Improving the efficiency of district hospitals: is contracting an option?

The political economy of health financing reforms in Zimbabwe: a scoping review

Background

Implementation of health financing reforms for Universal Health Coverage (UHC) is inherently political. Despite the political determinants of UHC, health financing reform in Zimbabwe is often portrayed as a technical exercise with a familiar path of a thorough diagnosis of technical gaps followed by detailed prescriptions of reform priorities. In this study, we sought to understand the interaction between political and economic aspects of health financing reforms since the country got its independence in 1980.

Methods

We conducted a scoping review of health financing reforms in Zimbabwe and reviewed 84 relevant sources of information. We then conducted a thematic analysis using an adapted Fox and Reich’s framework of ideas and ideologies, interests and institutions.

Results

We found that ideas, institutions and interests significantly influence health financing reforms in Zimbabwe with implications on health system performance. Reform priorities of the 1980s were influenced by socialist ideologies with an interest to address pervasive health inequities inherited from the colonial racial system. The progress in equity realized in the 1980s was severely disrupted from the 1990s partly due to neo-liberal ideologies which steered interests towards market-oriented reforms. The period from the 2000s is characterized by increasing donor influence on health financing and a cumulative socio-economic collapse that resulted in a sharp and protracted decline in health spending and widening of health inequities.

Conclusion

Health financing reform process in Zimbabwe is heavily influenced by political economy characteristics which favor certain financing arrangements over others with profound implications on health system performance. We concluded that the political economy factors that slow down UHC reforms are not rooted in the ambiguities of ideas on what needs to be done. Instead, the missing link is how to move from intention to action by aligning espoused ideas with interests and institutions which is an inherently political and redistributive process. International and domestic actors involved in UHC in Zimbabwe  need to explicitly consider the politics of health financing reforms to improve the implementation feasibility of desired reforms.

Efficiency Measurement in Health Facilities: A Systematic Review in Low- and Middle-Income Countries

BACKGROUND

Limited healthcare resources in low- and middle-income countries (LMICs) have led policy-makers to improve healthcare efficiency. Therefore, it is essential to understand how efficiency has been measured in the LMIC setting.

OBJECTIVE

This paper reviews methodologies used for efficiency studies in health facilities in LMICs.

METHODS

We searched MEDLINE, Embase, Global Health, EconLit and ProQuest Dissertations and Theses databases to Week 6 in 2018. We included all types of quantitative analysis studies relating to the measurement of the efficiency of services at health facilities in LMICs. We extracted data from eligible studies, and assessed the validity for each study. Because of the substantial heterogeneity of the studies, results were presented narratively.

RESULTS

A total of 137 papers were eligible for inclusion. These articles covered a wide range of health facility types, with more than half of the studies relating to hospitals. Our systematic review showed that there is an increasing trend in efficiency measurements in LMICs using various methods. Most studies employed data envelopment analysis as an efficiency measurement method. The studies typically included physical inputs and health services as outputs. Sixty-one percent of the studies analysed the contextual variables of the health facility efficiency.

CONCLUSION

This review highlights the potential for methodological improvement and policy impacts in efficiency measurements.

Recent trends in working with the private sector to improve basic healthcare: a review of evidence and interventions

The private sector provides the majority of health care in Africa and Asia. A number of interventions have, for many years, applied different models of subsidy, support and engagement to address social and efficiency failures in private health care markets. We have conducted a review of these models, and the evidence in support of them, to better understand what interventions are currently common, and to what extent practice is based on evidence. Using established typologies, we examined five models of intervention with private markets for care: commodity social marketing, social franchising, contracting, accreditation and vouchers. We conducted a systematic review of both published and grey literature, identifying programmes large enough to be cited in publications, and studies of the listed intervention types. 343 studies were included in the review, including both published and grey literature. Three hundred and eighty programmes were identified, the earliest having begun operation in 1955. Commodity social marketing programmes were the most common intervention type, with 110 documented programmes operating for condoms alone at the highest period. Existing evidence shows that these models can improve access and utilization, and possibly quality, but for all programme types, the overall evidence base remains weak, with practice in private sector engagement consistently moving in advance of evidence. Future research should address key questions concerning the impact of interventions on the market as a whole, the distribution of benefits by socio-economic status, the potential for scale up and sustainability, cost-effectiveness compared to relevant alternatives and the risk of unintended consequences. Alongside better data, a stronger conceptual basis linking programme design and outcomes to context is also required.

