The Need for Global Application of the Accountability for Reasonableness Approach to Support Sustainable Outcomes Comment on "Expanded HTA: Enhancing Fairness and Legitimacy".

The accountability for reasonableness (AFR) concept has been developed and discussed for over two decades. Its interpretation has been studied in several ways partly guided by the specific settings and the researchers involved. This has again influenced the development of the concept, but not led to universal application. The potential use in health technology assessments (HTAs) has recently been identified by Daniels et al as yet another excellent justification for AFR-based process guidance that refers to both qualitative and a broader participatory input for HTA, but it has raised concerns from those who primarily support the consistency and objectivity of more quantitative and reproducible evidence. With reference to studies of AFR-based interventions and the through these repeatedly documented motivation for their consolidation, we argue that it can even be unethical not to take AFR conditions beyond their still mainly formative stage and test their application within routine health systems management for their expected support to more sustainable health improvements. The ever increasing evidence and technical expertise are necessary but at times contradictory and do not in isolation lead to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. Legitimacy, accountability and fairness do not come about without an inclusive and agreed process guidance that can reconcile differences of opinion and indeed differences in evidence to arrive at a by all understood, accepted, but not necessarily agreed compromise in a current context - until major premises for the decision change. AFR should be widely adopted in projects and services under close monitoring and frequent reviews.

Healthy Ageing: Raising Awareness of Inequalities, Determinants, and What Could Be Done to Improve Health Equity.

PURPOSE OF THE STUDY: Social and scientific discourses on healthy ageing and on health equity are increasingly available, yet from a global perspective limited conceptual and analytical work connecting both has been published. This review was done to inform the WHO World Report on Ageing and Health and to inform and encourage further work addressing both healthy aging and equity. DESIGN AND METHODS: We conducted an extensive literature review on the overlap between both topics, privileging publications from 2005 onward, from low-, middle-, and high-income countries. We also reviewed evidence generated around the WHO Commission on Social Determinants of Health, applicable to ageing and health across the life course. RESULTS: Based on data from 194 countries, we highlight differences in older adults' health and consider three issues: First, multilevel factors that contribute to differences in healthy ageing, across contexts; second, policies or potential entry points for action that could serve to reduce unfair differences (health inequities); and third, new research areas to address the cause of persistent inequities and gaps in evidence on what can be done to increase healthy ageing and health equity. IMPLICATIONS: Each of these areas warrant in depth analysis and synthesis, whereas this article presents an overview for further consideration and action.

The feasibility of measuring and monitoring social determinants of health and the relevance for policy and programme - a qualitative assessment of four countries.

BACKGROUND: Since the publication of the reports by the Commission on Social Determinants of Health (CSDH), many research papers have documented inequities, explaining causal pathways in order to inform policy and programmatic decision-making. At the international level, the sustainable development goals (SDGs) reflect an attempt to bring together these themes and the complexities involved in defining a comprehensive development framework. However, to date, much less has been done to address the monitoring challenges, that is, how data generation, analysis and use are to become routine tasks. OBJECTIVE: To test proposed indicators of social determinants of health (SDH), gender, equity, and human rights with respect to their relevance in tracking progress in universal health coverage and population health (level and distribution). DESIGN: In an attempt to explore these monitoring challenges, indicators covering a wide range of social determinants were tested in four country case studies (Bangladesh, Brazil, South Africa, and Vietnam) for their technical feasibility, reliability, and validity, and their communicability and usefulness to policy-makers. Twelve thematic domains with 20 core indicators covering different aspects of equity, human rights, gender, and SDH were tested through a review of data sources, descriptive analyses, key informant interviews, and focus group discussions. To test the communicability and usefulness of the domains, domain narratives that explained the causal pathways were presented to policy-makers, managers, the media, and civil society leaders. RESULTS: For most countries, monitoring is possible, as some data were available for most of the core indicators. However, a qualitative assessment showed that technical feasibility, reliability, and validity varied across indicators and countries. Producing understandable and useful information proved challenging, and particularly so in translating indicator definitions and data into meaningful lay and managerial narratives, and effectively communicating links to health and ways in which the information could improve decision-making. CONCLUSIONS: This exercise revealed that for monitoring to produce reliable data collection, analysis, and discourse, it will need to be adapted to each national context and institutionalised into national systems. This will require that capacities and resources for this and subsequent communication of results are increased across countries for both national and international monitoring, including the successful implementation of the SDGs.

