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  • 1. Arbelaez, Maria Patricia
    et al.
    Gaviria, Marta Beatriz
    Franco, Alvaro
    Restrepo, Roman
    Hincapié, Doracelly
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    Tuberculosis control and managed competition in Colombia.2004In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 19 Suppl 1, p. S25-43Article in journal (Refereed)
    Abstract [en]

    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.

  • 2. Bian, Ying
    et al.
    Sun, Qiang
    Zhao, Zhengyan
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    Market reform: a challenge to public health--the case of schistosomiasis control in China.2004In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 19 Suppl 1, p. S79-94Article in journal (Refereed)
    Abstract [en]

    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.

  • 3.
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    The proof of the reform is in the implementation.2004In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 19 Suppl 1, p. S3-23Article in journal (Refereed)
    Abstract [en]

    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.

  • 4.
    Kullen Engström, Agneta
    et al.
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    Axlesson, Runo
    Nordic Council of Ministers, Nordic School of Public Health NHV.
    The double spiral of change--experiences of privatization in a Swedish hospital.2010In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 25, no 2, p. 156-68Article in journal (Refereed)
    Abstract [en]

    UNLABELLED: Privatization is a trend in countries with a public health system. It involves organizational change, a cultural transformation and changes for the employees as well as a more strictly controlled work. The objective of this study is to describe, analyse and interpret how privatization is perceived by the employees of a health care organization in Sweden.

    METHODOLOGY: In-depth interviews have been performed with physicians, paramedics, secretaries, nurses, assistant nurses and local managers, in all 14 respondents, after a private entrepreneur had taken over the management of a hospital. The interviews were tape-recorded and have been analysed and interpreted following a grounded theory approach.

    FINDINGS: The transcribed interviews show that trust is a core category and linked with emotions, commitment and security. The analysis shows that employees' experience of privatization within a health care organization differs and is full of nuances and complexities.

    CONCLUSION: A simultaneous virtuous and a vicious circle of experiences and reactions may describe how employees experience privatization. It can also be concluded that leadership is an important factor in the success of organizational change.

  • 5. Meng, Qingyue
    et al.
    Li, Renzhong
    Cheng, Gang
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    Provision and financial burden of TB services in a financially decentralized system: a case study from Shandong, China.2004In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 19 Suppl 1, p. S45-62Article in journal (Refereed)
    Abstract [en]

    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.

  • 6. Mubyazi, Godfrey
    et al.
    Kamugisha, Mathias
    Mushi, Adiel
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    Implications of decentralization for the control of tropical diseases in Tanzania: a case study of four districts.2004In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 19 Suppl 1, p. S167-85Article in journal (Refereed)
    Abstract [en]

    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.

  • 7. Zhan, Shaokang
    et al.
    Wang, Lanxiang
    Yin, Aitian
    Blas, Erik
    Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
    Revenue-driven in TB control--three cases in China.2004In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 19 Suppl 1, p. S63-78Article in journal (Refereed)
    Abstract [en]

    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.

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