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Health sector reforms in sub-Saharan Africa: lessons of the last 10 years.

Over the past 10 years the poorest countries, especially in Africa, have struggled with worsening economic conditions and reduced public finance for health services. Some governments have responded in a piecemeal fashion, reacting to internal and external pressures. Others have embarked on major reforms of various aspects of their health systems. This paper reviews two specific types of strategy that have been initiated by governments: reform of financing strategies, and reform of public sector organization and procedures. Particular attention is paid to the experience of introducing user fees, community financing and decentralization since these have been some of the most popular strategies. The paper describes the nature, objectives and extent of reforms. It then presents an evaluation framework related to the criteria of efficiency and equity, and evaluates current reform experience using this framework. It concludes that assessment of the potential impact of reforms on efficiency and equity is undermined by the limited duration of many reforms and the limited nature of existing evaluations. It is clear, however, that a policy package is required rather than implementation of isolated reform strategies, and that in order to design an effective policy package, more needs to be known about the implementation and operation of reforms--particularly with respect to the influence of context, actors and processes.

Africa South of the Sahara↗
PubMed1981

Independent living placement: five years later.

The placement success and quality of life of 69 mentally retarded persons placed into independent housing 5 years previously was evaluated. Eighty percent (n = 55) were still in their original independent housing placement. On the basis of multiple regression analysis, the most significant predictor variables were the behavioral skill areas of personal maintenance, communication, community integration, clothing care and use, and food preparation. Unsuccessful placements were related to bizarre behavior, nutritional problems, and inadequate home maintenance. Quality of life variables analyzed included employment, finances, community utilization, leisure-time usage, and friendship patterns. Analysis of the quality of life variables presented a mixed picture: Part of the data reflected low income and possible loneliness; on the other hand, community utilization occurred frequently and involved normal activities. Clients reported that they were proud of their apartments and felt good about "doing their own thing." In light of the results, an extended assistance-training model was presented.

Activities of Daily Living↗
PubMed2000

The community-based malaria control programme in Tigray, northern Ethiopia. A review of programme set-up, activities, outcomes and impact.

Tigray, the northernmost state of Ethiopia, has a population of 3.5 million, 86% rural, and 56% living in malarious areas. In 1992 a Community-Based Malaria Control Programme was established to provide region-wide and sustained access to early diagnosis and treatment of malaria at the village level. 735 volunteer community health workers (CHWs) serve 2,327 villages with a population of 1.74 million, treating an average of 489,378 patients yearly from 1994 to 1997. Recognition of clinical malaria is similar for CHWs and health staff at clinics where there is no access to microscopy. In 1996 a pilot community-financing scheme of insecticide-treated bednets was well accepted, but re-impregnation rates fell in 1998 because of war-related social upheaval. Indicators from health institutions show a progressive increase in malaria morbidity from 1994 to 1998. Repeated mortality surveys show a 40% reduction in death rates in under-5 children from 1994 to 1996 and a 10% increase from 1996 to 1998. These trends may be related to increased malaria transmission with water resources development, increased seasonal labour migration to malarious lowlands, prolongation of the transmission season with climate changes, and increasing chloroquine resistance throughout Ethiopia. Progressive extension of CHW services to ensure better coverage of women, children, migrant workers and communities near water development projects, change to first-line treatment with sulfadoxine-pyrimethamine, extension of the impregnated bednet initiative, and development of a regional warning system for epidemics should result in a greater impact on morbidity and mortality.

Age Factors↗
PubMed1999

Social movements and health insurance: a critical evaluation of voluntary, non-profit insurance schemes with case studies from Ghana and Cameroon.

This paper assesses the performance of voluntary, non-profit health insurance schemes and their potential contribution to health in the two African countries of Ghana and Cameroon. Based on fieldwork conducted in the two countries during the main rainy season (June-July) of 1996, the paper examines whether and in which way the presence or absence of a social movement component might affect the performance of voluntary, non-profit insurance schemes in attaining some key objectives of improving access to health care among the target population, as well as achieving equity, efficiency and financial viability. The paper makes this assessment by examining the performances of each of two case studies according to the criteria of social movement, efficiency, equity, access and financial results. Based on case studies of a community financing insurance scheme in Ghana and a mutual aid insurance association in Cameroon, the study concludes that the evidence is not sufficient to confirm that the presence or absence of such a social movement dynamic per se accounts for the perceived performance of either of the schemes. However, it is also argued that the dynamic of social movement could enhance the design and performance of a scheme, especially the efficiency and quality of health care. Such enhancement is possible provided that the scheme is set up in such a way as to benefit from the specific contribution of a movement component, in particular, if the scheme engages in direct negotiations with providers over the price and quality of care and makes direct payment contracts with such providers. A good scheme design is therefore one of the real keys to success. Moreover, it is arguable that a non-social movement based scheme can incorporate elements of a social movement (such as greater community participation, accountability and autonomy) in the course of time. It is argued that this process would enhance the success of a non-movement-based scheme. The study finally presents some lessons and suggestions from the examination of the schemes which could be of benefit in the design, implementation and evaluation of similar schemes.

