Health Sector Reform

The aim of this report is to describe the role of the nurse workforce in the development and implementation of primary health care (PHC) reform; identify key factors in the practice environment which inhibit or strengthen PHC reform; articulate the contribution nurses can make in future health sector reform. [adapted from summary]

This presentation was part of the University of New South Wales’ short course on managing human resources for health. The presention outlines the background of decentralization in the health sector including its meaning, forms, drivers, benefits and pitfalls. It also introduces the opportunities and challenges for HRH managment in a decentralized system and the concept of recentralization. [adapted from author]

This paper assesses whether the process of decentralizing human resources for health management and organization to the level of the state and municipal health departments has involved investments in technical, political and financial resources at the national level. [from abstract]

Devolution, as other types of decentralization (e.g. deconcentration, delegation, privatization), profoundly changes governance relations in the health system. This article assesses the key advantages and dilemmas associated with devolution such as responsiveness to local needs, downward accountability and health worker retention. Challenges of politics and capacities are also addressed in relation to human resources for health at the local level. [from abstract]

This study assesses the new decentralized service provision system for people living with HIV/AIDS in rural populations in China. [from abstract]

This paper looks at the potential for decentralization to lead to better health workforce recruitment, performance and retention in rural areas through the creation of additional revenue for the health sector; better use of existing financial resources; and creation of financial incentives for health workers. [from introduction]

This article describes the Public Health Resource Network, an innovative distance-learning course in training, motivating, empowering and building a network of health personnel from government and civil society groups. Its aim is to build human resource capacity for strengthening decentralized health planning, especially at the district level. [from abstract]

This paper advocates multiple strategies for the United States to further assist with solving the global health workforce crisis.

This study highlights the experiences and challenges associated with decentralisation and the partial re-centralisation in relation to the recruitment and distribution of health workers. [from abstract]

The objective of this article is to determine the stock of human resources for health in 15 districts, their service status and primary place of work. It also assesses the effect of decentralization on management of human resources and the implications for the future. [from abstract]

In developing countries, postabortion care (PAC) programs are frequently available only in urban or regional health facilities, placing rural women at greater risk for mortality and morbidity from complications because they lack access to services. This technical brief evaluates efforts to decentralize PAC activities in Senegal and Tanzania that show PAC can be safely and successfully decentralized with services capably provided by mid-level personnel in health centers, dispensaries, and some health posts when providers are trained and supervised and equipment and supplies are available.

This paper presents some of the basic governance issues related to decentralization and some examples of how projects and donor policies have contributed to more effective decentralization processes. [from author]

This report describes three health system developments introduced by the Rwandan government that are improving these barriers to care

Most Central American hospitals that provide decentralized HIV services struggle with issues such as weak infection prevention practices, poor nutritional care and persistent discriminatory practices. The Capacity Project is helping national HIV programs in Belize, Costa Rica, El Salvador, Guatemala, Nicaragua and Panama to improve performance and supervision systems that will help address these issues. [from author]

The aim of this study was to assess adequacy of HR of local public health agencies to meet the needs emerging from health care reforms in Georgia. [from abstract]

This presentation was given at the First Forum on Human Resources for Health in Kampala. It reviews a study of how Rwanda, faced with constrained fiscal conditions, has implemented innovative reforms to create fiscal space for human resources and to make these resources more responsive to needs through an analysis of budget documents and policy and regulation changes and key informant interviews. [adapted from author]

This article presents the results of a 2002 social audit of the health sector of three Baltic States. Comparisons were made of perceptions, attitudes and experience regarding unofficial payments in the health services of Estonia, Latvia and Lithuania. The findings can serve as a baseline for interventions and to compare each country’s approach to health service reform in relation to unofficial payments. [adapted from abstract]

Rural health care is changing. Following restructuring in the 1990s some small hospitals remained independent, while others reorganized as amalgamations and alliances. In 2004, Ontario was divided into 14 Local Health Integration Networks (LHINs) to create accessible, quality health care at a local level. Th is study was designed to gain an understanding of the impact on nursing work and the workforce. [from executive summary]

The development of the delivery of reproductive health services is continually confronted by challenges from a changing environment, an important element of which is health sector reform, in particular decentralization, which is being undertaken by most governments in Africa. The general objective of this research is to make health sector decentralisation more effective in the development of appropriate reproductive health services. In Chapter 8 human resource management and development as it has been affected by decentralization is discussed. [adapted from introduction]