The impact of contracting out on health outcomes and use of health services in low and middle-income countries

BACKGROUND

Recent literature on the lack of efficiency and acceptability of publicly provided health services has led to an interest in the use of partnerships with the private sector to deliver public services.

OBJECTIVES

To assess the effectiveness of contracting out healthcare services in improving access to care in low and middle-income countries and, where possible, health outcomes.

SEARCH STRATEGY

We searched a wide range of international databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, in addition to development studies and economic databases. We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature. The original searches were conducted between November 2005 and April 2006. An updated search in MEDLINE was carried out in May 2009.

SELECTION CRITERIA

Contracting out health services is defined as the provision of healthcare services on behalf of the government by non-state providers. Studies had to include an objective measure of at least one of the following outcomes: health care utilisation, health expenditure, health outcomes or equity outcomes. Studies also needed to use one of the following study designs: randomised controlled trial, non-randomised controlled trial, interrupted time series analysis or controlled before and after study.

DATA COLLECTION AND ANALYSIS

We made an attempt to present results from the different studies in a systematic way, however due to the diversity of sources, contexts and methods used, we undertook a narrative synthesis.

MAIN RESULTS

Three studies met our inclusion criteria (one after re-analysis of data). These studies suggest that contracting out services to non-state providers can increase access and utilisation of health services. One study found a reduction in out-of-pocket expenditures and improvement in some health outcomes. However, methodological weaknesses and particularities of the reported programme settings limit the strength and generalisability of their conclusions.

AUTHORS' CONCLUSIONS

Three studies suggest that contracting out may be an appropriate response to scale up service delivery in particular settings, such as post-conflict or fragile states. Evidence was not presented on whether this approach was more effective than making a similar investment in the public sector, as there was not an exact control available in any of the settings. In addition, the introduction of non-state providers into some settings and not others also brings many potentially confounding variables, such as the presence of additional management expertise or expatriate doctors, which may improve drug supply or increase utilisation.

Hospital management in the context of health sector reform: a planning model in Ethiopia

Through health sector reform in developing countries, Ministries of Health have sought to enhance health care through greater community governance and improved management effectiveness in their public hospitals. In this paper, we present a partnership-mentoring model for enhancing management capacity that has been piloted in Ethiopia and may be useful in other developing countries. The model included needs assessment and baseline evaluation using a hospital management indicator checklist, deployment of 24 Fellows (US and international hospital administrators) for 1 year to work as mentors with hospital management teams in 14 Ethiopian hospitals, continuing didactic and practical training in quality improvement methods for hospital management teams, and 24 management improvement projects to be completed during the year with plans for replication more broadly as appropriate. Surveys of Fellows and Ethiopian managers within the first quarter of onsite activity found high levels of trust in one another's abilities and intent to implement changes. The partnership-mentoring model promotes sustainability and may provide other countries with approaches for improving the quality of hospital care through improved hospital management.

Disintegrated care: the Achilles heel of international health policies in low and middle-income countries

PURPOSE

To review the evidence basis of international aid and health policy.

CONTEXT OF CASE

Current international aid policy is largely neoliberal in its promotion of commoditization and privatisation. We review this policy's responsibility for the lack of effectiveness in disease control and poor access to care in low and middle-income countries.

DATA SOURCES

National policies, international programmes and pilot experiments are examined in both scientific and grey literature.

