible, programmes need to be targeted narrowly to those stakeholders who will benefit most, for the greatest impact to be achieved. In sum, high quality tailor-made capacity development programmes should be based on thorough needs assessment of individual and organizational competences in a specific institutional setting. Conclusions The experience showed that complementary approaches to human resource development worked effectively in the context of organizations and systems, where an enabling environment was present, and country ownership and political will was complemented by strong technical assistance to design and deliver high quality tailor-made capacity building initiatives.

Several countries are increasingly relying on immigration as a means of coping with domestic shortages of health care professionals. This trend has led to concerns that in many of the source countries – especially within Africa – the outflow of health care professionals is adversely affecting the health care system. This paper examines the role of wages in the migration decision and discusses the likely effect of wage increases in source countries in slowing migration flows. This paper uses data on wage differentials in the health care sector between source country and receiving country (adjusted for purchasing power parity) to test the hypothesis that larger wage differentials lead to a larger supply of health care migrants. Differences in other important factors affecting migration are discussed and, where available, data are presented. There is little correlation between the supply of health care migrants and the size of the wage differential between source and destination country. In cases where data are available on other factors affecting migration, controlling for these factors does not affect the result. At current levels, wage differentials between source and destination country are so large that small increases in health care wages in source countries are unlikely to affect significantly the supply of health care migrants. The results suggest that non-wage instruments might be more effective in altering migration flows.