Bulletin of the World Health Organizationhttps://www.scielosp.org/feed/bwho/2006.v84n11/2016-01-01T00:02:00ZUnknown authorVol. 84 No. 11 - 2006WerkzeugIn this month's BulletinS0042-968620060011000012016-01-01T00:02:00Z2001-01-28T00:08:00ZUse of contracting in public healthS0042-968620060011000022016-01-01T00:02:00Z2001-01-28T00:08:00ZEvans, David
<em>Evans, David</em>;
<br/><br/>
The determinants of policy effectivenessS0042-968620060011000032016-01-01T00:02:00Z2001-01-28T00:08:00ZPotter, Christopher C.Harries, Jennifer
<em>Potter, Christopher C.</em>;
<em>Harries, Jennifer</em>;
<br/><br/>
Countries test new ways to finance health careS0042-968620060011000042016-01-01T00:02:00Z2001-01-28T00:08:00ZBraine, Theresa
<em>Braine, Theresa</em>;
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Pakistan, Afghanistan look to women to improve health careS0042-968620060011000052016-01-01T00:02:00Z2001-01-28T00:08:00ZGarwood, Paul
<em>Garwood, Paul</em>;
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Maternal health care wins district vote in UgandaS0042-968620060011000062016-01-01T00:02:00Z2001-01-28T00:08:00ZNakazibwe, Carolyne
<em>Nakazibwe, Carolyne</em>;
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Contracting and healthS0042-968620060011000072016-01-01T00:02:00Z2001-01-28T00:08:00ZRecent news from WHOS0042-968620060011000082016-01-01T00:02:00Z2001-01-28T00:08:00ZUnderstanding enrolment in community health insurance in sub-Saharan Africa: a population-based case-control study in rural Burkina FasoS0042-968620060011000092016-01-01T00:02:00Z2001-01-28T00:08:00ZDe Allegri, ManuelaKouyaté, BocarBecher, HeikoGbangou, AdjimaPokhrel, SubhashSanon, MamadouSauerborn, Rainer
<em>De Allegri, Manuela</em>;
<em>Kouyaté, Bocar</em>;
<em>Becher, Heiko</em>;
<em>Gbangou, Adjima</em>;
<em>Pokhrel, Subhash</em>;
<em>Sanon, Mamadou</em>;
<em>Sauerborn, Rainer</em>;
<br/><br/>
OBJECTIVE: To identify factors associated with decision to enrol in a community health insurance (CHI) scheme. METHODS: We conducted a population-based case-control study among 15 communities offered insurance in 2004 in rural Burkina Faso. For inclusion in the study, we selected all 154 enrolled (cases) and a random sample of 393 non-enrolled (controls) households. We used unconditional logistic regression (applying Huber-White correction to account for clustering at the community level) to explore the association between enrolment status and a set of household head, household and community characteristics. FINDINGS: Multivariate analysis revealed that enrolment in CHI was associated with Bwaba ethnicity, higher education, higher socioeconomic status, a negative perception of the adequacy of traditional care, a higher proportion of children living within the household, greater distance from the health facility, and a lower level of socioeconomic inequality within the community, but not with household health status or previous household health service utilization. CONCLUSION: Our study provides evidence that the decision to enrol in CHI is shaped by a combination of household head, household, and community factors. Policies aimed at enhancing enrolment ought to act at all three levels. On the basis of our findings, we discuss specific policy recommendations and highlight areas for further research.Different approaches to contracting in health systemsS0042-968620060011000102016-01-01T00:02:00Z2001-01-28T00:08:00ZPerrot, Jean
<em>Perrot, Jean</em>;
<br/><br/>
Contracting is one of the tools increasingly being used to enhance the performance of health systems in both developed and developing countries; it takes different forms and cannot be limited to the mere purchase of services. Actors adopt contracting to formalize all kinds of relations established between them. A typology for this approach will demonstrate its diversity and provide a better understanding of the various issues raised by contracting. In recent years the way health systems are organized has changed significantly. To remedy the under-performance of their health systems, most countries have undertaken reforms that have resulted in major institutional overhaul, including decentralization of health and administrative services, autonomy for public service providers, separation of funding bodies and service providers, expansion of health financing options and the development of the profit or nonprofit private sector. These institutional reshuffles lead not only to multiplication and diversification of the actors involved, but also to greater separation of the service provision and administrative functions. Health systems are becoming more complex and can no longer operate in isolation. Actors are gradually realizing that they need to forge relations. The simplest way to do that is through dialogue, although some prefer a more formal commitment. Interaction between actors may take various forms and be on different scales. There are several types of contractual relations: some are based on the nature of the contract (public or private), others on the parties involved and yet others on the scope of the contract. Here they are classified into three categories according to the object of the contract: delegation of responsibility, act of purchase of services, or cooperation.Contracting but not without caution: experience with outsourcing of health services in countries of the Eastern Mediterranean RegionS0042-968620060011000112016-01-01T00:02:00Z2001-01-28T00:08:00ZSiddiqi, SameenMasud, Tayyeb ImranSabri, Belgacem
<em>Siddiqi, Sameen</em>;
<em>Masud, Tayyeb Imran</em>;
<em>Sabri, Belgacem</em>;
