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The medical component of workers' compensation programs-now costing over $24 billion annually-and the rest of the nation's medical care system are linked. They share the same patients and providers. They provide similar benefits and services. And they struggle over who should pay for what. Clearly, health care reform and restructuring will have a major impact on the operation and expenditures of the workers' compensation system. For a brief period, during the 1994 national health care reform debate, these two systems were part of the same federal policy development and legislative process. With comprehensive health care reform no longer on the horizon, states now are tackling both workers' compensation and medical system reforms on their own. This paper reviews the major issues federal and state policy makers face as they consider reforms affecting the relationship between workers' compensation and traditional health insurance. What is the relationship of the workers' compensation cost crisis to that in general health care? What strategies are being considered by states involved in reforming the medical component of workers compensation? What are the major policy implications of these strategies?

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Background

Accounting for 36% of public spending on health care in Canada, hospitals are a major target for cost reductions through various efficiency initiatives. Some provinces are considering payment reform as a vehicle to achieve this goal. With few exceptions, Canadian provinces have generally relied on global and line-item budgets to contain hospital costs. There is growing interest amongst policy-makers for using activity based funding (ABF) as means of creating financial incentives for hospitals to increase the 'volume' of care, reduce cost, discourage unnecessary activity, and encourage competition. British Columbia (B.C.) is the first province in Canada to implement ABF for partial reimbursement of acute hospitalization. To date, there have been no formal examinations of the effects of ABF policies in Canada.

This study proposal addresses two research questions designed to determine whether ABF policies affect health system costs, access and hospital quality. The first question examines the impact of the hospital funding policy change on internal hospital activity based on expenditures and quality. The second question examines the impact of the change on non-hospital care, including readmission rates, amount of home care provided, and physician expenditures.

Methods/Design

A longitudinal study design will be used, incorporating comprehensive population-based datasets of all B.C. residents; hospital, continuing care and physician services datasets will also be used. Data will be linked across sources using anonymized linking variables. Analytic datasets will be created for the period between 2005/2006 and 2012/2013.

Discussion

With Canadian hospitals unaccustomed to detailed scrutiny of what services are provided, to whom, and with what results, the move toward ABF is significant. This proposed study will provide evidence on the impacts of ABF, including changes in the type, volume, cost, and quality of services provided. Policy- and decision-makers in B.C. and elsewhere in Canada will be able to use this evidence as a basis for policy adaptations and modifications. The significance of this proposed study derives from the fact that the change in hospital funding policy has the potential to affect health system costs, residents' access to care and care quality.

Health research systems consist of diverse groups who have some role in health research, but the boundaries around such a system are not clear-cut. To explore what various stakeholders need we reviewed the literature including that on the history of English health R&D reforms, and we also applied some relevant conceptual frameworks.

We first describe the needs and capabilities of the main groups of stakeholders in health research systems, and explain key features of policymaking systems within which these stakeholders operate in the UK. The five groups are policymakers (and health care managers), health professionals, patients and the general public, industry, and researchers. As individuals and as organisations they have a range of needs from the health research system, but should also develop specific capabilities in order to contribute effectively to the system and benefit from it.

Second, we discuss key phases of reform in the development of the English health research system over four decades - especially that of the English Department of Health's R&D system - and identify how far legitimate demands of key stakeholder interests were addressed.

Third, in drawing lessons we highlight points emerging from contemporary reports, but also attempt to identify issues through application of relevant conceptual frameworks. The main lessons are: the importance of comprehensively addressing the diverse needs of various interacting institutions and stakeholders; the desirability of developing facilitating mechanisms at interfaces between the health research system and its various stakeholders; and the importance of additional money in being able to expand the scope of the health research system whilst maintaining support for basic science.

We conclude that the latest health R&D strategy in England builds on recent progress and tackles acknowledged weaknesses. The strategy goes a considerable way to identifying and more effectively meeting the needs of key groups such as medical academics, patients and industry, and has been remarkably successful in increasing the funding for health research. There are still areas that might benefit from further recognition and resourcing, but the lessons identified, and progress made by the reforms are relevant for the design and coordination of national health research systems beyond England.