Addressing social determinants of health inequities: what can the state and civil society do?

In this Health Policy article, we selected and reviewed evidence synthesised by nine knowledge networks established by WHO to support the Commission on the Social Determinants of Health. We have indicated the part that national governments and civil society can play in reducing health inequity. Government action can take three forms: (1) as provider or guarantor of human rights and essential services; (2) as facilitator of policy frameworks that provide the basis for equitable health improvement; and (3) as gatherer and monitor of data about their populations in ways that generate health information about mortality and morbidity and data about health equity. We use examples from the knowledge networks to illustrate some of the options governments have in fulfilling this role. Civil society takes many forms: here, we have used examples of community groups and social movements. Governments and civil society can have important positive roles in addressing health inequity if political will exists.

How Uganda reversed its HIV epidemic.

Uganda is one of only two countries in the world that has successfully reversed the course of its HIV epidemic. There remains much controversy about how Uganda's HIV prevalence declined in the 1990s. This article describes the prevention programs and activities that were implemented in Uganda during critical years in its HIV epidemic, 1987 to 1994. Multiple resources were aggregated to fuel HV prevention campaigns at multiple levels to a far greater degree than in neighboring countries. We conclude that the reversed direction of the HIV epidemic in Uganda was the direct result of these interventions and that other countries in the developing world could similarly prevent or reverse the escalation of HIV epidemics with greater availability of HIV prevention resources, and well designed programs that take efforts to a critical breadth and depth of effort.

Decentralization and recentralization: effects on the health systems in Lao PDR.

In Lao PDR, lack of skilled manpower and financial resources in the central government, plus the policy urging local authorities to be self-sufficient and self-reliant caused the central government to decentralize all sectors to the provincial level in 1987. After 1987, the provinces took over all responsibilities such as planning, financing and provision of health services, only informing the Ministry of Health (MOH) about their activities. Because of economic differences between the 18 provinces, health services became unequal between the richer and poorer provinces. Some provinces generated high revenues, leading to over spending. The decentralized system had some negative impacts on the health service. The technical and planning functions managed from the ministry level became separated from management and financial decision making at the local level, and the ministry lost influence on the direction of health policy. Salaries from the local government were often delayed. Because health budgets were not allocated centrally by the Ministry of Health, there were no mechanisms by which health resources could be distributed preferentially to poorer areas with greater need. However, donors continued to support health programs through the Ministry of Health, sending drugs, vaccines, and other supplies to the provinces. The implementation of decentralization faced many difficulties due to the lack of experienced staff and insufficient training required for practicing decentralization. Similar problems in other sectors, such as agriculture, education, and communication, caused the central government to retake control from the provinces in 1992. During the recentralization period, utilization of health facilities increased. The Ministry of Health set rules and established regulations to strengthen the health system. A cost-recovery system was introduced to obtain additional funds, and conditions in the provinces gradually improved. The unique situation of decentralization followed by recentralization provides an excellent opportunity for study. We reviewed documents relating to these periods and interviewed officials at all levels who were concerned with the process.

The proof of the reform is in the implementation.

In 2000, TDR funded a series of studies to examine the opportunities and threats of health sector reform to the control of tropical diseases. This article is a cross-case analysis of ten of those studies, exploring the similarities in patterns across the countries covered: Colombia, China, Nigeria, the Philippines, Sudan, Tanzania and Uganda. The implementation experiences across countries were strikingly similar despite very different socio-economic and epidemiological situations. The reform implementation was neither complete nor clean and had in all the countries found some sort of least-energy equilibrium where the processes had stopped at a sub-optimal stage needing considerable renewed 'change-energy' to achieve its objectives. The role of the state had, in several cases, been reduced to a situation where it neither pursued the interest of the public nor protected the individual against harm caused by the behaviours of others. Whether one should follow a dedicated disease control programme or a systems approach is not a relevant question. Effective disease control cannot be implemented without strong and functioning health systems and health system performance cannot be improved without considering which purpose the system is to serve.

Tuberculosis control and managed competition in Colombia.