Cameroon↗
PubMed1995

A prepayment scheme for hospital care in the Masisi district in Zaire: a critical evaluation.

In most developing countries, government funding allocated to the health services is not sufficient to allow these services to provide appropriate health care accessible to all. Consequently, community financing has received much more attention in recent years and innovative schemes are being explored throughout the developing world. Risk-sharing schemes, like prepayment, are interesting because of their potential redistributive effects. At the end of the eighties, a prepayment scheme for hospital care was experimented with in the Masisi health district in Eastern Zaire. In the present paper, the experiment is described in a chronological way and the results are analyzed and discussed in detail. Although this particular case-study was not successful, it yields important lessons concerning the design, implementation and evaluation of prepayment schemes for hospital health care in developing countries. More specifically, phenomena like adverse selection and moral hazard are discussed. Finally, conditions for success of similar experiments are discussed. These conditions relate mainly to the organization pattern of the district health services system. The Masisi experiment is a nice illustration of the fact that prepayment is not a 'magic bullet': the lessons drawn from it may be of relevancy to health planners intending to implement hospital prepayment schemes in similar settings.

Democratic Republic of the Congo↗
PubMed1992

Considerations in setting up a positron emission tomography center.

Clinically oriented imaging with position emission tomography (PET) has come of age. Given an adequate referral base and physician interest, a compelling argument can be made at all levels of the review process for setting up a PET program in a clinical setting. PET is expensive. It is obvious that the cost of running a PET service depends heavily on an institution's ability to obtain reasonable financing. Educational institutions have the opportunity to acquire special funding through a variety of sources. On the other hand, money can be expensive for private entrepreneurs. It appears that in the near future PET centers will probably remain at educational institutions or large well-financed community hospitals able to raise money at reasonable rates until reimbursement issues are better resolved. Finally, the future of clinical PET may hinge significantly on the ability of commercial radiopharmaceutical suppliers to provide regional fluorodeoxyglucose distribution. As an institutional program development, PET offers opportunities by providing unique clinical data aiding the referral pattern. PET may serve as a magnet for recruitment in many areas and may promote interdisciplinary cooperation. A clinical PET center serves both as a model for future and more widespread use of PET and as a training ground for medical personnel. Finally, the unique capabilities of PET may facilitate grant opportunities.

Facility Design and Construction↗
PubMed2004

Development of the rural health insurance system in China.

Ever since the collapse of the once successful Rural Cooperative Medical System (RCMS) in the early 1980s, when China transformed its system of collective agricultural production to private production, many rural communities, especially the poorer residents, have faced several major problems. In 1993, insurance coverage for rural residents was already low, at 12.8%. By 1998, only 9.5% of the rural population was insured. User charges have effectively blocked access for many rural residents who lack adequate income to purchase basic health care when needed. Impoverishment due to medical expenses is also a serious problem, which begs the question: why has there been no vigorous development of the rural health insurance system in China despite the country's rapid economic growth? This paper analyzes the major underlying reasons for the lack of rural health insurance in China. We found that lack of demand for the voluntary community financing schemes and inadequate government policies are the two major hindrances. Recently, the Chinese government announced a new rural health financing policy that relies on 'matching-funds' by the central and local governments as well as household contributions. The potential for success of this new model might be inferred from China's past experiences, as well as from the pilot projects that are underway.

China↗
PubMed1985

Heuristic approaches to decision-making in the delivery of primary health care within developing regions.

The delivery of primary health care (PHC) services is now recognized as a crucial element in the development of low-income regions. Effective delivery of these services requires the ability to solve a variety of policy decision problems. Research has demonstrated the utility of operations research/management science (OR/MS) models and methodologies in the analysis and solution of such problems. However, this approach may be limited in some regions by the data and computational requirements of the models. Intuitive approaches in the spirit of OR/MS models, termed heuristics, can provide an effective alternative in such cases. The current paper proposes a general heuristic procedure for solving problems of PHC delivery in developing regions. The heuristic is applied, in detail, to the problem of identifying "best" community financing schemes for PHC services in low-income sections of Rio de Janeiro, Brazil.