Researchers often focus on the data and methods to assess policy changes, but data and methods can also be policy tools. To improve, health care systems need mechanisms and incentives for continually gathering, assessing, and acting on data. This requires (1) more comprehensive data, (2) converting data into information, and (3) incentives to apply that information. Restructured economic incentives can encourage clinicians to increase value (higher quality and/or lower cost) for their patients. While necessary, incentives are not sufficient—information is also needed. Incentives can lead clinicians to demand better information. Much of the necessary data is already used in patient care and billing; some additional variables will come directly from patients. The notion builds on two concepts: collective intelligence and positive deviance. The former characterizes knowledge gained from observing the behavior of many independent actors adapting to changing situations. Positive deviants are those who achieve far better results than expected. By rewarding positive deviants, rather than trying to identify and “correct” those who are problematic, providers will voluntarily identify themselves and their methods for achieving superior outcomes.

Background

This paper discusses the way in which women’s health concerns were addressed in Mexico as part of a health system reform.

Discussion

The first part sets the context by examining the growing complexity that characterizes the global health field, where women’s needs occupy center stage. Part two briefly describes a critical conceptual evolution, i.e. from maternal to reproductive to women’s health. In the third and last section, the novel “women and health” (W&H) approach and its translation into policies and programs in the context of a structural health reform in Mexico is discussed. W&H simultaneously focuses on women’s health needs and women’s critical roles as both formal and informal providers of health care, and the links between these two dimensions.

Summary

The most important message of this paper is that broad changes in health systems offer the opportunity to address women’s health needs through innovative approaches focused on promoting gender equality and empowering women as drivers of change.

Current policy statements discourage identification of disease carrier status in minors on the grounds that carrier information is of mainly reproductive significance. Such policies fail to consider that the carrier state may have important health implications for minors. They also fail to consider that carrier status of newborns is routinely discovered as an incidental finding in newborn screening programs. Finally, such policies fail to take into account that it may not be parents but adolescents who are seeking out this information and that adolescence may be a valid time to learn about one's reproductive risks. Here, I consider the issues that need to be addressed in revising current policies about the carrier detection of minors.

Over the past two years, the US pharmaceutical and biotechnology industries were preparing themselves for passage of some type of health-reform legislation with a clear appreciation—and concern— about the enormous impact any law would be likely to have on the structure and viability of the research-based industry. Now, with final passage in March 2010 of the patient Protection and Affordable Care Act and its companion “quick-fix” and budget bill, the Health Care and Education Reconciliation Act, it is a good time to take a look at how the industry fared and assess how the various provisions of the health-care reform bill might affect the industry’s long-term prosperity and growth.

Background

On 1 January 2006 a number of far-reaching changes in the Dutch health insurance system came into effect. In the new system of managed competition consumer mobility plays an important role. Consumers are free to change their insurer and insurance plan every year. The idea is that consumers who are not satisfied with the premium or quality of care provided will opt for a different insurer. This would force insurers to strive for good prices and quality of care. Internationally, the Dutch changes are under the attention of both policy makers and researchers. Questions answered in this article relate to switching behaviour, reasons for switching, and differences between population categories.

Methods

Postal questionnaires were sent to 1516 members of the Dutch Health Care Consumer Panel and to 3757 members of the National Panel of the Chronically ill and Disabled (NPCD) in April 2006. The questionnaire was returned by 1198 members of the Consumer Panel (response 79%) and by 3211 members of the NPCD (response 86%). Among other things, questions were asked about choices for a health insurer and insurance plan and the reasons for this choice.

Results

Young and healthy people switch insurer more often than elderly or people in bad health. The chronically ill and disabled do not switch less often than the general population when both populations are comparable on age, sex and education.

For the general population, premium is more important than content, while the chronically ill and disabled value content of the insurance package as well. However, quality of care is not important for either group as a reason for switching.

Conclusion

There is increased mobility in the new system for both the general population and the chronically ill and disabled. This however is not based on quality of care. If reasons for switching are unrelated to the quality of care, it is hard to believe that switching influences the quality of care. As yet there are no signs of barriers to switch insurer for the chronically ill and disabled. This however could change in the future and it is therefore important to monitor changes.

Background

Human resources (HR) are one of the most important components determining performance of public health system. 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.

Methods

We used the Human Resources for Health Action Framework, which includes six components: HR management, policy, finance, education, partnerships and leadership. The study employed: (a) quantitative methods: from September to November 2004, 30 randomly selected district Centers of Public Health (CPH) were surveyed through face-to-face interviews with the CPH director and one public health worker randomly selected from all professional staff; and (b) qualitative methods: in November 2004, Focus Group Discussions (FGD) were held among 3 groups: a) 12 district public health professionals, b) 11 directors of district public health centers, and c) 10 policy makers at central level.

