Use of a Balanced Scorecard in strengthening health systems in developing countries: an analysis based on nationally representative Bangladesh Health Facility Survey.

This paper illustrates the importance of collecting facility-based data through regular surveys to supplement the administrative data, especially for developing countries of the world. In Bangladesh, measures based on facility survey indicate that only 70% of very basic medical instruments and 35% of essential drugs were available in health facilities. Less than 2% of officially designated obstetric care facilities actually had required drugs, injections and personnel on-site. Majority of (80%) referral hospitals at the district level were not ready to provide comprehensive emergency obstetric care. Even though the Management Information System reports availability of diagnostic machines in all district-level and sub-district-level facilities, it fails to indicate that 50% of these machines are not functional. In terms of human resources, both physicians and nurses are in short supply at all levels of the healthcare system. The physician-nurse ratio also remains lower than the desirable level of 3.0. Overall job satisfaction index was less than 50 for physicians and 66 for nurses. Patient satisfaction score, however, was high (86) despite the fact that process indicators of service quality were poor. Facility surveys can help strengthen not only the management decision-making process but also the quality of administrative data.

Generating Political Priority for Primary Health Care Reform in Romania.

This paper examines how political priority was generated for comprehensive reforms to address inequitable access to high-quality primary health care (PHC) in Romania. We apply John Kingdon's model of political agenda setting to explore how the convergence of problems, solutions, and political developments culminated in the adoption of a government program that included critical PHC reforms and approval of a results-based funding instrument for implementation. We draw on a review of the gray and peer-reviewed literature and stakeholder consultations, and use content analysis to identify themes organized in line with the dimensions of Kingdon's model. We conclude this paper with three lessons that may be relevant for generating political priority for PHC reforms in other contexts. First, national PHC reforms are likely to be prioritized when there is political alignment of health reforms with the broader political agenda. Second, the availability of technically sound and feasible policy proposals makes it possible to seize the political opportunity when the window opens. Third, partners' coordinated technical and financial support for neglected issues can serve to raise their priority on the political agenda.

China's Health Expenditure Projections To 2035: Future Trajectory And The Estimated Impact Of Reforms.

To understand the future trajectory of health expenditure in China if current trends continue and the estimated impact of reforms, this study projected health expenditure by disease and function from 2015 to 2035. Current health expenditure in China is projected to grow 8.4 percent annually, on average, in that period. The growth will mainly be driven by rapid increases in services per case of disease and unit cost, which respectively contribute 4.3 and 2.4 percentage points. Circulatory disease expenditure is projected to increase to 23.4 percent of health expenditure by 2035. The biggest challenge facing the Chinese health system is the projected rapid growth in inpatient services. Three percent of gross domestic product could be saved by 2035 by slowing the growth of inpatient service use from 8.2 percent per year in 2016 to 3.5 percent per year in 2035. Health expenditure in 2035 could be reduced by 3.5 percent if the smoking rate were cut in half and by 3.4 percent if the high blood pressure rate were cut by 25 percent. Future action in controlling health expenditure growth in China should focus on the high growth in inpatient services expenditure and interventions to reduce risk factors.

Costing of scaling up HIV/AIDS treatment in Mexico.

OBJECTIVE: To determine the net effect of introducing highly active antiretroviral treatment (HAART) in Mexico on total annual per-patient costs for HIV/AIDS care, taking into account potential savings from treatment of opportunistic infections and hospitalizations. MATERIAL AND METHODS: A multi-center, retrospective patient chart review and collection of unit cost data were performed to describe the utilization of services and estimate costs of care for 1003 adult HIV+ patients in the public sector. RESULTS: HAART is not cost-saving and the average annual cost per patient increases after initiation of HAART due to antiretrovirals, accounting for 90% of total costs. Hospitalizations do decrease post-HAART, but not enough to offset the increased cost. CONCLUSIONS: Scaling up access to HAART is feasible in middle income settings. Since antiretrovirals are so costly, optimizing efficiency in procurement and prescribing is paramount. The observed adherence was low, suggesting that a proportion of these high drug costs translated into limited health benefits.

Assessing Latin America's Progress Toward Achieving Universal Health Coverage.

Two commonly used metrics for assessing progress toward universal health coverage involve assessing citizens' rights to health care and counting the number of people who are in a financial protection scheme that safeguards them from high health care payments. On these metrics most countries in Latin America have already "reached" universal health coverage. Neither metric indicates, however, whether a country has achieved universal health coverage in the now commonly accepted sense of the term: that everyone--irrespective of their ability to pay--gets the health services they need without suffering undue financial hardship. We operationalized a framework proposed by the World Bank and the World Health Organization to monitor progress under this definition and then constructed an overall index of universal health coverage achievement. We applied the approach using data from 112 household surveys from 1990 to 2013 for all twenty Latin American countries. No country has achieved a perfect universal health coverage score, but some countries (including those with more integrated health systems) fare better than others. All countries except one improved in overall universal health coverage over the time period analyzed.

Study raises questions about measurement of 'additionality,'or maintaining domestic health spending amid foreign donations.

Donor nations and philanthropic organizations increasingly require that funds provided for a specific health priority such as HIV should supplement domestic spending on that priority-a concept known as "additionality." We investigated the "additionality" concept using data from Honduras, Rwanda, and Thailand, and we found that the three countries increased funding for HIV in response to increased donor funding. In contrast, the study revealed that donors, faced with increased Global Fund resources for HIV in certain countries, tended to decrease their funding for HIV or shift funds for use in non-HIV health areas. More broadly, we found many problems in the measurement and interpretation of additionality. These findings suggest that it would be preferable for donors and countries to agree on how best to use available domestic and external funds to improve population health, and to develop better means of tracking outcomes, than to try to develop more sophisticated methods to track additionality.