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The public sector in developing countries is increasingly contracting with the non-state sector to improve access, efficiency and quality of health services. We conducted a multicountry study to assess the range of health services contracted out, the process of contracting and its influencing factors in ten countries of the Eastern Mediterranean Region: Afghanistan, Bahrain, Egypt, Islamic Republic of Iran, Jordan, Lebanon, Morocco, Pakistan, the Syrian Arab Republic and Tunisia. Our results showed that Afghanistan, Egypt, Islamic Republic of Iran and Pakistan had experience with outsourcing of primary care services; Jordan, Lebanon and Tunisia extensively contracted out hospital and ambulatory care services; while Bahrain, Morocco and the Syrian Arab Republic outsourced mainly non-clinical services. The interest of the non-state sector in contracting was to secure a regular source of revenue and gain enhanced recognition and credibility. While most countries promoted contracting with the private sector, the legal and bureaucratic support in countries varied with the duration of experience with contracting. The inherent risks evident in the contracting process were reliance on donor funds, limited number of providers in rural areas, parties with vested interests gaining control over the contracting process, as well as poor monitoring and evaluation mechanisms. Contracting provides the opportunity to have greater control over private providers in countries with poor regulatory capacity, and if used judiciously can improve health system performance.Hard gains through soft contracts: productive engagement of private providers in tuberculosis controlS0042-968620060011000122016-01-01T00:02:00Z2001-01-28T00:08:00ZLönnroth, KnutUplekar, MukundBlanc, Léopold
<em>Lönnroth, Knut</em>;
<em>Uplekar, Mukund</em>;
<em>Blanc, Léopold</em>;
<br/><br/>
Over the past decade, there has been a rapid increase in the number of initiatives involving "for-profit" private health care providers in national tuberculosis (TB) control efforts. We reviewed 15 such initiatives with respect to contractual arrangements, quality of care and success achieved in TB control. In seven initiatives, the National TB Programme (NTP) interacted directly with for-profit providers; while in the remaining eight, the NTP collaborated with for-profit providers through intermediary not-for-profit nongovernmental organizations. All but one of the initiatives used relational "drugs-for-performance contracts" to engage for-profit providers, i.e. drugs were provided free of charge by the NTP emphasizing that providers dispense them free of charge to patients and follow national guidelines for diagnosis and treatment. We found that 90% (range 61-96%) of new smear-positive pulmonary TB cases were successfully treated across all initiatives and TB case detection rates increased between 10% and 36%. We conclude that for-profit providers can be effectively involved in TB control through informal, but well defined drugs-for-performance contracts. The contracting party should be able to reach a common understanding concerning goals and role division with for-profit providers and monitor them for content and quality. Relational drugs-for-performance contracts minimize the need for handling the legal and financial aspects of classical contracting. We opine that further analysis is required to assess if such "soft" contracts are sufficient to scale up private for-profit provider involvement in TB control and other priority health interventions.Performance-based financing and changing the district health system: experience from RwandaS0042-968620060011000132016-01-01T00:02:00Z2001-01-28T00:08:00ZSoeters, RobertHabineza, ChristianPeerenboom, Peter Bob
<em>Soeters, Robert</em>;
<em>Habineza, Christian</em>;
<em>Peerenboom, Peter Bob</em>;
<br/><br/>
Evidence from low-income Asian countries shows that performance-based financing (as a specific form of contracting) can improve health service delivery more successfully than traditional input financing mechanisms. We report a field experience from Rwanda demonstrating that performance-based financing is a feasible strategy in sub-Saharan Africa too. Performance-based financing requires at least one new actor, an independent well equipped fundholder organization in the district health system separating the purchasing, service delivery as well as regulatory roles of local health authorities from the technical role of contract negotiation and fund disbursement. In Rwanda, local community groups, through patient surveys, verified the performance of health facilities and monitored consumer satisfaction. A precondition for the success of performance-based financing is that authorities must respect the autonomous management of health facilities competing for public subsidies. These changes are an opportunity to redistribute roles within the health district in a more transparent and efficient fashion.Public-private partnerships for hospitalsS0042-968620060011000142016-01-01T00:02:00Z2001-01-28T00:08:00ZMcKee, MartinEdwards, NigelAtun, Rifat
<em>Mckee, Martin</em>;
<em>Edwards, Nigel</em>;
<em>Atun, Rifat</em>;
<br/><br/>
While some forms of public-private partnerships are a feature of hospital construction and operation in all countries with mixed economies, there is increasing interest in a model in which a public authority contracts with a private company to design, build and operate an entire hospital. Drawing on the experience of countries such as Australia, Spain, and the United Kingdom, this paper reviews the experience with variants of this model. Although experience is still very limited and rigorous evaluations lacking, four issues have emerged: cost, quality, flexibility and complexity. New facilities have, in general, been more expensive than they would have been if procured using traditional methods. Compared with the traditional system, new facilities are more likely to be built on time and within budget, but this seems often to be at the expense of compromises on quality. The need to minimize the risk to the parties means that it is very difficult to "future-proof" facilities in a rapidly changing world. Finally, such projects are extremely, and in some cases prohibitively, complex. While it is premature to say whether the problems experienced relate to the underlying model or to their implementation, it does seem that a public-private partnership further complicates the already difficult task of building and operating a hospital.The benefits of setting the ground rules and regulating contracting practicesS0042-968620060011000152016-01-01T00:02:00Z2001-01-28T00:08:00ZKadaï, AbatchaSall, Farba LamineAndriantsara, GuyPerrot, Jean