Law 100 introduced the Health Sector Reform in Colombia, a model of managed competition. This article addresses the effects of this model in terms of output and outcomes of TB control. Trends in main TB control indicators were analysed using secondary data sources, and 25 interviews were done with key informants from public and private insurers and provider institutions, and from the health directorate level. We found a deterioration in the performance of TB control: a decreasing number of BCG vaccine doses applied, a reduction in case finding and contacts identification, low cure rates and an increasing loss of follow up, which mainly affects poor people. Fragmentation occurred as the atomization and discontinuity of the technical processes took place, there was a lack of coordination, as well as a breakdown between individual and collective interventions, and the health information system began to disintegrate. The introduction of the Managed Competition (MC) in Colombia appeared to have adverse effects on TB control due to the dominance of the economic rationality in the health system and the weak state stewardship. Our recommendations are to restructure the reform's public health component, strengthen the technical capacity in public health of the state, mainly at the local and departmental levels, and to improve the health information system by reorienting its objectives to public health goals.

Provision and financial burden of TB services in a financially decentralized system: a case study from Shandong, China.

Both challenges and opportunities have been created by health sector reforms for TB control programmes in developing countries. China has initiated radical economic and health reforms since the late 1970s and is among the highest TB endemic countries in the world. This paper examines the operation of TB control programmes in a decentralized financial system. A case study was conducted in four counties of Shandong Province and data were collected from document reviews, and key informant and TB patient interviews. The main findings include: direct government support to TB control weakened in poorer counties after its decentralization to township and county governments; DOTS programmes in poorer counties was not implemented as well as in more affluent ones; and TB patients, especially the low-income patients, suffered heavy financial burdens. Financial decentralization negatively affects the public health programmes and may have contributed to the more rapid increase in the number of TB cases seen over the past decade in the poorer areas of China compared with the richer ones. Establishing a financial transfer system at central and provincial levels, correcting financial incentives for health providers, and initiating pro-poor projects for the TB patients, are recommended.

Revenue-driven in TB control--three cases in China.

One quarter of all TB cases occur in China, which, during the past 20 years has moved from a planned economy to a socialist market economy. In the health sector, an important proportion of the financing originates from user payment. TB control is not an exception and different programmatic models are in place. This study examines, using a case study approach, three different TB programmes, one supposed to provide free service, one subsidized service and one with full cost recovery. The aim was to better understand the driving forces for programme performance in terms of case detection, case management and patient payments. The study found for all models that control and case management approaches were, to some extent, adapted to generate maximum income to the providers. The drive for income led to fewer cases detected, administration of unnecessary procedures and drugs, and a higher than necessary cost to the patients. The latter possibly leading to exclusion of poor people from the services. If user charges are to stay, TB control programmes need to be designed to take advantage of the financial incentives to improve performance. The referral system needs to be restructured, not to provide disincentives for good practices.

Market reform: a challenge to public health--the case of schistosomiasis control in China.

This study examines how the provision of schistosomiasis control has adapted to increased exposure to market forces which has occurred in China over the past decades with the main emphasis on contemporary performance of the services. Financial and service data were collected and analysed from ten schistosomiasis stations in the Hunan province. A document and literature review, key informant interviews, as well as two focus group discussions were conducted to establish their context. The study found that the schistosomiasis control stations had shifted their emphasis from prevention to clinical services and that 62% of the stations' total income now comes from charging for individual clinical services, while 90% of the total costs was related to providing these services. The study found that revenue generation had become the primary motive, and that over-treatment and prescription had become an accepted practice for all the stations. The study concludes that a combination of lax supervision and accountability, and a greater reliance on user-payment and market mechanisms has severely compromised the provision of the public goods elements of the schistosomiasis control programme.

Implications of decentralization for the control of tropical diseases in Tanzania: a case study of four districts.

Decentralization has been and is still high on the agenda in contemporary health sector reforms. However, despite extensive literature on the topic, little is known about the processes and results of decentralization, including the relationship with the control of major public health problems caused by communicable diseases. This paper reports from a study of decentralization and control of tropical diseases in districts implementing health sector and local government reforms in Tanzania. The study was undertaken in four districts, involving interviews and discussions with key stakeholders from individual household members to the district commissioner, and a review of official health policy, planning and management documents. The study findings reveal devolution of financial, planning and managerial authority being theoretical rather than practical, as district health plans are largely directed by national and international priorities rather than by local priorities. Vertical programmes still exist, focusing narrowly on single diseases. The local mechanisms for multisectoral collaboration, as well as community participation functions, are far from optimal. Further, inappropriate and weak information systems prevent adequate local responsiveness in setting priorities. In conclusion, decentralization might have a large potential for improving health system performance, but problems of implementation pose serious challenges to releasing this potential.