Results

There was an unequal distribution of public health workers across selected institutions, with lack of professionals in remote rural district centers and overstaffing in urban centers. Survey respondents disagreed or were uncertain that public health workers possess adequate skills and knowledge necessary for delivery of public health programs. FGDs shed additional light on the survey findings that there is no clear vision and plans on HR development. Limited budget, poor planning, and ignorance from the local government were mentioned as main reasons for inadequate staffing. FGD participants were concerned with lack of good training institutions and training programs, lack of adequate legislation for HR issues, and lack of necessary resources for HR development from the government.

Conclusion

After ten years of public health system reforms in Georgia, the public health workforce still has major problems such as irrational distribution and inadequate knowledge and skills. There is an urgent need for re-training and training programs and development of conducive policy environment with sufficient resources to address these problems and assure adequate functionality of public health programs.

Human resources are the most important assets of any health system, and health workforce problems have for decades limited the efficiency and quality of Latin America health systems. World Bank-led reforms aimed at increasing equity, efficiency, quality of care and user satisfaction did not attempt to resolve the human resources problems that had been identified in multiple health sector assessments. However, the two most important reform policies – decentralization and privatization – have had a negative impact on the conditions of employment and prompted opposition from organized professionals and unions. In several countries of the region, the workforce became the most important obstacle to successful reform.

This article is based on fieldwork and a review of the literature. It discusses the reasons that led health workers to oppose reform; the institutional and legal constraints to implementing reform as originally designed; the mismatch between the types of personnel needed for reform and the availability of professionals; the deficiencies of the reform implementation process; and the regulatory weaknesses of the region.

The discussion presents workforce strategies that the reforms could have included to achieve the intended goals, and the need to take into account the values and political realities of the countries. The authors suggest that autochthonous solutions are more likely to succeed than solutions imported from the outside.

Conclusion

Culture and class remain contested terrains in policy narratives about the right of the urban poor to access health and social services delivery systems under welfare reform. An urban bioethics agenda is needed to address these dilemmas that have arisen in the context of PRWORA and had an impact on access to health and social services in the urban environment.2;18 Such efforts, however, must address the intellectual framing of the urban poor, as well as the public policies that inscribe deterministic and stereotypical ideas about the poor alongside incomplete portraits of barriers to greater social and occupational mobility.

The focus of social science researchers on the delineation of behavioral characteristics among an urban “underclass” in some instances further marginalizes and stigmatizes an already isolated urban poor. Even though Wilson, the Harvard sociologist who popularized the term “underclass” in his earlier research, has now largely disowned it, tales and stories a bound in the social policy and health literature. The media also commonly underscore perceptions that establish rumor as social science and promote stereotypes that the poor are lazy and unwilling to work. Wilson, who has analyzed contextual and neighborhood factors such as the migration of jobs to the suburbs, has also declared stance that is in opposition to those, such as New York University political science professor Lawrence Mead, who embrace a “culture of poverty” thesis and have set the tone for some welfare reform initiatives by arguing that behavior, and not joblessness, is the key, “My guess,” Mead stated after welfare reform was enacted in 1996, ”is that culture came first, and drove away the economy or the good jobs, rather than the other way around,” 21(p3)These statements continue to have dramatic impacts on the stigmas attached to public programs by promoting the idea that those in spatially concentrated radical and ethnic groups in urban areas are not members of the working class. Such perceptions have also contributed to a belief that those who participate in publicly subsidized social welfare and health insurance programs do not work.

Whether one accepts that the denial of health care to citizens and noncitizens in contemporary America derives in large part from the promotion of images of the poor as pathological, states have moved steadily to institute a variety of policies under welfare reform that continue to prescribe narrower eligibility criteria for access to service delivery systems. This is occurring as the US Congress hesitates to restore excluded populations, and there are reports of questionable practices targeted at those who are eligible based on current legislation. On several occasions, for example, the Civil Rights Division of the US Department of Health and Human Services has made inquiries (and issued sanctions) in cases for which state and local governments have discriminated against potential Medicaid and TANF applicants by ignoring regulations that stipulate that applications be delivered to applicants on request in a timely manner.3