<em>Kadaï, Abatcha</em>;
<em>Sall, Farba Lamine</em>;
<em>Andriantsara, Guy</em>;
<em>Perrot, Jean</em>;
<br/><br/>
In recent years, health systems have increasingly made use of contracting practices; despite results that are often promising, there have also been failures and occasionally harsh criticism of such practices. This has made it even more necessary to regulate contracting practices. As part of its stewardship function, in other words its responsibility to protect the public interest, the ministry of health has the responsibility of introducing the tools needed for such regulation. Several tools are available to help it do this. Some of them, such as standard contracts or framework contracts, useful as they may be, are nevertheless specific and ad hoc. Contracting policies, when carefully linked to overall health policies, are undoubtedly the most comprehensive of these tools, since they enable contracting to be accommodated within the management of the health system as a whole and thus take into account its potential contribution to improving health system performance. However, the requirements for success are not present automatically and it has to be ensured that there are mechanisms for vitalizing these regulatory mechanisms and that the key actors make proper use of the framework laid down by the ministry of health. The first three authors of this article have participated in the preparation and implementation of national policies on contracting in their own countries, viz. Chad, Madagascar and Senegal.Knowledge gaps in scientific literature on maternal mortality: a systematic reviewS0042-968620060011000162016-01-01T00:02:00Z2001-01-28T00:08:00ZGil-González, DianaCarrasco-Portiño, MercedesRuiz, Maria Teresa
<em>Gil-González, Diana</em>;
<em>Carrasco-Portiño, Mercedes</em>;
<em>Ruiz, Maria Teresa</em>;
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Issues related to maternal mortality have generated a lot of empirical and theoretical information. However, despite the amount of work published on the topic, maternal mortality continues to occur at high rates and solutions to the problem are still not clear. Scientific research on maternal mortality is focused mainly on clinical factors. However, this approach may not be the most useful if we are to understand the problem of maternal mortality as a whole and appreciate the importance of economical, political and social macrostructural factors. In this paper, we report the number of scientific studies published between 2000 and 2004 about the main causes of maternal death, as identified by WHO, and compare the proportion of papers on each cause with the corresponding burden of each cause. Secondly, we systematically review the characteristics and quality of the papers on the macrostructural determinants of maternal mortality. In view of their burden, obstructed labour, unsafe abortion and haemorrhage are proportionally underrepresented in the scientific literature. In our review, most studies analysed were cross-sectional, and were carried out by developed countries without the participation of researchers in the developing countries where maternal mortality was studied. The main macrostructural factors mentioned were socioeconomic variables. Overall, there is a lack of published information about the cultural and political determinants of maternal mortality. We believe that a high-quality scientific approach must be taken in studies of maternal mortality in order to obtain robust comparative data and that study design should be improved to allow causality between macrostructural determinants and maternal mortality to be shown.Is contracting a form of privatization?S0042-968620060011000172016-01-01T00:02:00Z2001-01-28T00:08:00ZPerrot, Jean
<em>Perrot, Jean</em>;
<br/><br/>
Contracting is often seen as a form of privatization, with contracts functioning as the tool that makes privatization possible. But contracting is also viewed by some as a means for the private sector to expand in a covert way its presence within the health sector. This article discusses the wider meaning of the term privatization in the health sector and the ways in which it is achieved. Privatization is seen here not simply as an action that leads to a new situation but also as one that leads to a change in behaviour. It is proposed that privatization may be assessed by looking at the ownership, management, and mission or objectives of the entity being privatized. Discussed also is the use of contracting by the state as a tool for state interventionism that is not based on authoritarian regulation.Round table discussionS0042-968620060011000182016-01-01T00:02:00Z2001-01-28T00:08:00ZHealth impact assessment and health promotionS0042-968620060011000192016-01-01T00:02:00Z2001-01-28T00:08:00ZBos, Robert
<em>Bos, Robert</em>;
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Rousseau's "social contract": contracting ahead of its time?S0042-968620060011000202016-01-01T00:02:00Z2001-01-28T00:08:00ZCarrin, Guy J
<em>Carrin, Guy J</em>;
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Health-care patents and interests of patientsS0042-968620060011000212016-01-01T00:02:00Z2001-01-28T00:08:00ZLuthra, Rita
<em>Luthra, Rita</em>;
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Reaching the poor with health, nutrition, and population services: what works, what doesn't, and whyS0042-968620060011000222016-01-01T00:02:00Z2001-01-28T00:08:00ZFriel, Sharon
<em>Friel, Sharon</em>;
<br/><br/>