Costs of maternal health care services in three anglophone African countries.

This paper is a synthesis of a case study of provider and consumer costs, along with selected quality indicators, for six maternal health services provided at one public hospital, one mission hospital, one public health centre and one mission centre, in Uganda, Malawi and Ghana. The study examines the costs of providing the services in a selected number of facilities in order to examine the reasons behind cost differences, assess the efficiency of service delivery, and determine whether management improvements might achieve cost savings without hurting quality. This assessment is important to African countries with ambitious goals for improving maternal health but scarce public health resources and limited government budgets. The study also evaluates the costs that consumers pay to use the maternal health services, along with the contribution that revenues from fees for services make to recovering health facility costs. The authors find that costs differ between hospitals and health centres as well as among mission and public facilities in the study sample. The variation is explained by differences in the role of the facility, use and availability of materials and equipment, number and level of personnel delivering services, and utilization levels of services. The report concludes with several policy implications for improvements in efficiency, financing options and consumer costs.

Costing of scaling up HIV/AIDS treatment in Mexico / Costos del tratamiento de VIH/SIDA en México

OBJECTIVE: To determine the net effect of introducing highly active antiretroviral treatment (HAART) in Mexico on total annual per-patient costs for HIV/AIDS care, taking into account potential savings from treatment of opportunistic infections and hospitalizations. MATERIAL AND METHODS: A multi-center, retrospective patient chart review and collection of unit cost data were performed to describe the utilization of services and estimate costs of care for 1003 adult HIV+ patients in the public sector. RESULTS: HAART is not cost-saving and the average annual cost per patient increases after initiation of HAART due to antiretrovirals, accounting for 90 percent of total costs. Hospitalizations do decrease post-HAART, but not enough to offset the increased cost. CONCLUSIONS: Scaling up access to HAART is feasible in middle income settings. Since antiretrovirals are so costly, optimizing efficiency in procurement and prescribing is paramount. The observed adherence was low, suggesting that a proportion of these high drug costs translated into limited health benefits.

OBJETIVO: Determinar el efecto neto de la introducción de la terapia antirretroviral altamente activa (TARAA) en México sobre los costos anuales totales por paciente en el tratamiento de VIH/SIDA, tomando en cuenta el posible ahorro en el tratamiento de infecciones oportunistas y hospitalización. MATERIAL Y MÉTODOS: Se hizo un estudio retrospectivo, multicéntrico, mediante la revisión de los expedientes de los pacientes y la recolección de datos de costos unitarios para describir la utilización de los servicios y calcular los costos de la atención de 1 003 pacientes adultos VIH positivos en el sector público. RESULTADOS: La TARAA no ahorra costos y el costo promedio anual por paciente aumenta después de su inicio debido a los antirretrovirales, que representan 90 por ciento del costo total. Las hospitalizaciones disminuyen después de iniciada la TARAA, pero no lo suficiente como para compensar el aumento en costos. CONCLUSIONES: Incrementar el acceso a la TARAA es factible en países con ingresos medios. Debido al alto costo de los antirretrovirales resulta esencial que se optimice la eficiencia en la compra y prescripción. El apego al tratamiento observado fue bajo, lo que sugiere que una proporción de estos altos costos en medicamentos no se traducen en beneficios a la salud significativos.

Toward universal health coverage and equity in Latin America and the Caribbean: evidence from selected countries

En las últimas tres décadas, muchos países de América Latina y el Caribe han reconocido la salud como un derecho humano. Desde principios de la década de 2000, 46 millones más de personas en los países estudiados están cubiertos por programas de salud con derechos explícitos a la atención. Las reformas han sido acompañadas por un aumento en el gasto público en salud, financiado en gran parte por ingresos generales que priorizan o se dirigen explícitamente a la población sin capacidad de pago. El compromiso político generalmente se ha traducido en presupuestos más grandes, así como en la aprobación de leyes que restringen la financiación de la salud. La mayoría de los países han priorizado la atención primaria rentable y han adoptado métodos de compra que incentivan la eficiencia y la rendición de cuentas por los resultados y que otorgan a los administradores del sector de la salud un mayor poder para dirigir a los proveedores a cumplir las prioridades de salud pública. A pesar del progreso, siguen existiendo disparidades en la financiación y la calidad de la prestación de servicios en los subsistemas de salud. Cumplir el compromiso con la cobertura universal de salud requerirá esfuerzos concertados para mejorar la generación de ingresos de manera fiscalmente sostenible y para aumentar la productividad de los gastos. En Hacia la cobertura universal de salud y equidad en América Latina y el Caribe: Evidencia de países seleccionados, los autores muestran que la evidencia de un análisis de 54 encuestas de hogares corrobora que las inversiones en la extensión de la cobertura están dando resultados. Aunque los pobres aún tienen peores resultados de salud que los ricos, las disparidades se han reducido considerablemente, particularmente en las primeras etapas de la vida. Los países han alcanzado altos niveles de cobertura y equidad en la utilización de los servicios de salud maternoinfantil.

Evaluación del seguro nacional de maternidad niñez en Bolivia / Evaluation of a national insurance of maternity chilhood in Bolivia. technical report. Vol.28 (sept. 1998)

El documento trata de las siguientes áreas: Promover el diálogo y la participación en la formulación de las políticas de reforma en el sector de la salud. Desarrollar sistemas financieros equitativos y viables. Mejorar la organización y la gestión de los sistemas de salud. Desarrollar incentivos para promover servicios de atención médica eficaces y de calidad