As part of the United Republic of Tanzania, Zanzibar maintains its own government and an independent Ministry of Health and Social Welfare. To improve the quality of health care, the Ministry created a Human Resources for Health 5-Year Development Plan. A key strategy is the development of Mnazi Mmoja Hospital (MMH) into a semi-autonomous organization. [author’s description]

Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers responses to the changes in their working environments by taking a realistic evaluation approach. [abstract]

Ensuring high performance of health care delivery systems is a challenge facing all governments. Dealing with the incentive problems underlying public health care delivery to improve productivity, quality, and performance is a common theme of health sector reforms in many countries. However, the impact of these reforms is often hard to establish. This book presents a series of case studies of health systems innovations by the Central American republics in the 1990s. The cases have a common theme of efforts to improve specific aspects of health system performance through the introduction of innovative and alternative financial, organizational, or delivery models…The case studies in this book report on the results of these experiences, encompassing a range of issues from the expansion of primary care to the use of public-private partnerships and the establishment of a social security-financed delivery system.

This paper describes the specific policy measures that the Zimbabwean government has recently implemented to try to improve health sector performance, and promote higher levels of motivation amongst public sector health care workers. The overall reform package is to include financial reforms (user fees and social insurance), strengthening of health management, liberalization and regulation of the private health sector, decentralization, and contracting out. Unfortunately, the process of reform implementation in Zimbabwe and the government’s poor communication with workers, combined with a conflict between local cultures and the measures being implemented, has undermined the potentially positive effect of reforms on health worker motivation.

This paper reports the experiences of primary care reform in the Zhezkazgan region of Kazakhstan. After the collapse of the Soviet regime, Kazakhstan undertook a radical program of reform to restructure the health sector, making primary care the centerpiece of their health reform agenda. The reforms included the creation of independent family group practices financed on a capitation basis directly from the Ministry of Health, allowing free choice of primary care providers through open enrollment, and creating a non-governmental primary care physician association. This program has had remarkable success in improving motivation among primary health care workers.

This paper offers a conceptual framework for considering the many layers of influences upon health worker motivation. It suggests that worker motivation is influenced not only by specific incentive schemes targeted at workers, but also by the whole range of health sector reforms which potentially affect organizational culture, reporting structures, channels of accountability, etc.

This issue of The Manager shows how health managers, though faced with multiple challenges of decentralization, can redefine their roles and responsibilities to better support both the people they serve and the staff at management levels closest to the population. It shows how health managers can adopt leadership practices to carry out their new roles and ultimately make decentralization work. [editor’s description]

This issue of The Manager will help managers at all levels understand the principles of local-level performance assessment and improvement. It also presents the concept of essential public health functions as a useful policy framework for decentalizing service management while maintaining and improving the coverage and quality of services. [editor’s description]

This publication is an effort to respond to the different needs for capacity building in management and implementation of health programmes and delivery of essential services. It reflects the thinking acquired from experience working with health sector reforms being implemented in the African Region. The District Health Management Training modules cover the principles that are applicable across the Region and are meant to guide and strengthen the management capacity of district health management teams. [author’s description]

In 1993, Uganda began decentralization of its health care sector to the district and subdistrict levels. Its objectives were to increase local revenue for health service provision, in part through user fees; involve the consumers in the management of their health care services; and integrate all providers, including non-governmental organizations, missions, and non-traditional providers, into the care delivery system. The increased revenues and consumer participation was expected to improve quality and increase utilization of services. With a focus on maternal and child health (MCH) services, this study used statistical data and interviews with local health administrators and physicians to assess how the reform policies have been implemented and how they have impacted MCH service provision and utilization.

Dissatisfied with centralized approaches to delivering local public services, a large number of countries are decentralizing responsibility for these services to lower- level, locally elected governments. The results have been mixed. This chapter provides a framework for evaluating the benefits and costs, in terms of service delivery, of different approaches to decentralization, based on relationships of accountability between different actors in the delivery chain. Moving from a model of central provision to that of decentralization to local governments introduces a new relationship of accountability—between national and local policymakers—while altering existing relationships, such as that between citizens and elected politicians.