CONCLUSIONS AND DISCUSSION

We document how health care privatisation has led to the pool of patients being cut off from public disease control interventions--causing health care disintegration--which in turn resulted in substandard performance of disease control. Privatisation of health care also resulted in poor access. Our analysis consists of three steps. Pilot local contracting-out experiments are scrutinized; national health care records of Colombia and Chile, two countries having adopted contracting-out as a basis for health care delivery, are critically examined against Costa Rica; and specific failure mechanisms of the policy in low and middle-income countries are explored. We conclude by arguing that the negative impact of neoliberal health policy on disease control and health care in low and middle-income countries justifies an alternative aid policy to improve both disease control and health care.

Quality-based purchasing in health care

Quality-based purchasing is a growing trend that seeks to improve healthcare quality through the purchaser-provider relationship. This article provides a unifying conceptual framework, presents examples of the purchaser-provider relationship in countries at different income levels, and identifies important supporting mechanisms for quality-based purchasing. As countries become wealthier, a higher proportion of healthcare spending is channeled through pooled arrangements, allowing for greater involvement of purchasers in promoting the quality of service provision. Global and line item budgets are the most common type of provider payment system in low and middle-income countries. In these countries, improving public hospital performance through contracting and incentives is a key issue. In middle and high-income countries, there are several documented examples of governments contracting to private or non-governmental health care providers, resulting in higher perceived quality of care and lower delivery costs. Encouraging quality through employer purchasing arrangements has been promoted in several countries, particularly the United States. Community-based financing schemes are an increasingly common form of health financing in parts of sub-Saharan Africa and Asia, but these schemes still cover less than 10% of national populations in countries in which they are active. To date, there is little evidence of their impact on healthcare quality. The availability of information--concerning healthcare service provision and outcomes--determines the options for establishing and monitoring contract provisions and promoting quality. Regardless of the context, quality-based purchasing depends critically on informa-tion--reporting, monitoring, and providing useful information to healthcare consumers. In many low and middle-income countries, the lack of availability of information is the principal constraint on measuring performance, a critical component of quality-based purchasing.

Hospital costs of high-burden diseases: malaria and pulmonary tuberculosis in a high HIV prevalence context in Zimbabwe

This paper explores the measurement of hospital costs and efficiency in a context where data is scarce, incomplete or of poor quality. It argues that there is scope for using tracers to examine and compare hospital cost structures and relative efficiency in such contexts. Two high-burden diseases, malaria and pulmonary tuberculosis, are used as tracers to calculate the average costs of inpatient care at selected tertiary hospitals. This study shows that it is feasible to prospectively collect cost data for specific diseases and explore in detail both patient cost distribution and susceptible areas for efficiency improvement. The present study found that the critical source of efficiency variation in public hospitals in Zimbabwe lies in the way hospital beds are used.

A shared mission? Changing relationships between government and church health services in Africa

This article reviews the relationships between government and church health providers within sub-Saharan Africa with a particular focus on East and Southern Africa. This is of particular interest at this time, given the changing configuration of the health sector in many countries as a result of health sector reform policies. The article provides a historical overview of the development and emerging role of the church health services within this changing environment. The factors affecting the relationship between the government and church sector are identified. These include differences in objectives, types of service provided, and the organizational culture and management styles. The paper then explores key issues seen to affect the future pattern of relationships including the changing scene, and identifies different models for relationships and implications for key actors including the Ministry of Health, church health agencies and coordinating bodies. The article concludes that church health services will continue to play a key role in health care in sub-Saharan Africa; however, there are challenges facing them and both parties need to develop a response to these.

Leopard or chameleon? The changing character of international health economics

Over the last 25 years the discipline of health economics has developed substantially. As an applied discipline, it has adapted and changed over time in response to the changing concerns of policy-makers, planners and managers. This paper questions whether it is like a chameleon, changing its appearance in response to the external environment, or like the leopard that never changes its spots. In answering the question, the paper presents an overview of the development of health economics as it has been applied in low and middle income countries distinguishing three eras, the 1970s, 1980s, and 1990s, and argues that in each of these eras the preoccupations of health economists have been somewhat different. In each era the key contributions of health economics are identified. The paper ends by considering future research priorities, and the obligations of developed country institutions in terms of research topics and mode of work.