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PubMed1994

Public sector financing of community-based services for children with serious emotional disabilities and their families: results of a national survey.

This article presents the results of a survey of all state directors of mental health programs for children on the agreement with and use of financial policies and practices which promote home- and community-based mental health care for children and adolescents and their families. Whereas only five states reported the implementation of all the financial mechanisms feasible in their states, a majority of states reported the use of mechanisms such as federal funds, state resources and incentives, and flexible funds to encourage the development of community-based care. Results also indicated that states with a local form of government or local district or board that served as the local mental health authority tended to have more of the community-based financial practices in place than did states that contracted directly with providers at the local level.

Adolescent↗
PubMed1997

Local cost sharing in Bamako Initiative systems in Benin and Guinea: assuring the financial viability of primary health care.

The fourth in a series of five, this article presents and analyses data on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea since 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in the two national scale programmes is also described. In Benin and Guinea, a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker salaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in decision making, strategy definition and quality control. In Benin in 1993, community financing revenue amounted to about US$0.6 per capita per year and generally covered all local recurrent non salary costs except vaccines and left a surplus. Although total costs and revenues were slightly lower in Guinea for the same period, over-all user fee revenue (around US$0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and revenue between regions and individual health centres revealed important differences in cost recovery ratios. In Benin, some centres recovered more than twice the local costs targeted for community financing. Twenty-five per cent of centres in Guinea did not manage to cover their designated local recurrent costs. The longitudinal analysis showed that the level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better understand the most important characteristics affecting cost recovery levels, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed that the size of the target population of the health centre is a key determinant of cost-recovery in both countries. In addition, in Guinea the utilization of curative care linked to geographical access and in Benin the average revenue per case linked to the number of deliveries proved to be additional factors of importance. In best performing centres, financial viability improved over time in both countries between 1990 and 1993. Finally, the implications of these conclusions for the planning of health centre revitalization in West Africa are discussed.

Benin↗
PubMed2003

Improving access to capital for health care infrastructure: the experience of the Southern Rural Access Program's revolving loan fund.

Lack of access to affordable capital is a formidable barrier that compromises rural health care infrastructure development in poor rural areas. Commercial lending institutions are often limited in their ability to respond to those needs due to traditional lending criteria: creditworthiness, equity, management ability, experiences, and cash flow or profits. In the Southern Rural Access Program, a development model more frequently used in other sectors has been successfully applied to health care to help clear these hurdles. This paper describes the 5 operational loan funds in Arkansas, Louisiana, Mississippi, South Carolina, and West Virginia receiving support from the Southern Rural Access Program. Two models of loan funds have evolved: those led by health agencies and those led by community development finance institutions whose mission is rural economic development. This paper outlines major distinctive features of these 2 approaches and describes major implementation challenges these loan funds face. Key accomplishments are high-lighted, including the ability to leverage additional resources from state, federal, philanthropic, and private sources through these funds. These loan fund programs provide models for other states interested in improving access to capital to help build the rural health care infrastructure while making health care more economically viable through integration with other community development initiatives.

Capital Financing↗
PubMedDate not supplied

Financing geriatric programs in community health centers.

There are approximately 600 Community and Migrant Health Centers (C/MHCs) providing preventive and primary health care services principally to medically underserved rural and urban areas across the United States. The need to develop geriatric programs within C/MHCs is clear. Less clear is how and under what circumstances a comprehensive geriatric program can be adequately financed. The Health Resources and Services Administration of the Public Health Service contracted with La Jolla Management Corporation and Duke University Center on Aging to identify successful techniques for obtaining funding by examining 10 "good practice" C/MHC geriatric programs. The results from this study indicated that effective techniques included using a variety of funding sources, maintaining accurate cost-per-user information, developing a marketing strategy and user incentives, collaborating with the area agency on aging and other community organizations, and developing special services for the elderly. Developing cost-per-user information allowed for identifying appropriate "drawing card" services, negotiating sound reimbursement rates and contracts with other providers, and assessing the financial impact of changing service mixes. A marketing strategy was used to enhance the ability of the centers to provide a comprehensive package of services. Collaboration with the area agency on aging and other community organizations and volunteers in the aging network was found to help establish referral networks and subsequently increase the number of elderly patients served. Finally, development of special services for the elderly, such as adult day care, case management, and health education, was found to increase program visibility, opportunities to work with the network of services for the aging, and clinical utilization.

Community Health Centers↗
PubMed1996

Financing pediatric education in community settings.

Increasingly, hospital-based pediatric outpatient departments are recognized as settings that attempt to combine two critical, but not always compatible, mandates: (1) education of medical students and pediatric residents in outpatient pediatrics, and (2) service, often with inadequate resources, to a socially highrisk population with a disproportionately high prevalence of social, family, and psychological dysfunction. Coexistence of these two mandates has raised a number of concerns, because pediatric ambulatory care education and training have historically been based almost exclusively in a hospital setting. Trainees often get a false impression of the types of problems they will be dealing with in pediatric primary care and of how an efficient pediatric practice is managed. In addition, they often are supervised by full-time faculty who have little if any experience in community settings and who practice only part time or not at all. These problems have led to a widespread desire to train pediatric residents outside the hospital, in settings that more closely approximate the places in which they will practice in the future. Residency programs that address this issue also provide residents with the opportunity to be trained by seasoned practitioners whose primary professional responsibility is the outpatient care of children. To date, little has been written about the cost or the financing of such educational efforts. This article summarizes what is known about the costs. We also attempt to specify the costs that should be anticipated for the various components and steps involved in devising and implementing pediatric community-based educational programs and to describe potential sources of funding for such programs.

Costs and Cost Analysis↗
PubMed1987

Community care demonstrations: what have we learned?

Based on a review of community care demonstrations, we conclude that expanding public financing of community services beyond what already exists is likely to increase costs. Small nursing home cost reductions are more than offset by the increased costs of providing services to those who would remain at home even without the expanded services. However, expanded community services appear to make people better off and not to cause substantial reductions in family caregiving. Policymakers should move beyond asking whether expanding community care will reduce costs to addressing how much community care society is willing to pay for, who should receive it, and how it can be delivered efficiently.

Community Health Services↗
PubMedDate not supplied

Developing a local public health infrastructure: the Maine Turning Point experience.

This article describes the efforts of public health leaders to develop local public health capacity across Maine. More than 200 individuals representing both government and nongovernmental organizations became engaged in The Robert Wood Johnson Foundation-sponsored Turning Point project in 1999. In recent years, the state has had only two local (city) health departments, only one of substantial capacity covering an extremely small proportion of the total state population. This article describes Maine Turning Point organizational efforts, challenges, successes, and failures, from the perspective of 3 individuals involved in the process. Five years later, a new network of state-financed, community-based partnerships focused on chronic disease risk factors has been established, apparently strong enough politically to survive in an era of severe state budget cuts. Tobacco use has been reduced. Many other serious public health issues, however, from obesity to mental illness and substance abuse, remain to be successfully addressed. The development of a sustainable statewide network of local agencies providing the essential public health services remains an elusive goal.

Community Health Planning↗