Anne Mills, Health Policy Unit, London School of Hygiene and Tropical Medicine. Ruairi Brugha, Kara Hanson, Barbara McPake. Bulletin of the World Health Organization 2002;80(4):325-330. April 2002. Available on PDF. A very large private health sector exists in low-income countries. It consists of a great variety of providers and is used by a wide cross-section of the population. There are substantial concerns about the quality of care given, especially at the more informal end of the range of providers. This is particularly true for diseases of public health importance such as tuberculosis, malaria, and sexually transmitted infections. How can the activities of the private sector in these countries be influenced so that they help to meet national health objectives? Although the evidence base is not good, there is a fair amount of information on the types of intervention that are most successful in directly influencing the behaviour of providers and on what might be the necessary conditions for success. There is much less evidence, however, of effective approaches to interventions on the demand side and policies that involve strengthening the purchasing and regulatory roles of governments.
Public-Private Mix
Sara Bennett, Lucy Gilson
DFID Health Systems Resource Centre
UK Department for International Development, 2001
Health financing reforms are a core part of health sector development in low and middle income countries.The current focus of the international debate is on the need to move away from excessive reliance on out-of-pocket payment towards a system which incorporates a greater element of risk pooling (for example through health insurance) and thus affords a greater protection for the poor. This paper summarises what is known about the effects of the main health care financing systems, and how they can be designed and implemented to be 'pro-poor'.
Public health interventions tend to be complex, programmatic, and context dependent. The evidence for their effectiveness must be sufficiently comprehensive to encompass that complexity. This paper asks whether and to what extent evaluative research on public health interventions can be adequately appraised by applying well established criteria for judging the quality of evidence in clinical practice. It is adduced that these criteria are useful in evaluating some aspects of evidence. However, there are other important aspects of evidence on public health interventions that are not covered by the established criteria. The evaluation of evidence must distinguish between the fidelity of the evaluation process in detecting the success or failure of an intervention, and the success or failure of the intervention itself. Moreover, if an intervention is unsuccessful, the evidence should help to determine whether the intervention was inherently faulty (that is, failure of intervention concept or theory), or just badly delivered (failure of implementation). Furthermore, proper interpretation of the evidence depends upon the availability of descriptive information on the intervention and its context, so that the transferability of the evidence can be determined. Study design alone is an inadequate marker of evidence quality in public health intervention evaluation.
Health Systems Trust will be publishing a couple of chapters and indicators covering this area in the upcoming South African Health Review (2001) - but this will only be available at the end of March. Meanwhile you may wish to look at previous editions which also cover the topic.
November 2001
Richard Strouse, Barbara Carlson, John Hall, Center for Studying Health System Change, Washington, DC Peter Cunningham, Mathematica Policy Research, Inc. Princeton, NJ
In this report, the authors describe site selection, sample design, instrumentation and survey preparation, data collection methods, response rates, and sample weights. The Community Tracking Study (CTS) addresses two broad questions that are important to public and private health decision makers:
1. How is the health system changing? How are hospitals, health plans, physicians, safety net providers, and other provider groups restructuring, and what key forces are driving organizational change?
2. How do these changes affect people? How are insurance coverage, access to care, use of services, health care costs, and perceived quality of health care changing over time?
Governments and donor agencies increasingly recognise the need to provide protection for the poor against income fluctuations or livelihood shocks. In this context, ‘social protection’ is an umbrella term covering a range of interventions, from formal social security systems to ad hoc emergency interventions to project food aid (e.g. school feeding, public works). This paper synthesises current thinking and evidence on a number of issues around the design and impact of social protection programmes, including: the case for and against targeting resource transfers; alternative approaches to targeting; what form resource transfers should take (cash, food, agricultural inputs); the ‘crowding out’ debate; cost-efficiency of transfer programmes; whether these programmes meet the real and articulated needs of their ‘beneficiaries’; impacts on poverty and vulnerability, and fiscal and political sustainability.
Universal access to contraceptives is a key goal of sexual and reproductive health programmes. But what is the best way to supply them? Donated or subsidised contraceptive supplies raise questions of sustainability whereas there are concerns that market-based distribution has negative impacts on equity and access.
The perception that governments cannot efficiently provide water and sanitation (WSS) services has led to greatly increased private sector participation (PSP). Are regulatory regimes ensuring that service providers do not exploit their customers? Can PSPs save water and make it safer? Are the poor getting basic services?
Universal access to contraceptives is a key goal of sexual and reproductive health programmes. But what is the best way to supply them? Donated or subsidised contraceptive supplies raise questions of sustainability whereas there are concerns that market-based distribution has negative impacts on equity and access.
User fees are an increasingly common component of public health financing. The intention is to provide patients with a cheaper but high quality alternative to private healthcare. But does it work? What is the impact on the poorest households? Do poor people still use public health services when they have to pay fees?