The impact of introducing new vaccines on the health system: case studies from six low- and middle-income countries.

OBJECTIVE: We aimed to explore the impacts of new vaccine introductions on immunization programmes and health systems in low- and middle-income countries. METHODS: We conducted case studies of seven vaccine introductions in six countries (Cameroon, PCV;Ethiopia, PCV; Guatemala, rotavirus; Kenya, PCV; Mali, Meningitis A; Mali, PCV; Rwanda, HPV). Inter-views were conducted with 261 national, regional and district key informants and questionnaires were completed with staff from 196 health facilities. Routine data from districts and health facilities were gathered on vaccination and antenatal service use. Data collection and analysis were structured around the World Health Organisation health system building blocks. FINDINGS: The new vaccines were viewed positively and seemed to integrate well into existing health systems. The introductions were found to have had no impact on many elements within the building blocks framework. Despite many key informants and facility respondents perceiving that the new vaccine introductions had increased coverage of other vaccines, the routine data showed no change. Positive effects perceived included enhanced credibility of the immunisation programme and strengthened health workers' skills through training. Negative effects reported included an increase in workload and stock outs of the new vaccine, which created a perception in the community that all vaccines were out of stock in a facility. Most effects were found within the vaccination programmes; very few were reported on the broader health systems. Effects were primarily reported to be temporary, around the time of introduction only. CONCLUSION: Although the new vaccine introductions were viewed as intrinsically positive, on the whole there was no evidence that they had any major impact, positive or negative, on the broader health systems.

The consequences of hospital autonomization in Colombia: a transaction cost economics analysis.

Granting autonomy to public hospitals in developing countries has been common over recent decades, and implies a shift from hierarchical to contract-based relationships with health authorities. Theory on transactions costs in contractual relationships suggests they stem from relationship-specific investments and contract incompleteness. Transaction cost economics argues that the parties involved in exchanges seek to reduce transaction costs. The objective of this research was to analyse the relationships observed between purchasers and the 22 public hospitals of the city of Bogota, Colombia, in order to understand the role of relationship-specific investments and contract incompleteness as sources of transaction costs, through a largely qualitative study. We found that contract-based relationships showed relevant transaction costs associated mainly with contract incompleteness, not with relationship-specific investments. Regarding relationships between insurers and local hospitals for primary care services, compulsory contracting regulations locked-in the parties to the contracts. For high-complexity services (e.g. inpatient care), no restrictions applied and relationships suggested transaction-cost minimizing behaviour. Contract incompleteness was found to be a source of transaction costs on its own. We conclude that transaction costs seemed to play a key role in contract-based relationships, and contract incompleteness by itself appeared to be a source of transaction costs. The same findings are likely in other contexts because of difficulties in defining, observing and verifying the contracted products and the underlying information asymmetries. The role of compulsory contracting might be context-specific, although it is likely to emerge in other settings due to the safety-net role of public hospitals.

From Mexico to Mali: progress in health policy and systems research.

In 2004, the ministerial summit in Mexico drew attention to the historic neglect of health policy and systems research (HPSR) and called for increased funding, investment in national institutional capacity for HPSR, and resources for selected priority research topics. On the basis of meeting discussions, published reports, and available data from research funders and organisations in low-income and middle-income countries, we discuss how HPSR has evolved since the summit in Mexico. Funding for HPSR, particularly in low-income countries, is mainly supported by international and bilateral organisations. Increased interest in health systems has translated into increased support for HPSR. However, small grants and lack of coordination between funders inhibit capacity development, and substantial gaps remain between institutional capacities of high-income and low-income countries. Lack of national capacity is judged to be the key constraint to the development of HPSR. Recommendations from the summit in Mexico remain pertinent, and momentum towards their achievement must be accelerated through the ministerial forum in Mali and beyond.

The role of regulation in influencing income-generating activities among public sector doctors in Peru.

OBJECTIVE: To examine in Peru the nature of dual practice (doctors holding two jobs at once - usually public sector doctors with private practices), the factors that influence individuals' decisions to undertake dual practice, the conditions faced when doing so and the potential role of regulatory intervention in this area. METHODS: The study entailed qualitative interviews with a sample of twenty medical practitioners based in metropolitan Lima, representing a cross-section of those primarily employed in either the private or public sectors and engaged in clinical practice or policy making. The interviews focused on: 1. individuals' experience with dual practice; 2. the general underlying pressures that influence the nature and extent of such activities; and 3. attitudes toward, and the influence of, regulation on such activities. RESULTS: Dual practice is an activity that is widespread and well-accepted, and the prime personal motivation is financial. However, there are also a number of important broad macroeconomic influences on dual practice particularly the oversupply of medical services, the deregulated nature of this market, and the economic crisis throughout the country, which combine to create major hardships for those attempting to make a living through medical practice. There is some support among doctors for tighter regulation. CONCLUSION: Research findings suggest appropriate policy responses to dual practice involve tighter controls on the supply of medical practitioners; alleviation of financial pressures brought by macro-economic conditions; and closer regulation of such activities to ensure some degree of collective action over quality and the maintenance of professional reputations. Further research into this issue in rural areas is needed to ascertain the geographical generalizability of these policy responses.