Health equity in transition from planned to market economy in China

Despite improvement in the health status of the Chinese population from 1993 to 1998, as expressed by the declining overall and infant mortality rates and possible decline in health care needs, there is reason for concern. There is a general trends to reduced equity with respect to receiving health care according to need within and between the urban and rural populations. Furthermore, there is evidence that the higher income earners do not shoulder a burden of financing health care service commensurate with their ability to pay. Document in PDF format, required Acrobat Reader.

Economic transition and maternal health care for internal migrants in Shanghai, China

There are clear inequities with respect to both service access and pregnancy outcome between permanent residents and migrants in Shanghai. There are several barriers for migrants preventing them from using the services. All of which leads to marginalization. Document in PDF format, required Acrobat Reader.

Health equity in transition from planned to market economy in China.

This paper examines the impact of economic transition and health sector reform on health equities in the urban and rural populations of China in the 1990s. Since 1980, China has experienced a rapid economic development and fundamental transformation of its society. Three secondary data sources were used as the basis for the analysis and discussion: mortality data from the National Death Notification System; infant mortality from the National Maternal and Child Health Surveillance System; and morbidity, health care utilization and financing data from the National Health Household Interview Surveys. The analysis revealed a very complex picture with: general mortality rates decreasing in both urban and rural populations, but the differences between urban and rural increasing; declining infant mortality rates with narrowing of the urban-rural gap; health care needs declining in both urban and rural populations, but more rapidly in the urban areas; health service payments increasing in both urban and rural areas, while, at the same time, health insurance coverage decreased. The analysis suggests that despite overall improvements in the population's health status, the economic and health system policy reforms are leading to increased inequities in health care. The lowest income quintiles in both urban and rural areas are receiving less health care compared with their needs in 1998 than in 1993, and the urban-rural divide, in particular with regard to receiving inpatient health care, is widening appreciably. The reform of the health insurance system, combined with the market setting of prices for care, have had profound implications for all population groups, in particular the lower income segments and the rural populations. During the period 1993-98 the proportion of the urban population that had to cover the increasing cost of medical care themselves doubled.

Economic transition and maternal health care for internal migrants in Shanghai, China.

Economic migration and growth in informal employment in many of the major cities of developing countries, combined with health sector reforms that are increasingly relying on insurance and out-of-pocket payment, are raising concerns about equity and sustainability of economic and social development. In China, the number of internal migrants has dramatically grown since economic transition started in 1980, and maternal health care for these is a pressing issue to be addressed. To provide information for policy-makers and health administrators, a medical records review, a questionnaire survey and qualitative interviews were carried out in Minhang District, Shanghai. This paper describes important inequities in main maternal health outcomes and utilization indicators relating to economic and social transformation of the Chinese society. Analysis of the data collected clarifies that insufficient antenatal care is one of the main determinants for poor maternal health outcomes and that migrants are using antenatal care services significantly less than permanent residents. The data suggest that there is no single explanatory factor, but that migrants are faced with a package of obstacles to accessing health care services, and that health systems may need to rethink and redesign their delivery approaches to specifically target those groups that are faced with such multi-faceted packages of obstacles to service-access. Although the study addresses a specific Chinese phenomenon related to internal migration and registration of residency, parallels can be drawn to other settings where a combination of economic and social transitions of the society and a reform of health care financing are potentially creating the same conditions of significant inequalities.

Strategic emphases for tropical diseases research: a TDR perspective.

Setting priorities for health research is a difficult task, especially for the neglected diseases of the poor. A new approach to priority setting for tropical diseases research has been adopted by the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (known as the TDR). Priorities are defined on the basis of a comprehensive analysis of research needs and research opportunities for each of the ten major tropical diseases in the TDR portfolio. The resulting strategic emphases matrix reflects the priorities for tropical diseases research from the perspective of the TDR. Its purpose is not to impose global research priorities, but we believe the results could be useful to other organizations.