Decision Making↗
PubMed1987

Primary health care is not cheap: a case study from Guinea Bissau.

In 1977 the Ministry of Health in Guinea Bissau started two regional community health projects. In this article we describe the progress of the Tombali project. Three aspects are discussed: the "Learning Process Approach" used in the project; measurement of the effectiveness of the project and the problems of collecting and interpreting these data; and the ratio of investment to recurrent costs and the proportions borne by government and by villagers. Primary health care projects evolve slowly, and the importance of the willingness of project workers, donor agencies, and the national government to work without a blueprint plan is emphasized. We discuss ways of evaluating the success of primary health care schemes; the measurement of any change in health status is difficult and discounts other benefits that may result, such as encouraging community participation and involving villagers in government activities. Both government and villagers contribute significantly to the scheme, the government and donors bearing most of the investment costs, while most of the recurrent costs fall on the villagers. The data show that for neither government nor villagers is the scheme a cheap option to secure health care for rural populations. Finally, we discuss the lessons to be learned by national governments, donor agencies, and health workers from this attempt to implement a primary health care program.

Budgets↗
PubMed2001

An assessment of the quality of referral letters sent to a specialist periodontist during a nine month period.

There have been concerns about the quality of referral letters received by specialist periodontists. This retrospective study aimed to assess the quality of all referral letters received over a nine month period, by a specialist periodontist working in a publicly financed community clinic, and to compare the results with those obtained from a study which assessed referral letters received by the periodontal department of a London teaching hospital during the same period. After the assessors had trained for intra- and inter-examiner reproducibility, the letters were assessed using the Categorisation System for Periodontal Referral Quality (CSPRQ) (Snoad et al., 1999). The year and country of qualification (UK or non-UK), and possession or otherwise of postgraduate qualifications for each of the referring dentists was ascertained from the UK Dentists Register. The results from this study and those from the hospital study were statistically tested using the Chi-squared test. Before the studies commenced the assessors achieved 100% inter-examiner reproducibility when applying the CSPRQ. A total of 114 letters was received, six of which were excluded. Of the remaining 108, 38 were categorised as of an acceptable standard. There were differences in the performance of dentists from different age groups in that 56% of letters from those qualified from 10-20 years, 29% of those from dentists qualified < 10 years and 27% of those qualified > 20 years were of an acceptable standard. The results were broadly similar to those of the hospital study except that there was a statistically significant difference (P< 0.05) between the quality of referrals from dentists qualified between 10 and 20 years and those with non-UK primary qualifications. It was concluded that the overall quality of referral letters assessed in this study was poor and that the CSPRQ provided a highly reproducible technique for assessing the quality of periodontal referral letters.

Age Factors↗
PubMed1992

People's Community Clinic: collaboration in the Third World.

A West African government undertook to improve primary health care (PHC) training of mid-level health workers. In partnership with a neighboring squatter settlement, the premiere local training institution created a community-sponsored clinic, providing low-cost, PHC services, and a birthing center, as well as student experiences. Their collaboration in mobilization, research, planning and operations are described. Their success should encourage other educational and training institutions to consider a similar approach.

Africa, Western↗
PubMed1991

Utilization of village health workers within a primary health care programme in The Gambia.

The utilization of Village Health Workers (VHWs) was studied in a rural area of The Gambia 3 years after the introduction of a village-based Primary Health Care (PHC) programme. Of 23 children who died from conditions treatable at village level, only five were first seen by the VHW. Fourteen were seen elsewhere in the region by staff more qualified than the first tier workers. The implications of this pattern of utilization on the lack of impact of VHWs on mortality are discussed. Only half of the non-fatal illnesses were attended to by VHWs. Reasons for this included such factors as lack of knowledge of services available, shortages of money, absence of the VHW at critical periods and social or political disputes with VHWs. Attempts must be made to tackle these fundamental problems if VHWs are to be successfully incorporated into the health services.

Cause of Death↗
PubMed2001

A survey of state programs to finance rehabilitation and community services for individuals with brain injury.

This article will review and compare existing state-funded programs and their approaches to financing, administering, and delivering an array of services, including rehabilitation and home and community-based services and supports to individuals with traumatic brain injury (TBI) and their families. A state-by-state chart provides funding and operational characteristics of the programs. The state menu of services provided and how they are delivered are also described. The article addresses how these programs fit within their overall state service delivery system, trends and changes that programs may be undergoing, and the influences that shape these programs.

Brain Injuries↗