While it is the explicit responsibility under welfare reform of the US Congress to pass legislation restoring eligibility to excluded populations, an urban bioethics agenda framed in a historical context has much to offer prevailing policy discourses. If, as political theorist Stone notes, a policy alternative is to be judged “by the company that it keeps,” then urban bioethicists can offer human rights paradigms and additional policy alternatives based an assessments of earlier historical experiences of stigmatization that embodied similar forms of evil.23

New Zealand's health sector has undergone three significant restructures within 10 years. The most recent has involved a Primary Health Care Strategy, launched in 2001. Primary Health Organisations (PHOs), administered by 21 District Health Boards, are the local structures for implementing the Primary Health Care Strategy. Ninety-three percent of the New Zealand population is now enrolled within 79 PHOs, which pose a challenge to the well-established Independent Practitioner Associations (IPAs).

Although there was initial widespread support for the philosophy underlying the Primary Health Care Strategy, there are concerns amongst general practitioners (GPs) and their professional organisations relating to its implementation. These centre around 6 main issues:

1. Loss of autonomy

2. Inadequate management funding and support

3. Inconsistency and variations in contracting processes

4. Lack of publicity and advice around enrolment issues

5. Workforce and workload issues

6. Financial risks

On the other hand, many GPs are feeling positive regarding the opportunities for PHOs, particularly for being involved in the provision of a wider range of community health services. Australia has much to learn from New Zealand's latest health sector and primary health care reforms.

The key lessons concern:

• the need for a national primary health care strategy

• active engagement of general practitioners and their professional organisations

• recognition of implementation costs

• the need for infrastructural support, including information technology and quality systems

• robust management and governance arrangements

• issues related to critical mass and population/distance trade offs in service delivery models

Jason Lakin discusses and critiques a Policy Forum that reviews 25 years of reform to the Mexican health system and argues that more comprehensive reform is needed.

Background

For nearly two decades calls have been made to expand the role of midwives within maternity services in Australia. Although some progress has been made, it has been slow and, at system-wide level, limited. There are many barriers that prevent the expansion of midwifery-led services in Australia including funding arrangements for midwifery care, a lack of political will and resistance from powerful medical interest groups. The ongoing debate that exists about the evidence for the safety of midwifery-led care, particularly for the intrapartum phase, is likely to be an important reason why policy-makers are reluctant to implement system-wide reforms of maternity services.

Discussion

Those opposed to the expansion of midwifery-led care argue that these services are only appropriate for low-risk women. They claim the evidence in support of midwifery-led care has too many holes in it to guarantee that services are safe for higher risk women. Midwifery advocates, however, argue there is no evidence to support the claim that midwifery-led services lead to poorer outcomes in any risk group. Despite this, funding for midwifery-led care outside hospitals remains limited. This article contends that calls for the system-wide expansion of midwifery-led care (such as through funding independently practising midwives) based on the available evidence are unlikely to succeed. There are too many methodological challenges in this area to ever "prove" that midwifery-led services are safe – except for the lowest risk women – and when there is doubt, policy-makers are likely to err on the side of caution.

Summary

In order to expand access to midwifery care, advocates should abandon the idea of system-wide reform for now. Instead, they should concentrate on implementing small-scale, locally based changes because it is at this grass roots level that health professionals can work together to resolve the major sticking points – accurately assessing risk, identifying when it changes and responding appropriately. While a lack of political will is a major obstacle to reform it is amenable to change. We argue that system-wide reform is most likely to occur when policy-makers can reference examples of successful locally-based midwifery-led programs across Australia.

It is widely recognized that the dramatic increase in health care costs in the United States has not led to a corresponding improvement in the health care experience of patients or the clinical outcomes of medical care. In no area of medicine is this more true than in the area of spine related disorders (SRDs). Costs of medical care for SRDs have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine. We explain the reasons we think a primary spine care practitioner would be beneficial to patients, the health care system and society, some of the obstacles that will need to be overcome in establishing a primary spine care specialty and the ways in which these obstacles can be overcome.

Recent reform in the National Health Service has moved general practice towards a more intense market and competition structure. Meanwhile in the United States of America there has been an attempt to modify the free enterprise approach to medical care towards a more socially responsive system. This discussion paper provides a family doctor's perspective of primary care and the maelstrom of health care reform in the USA. The cultural, economic and organizational issues underlying the need for reform are considered in turn, and the current situation with regard to health care provision, medical research, medical education and primary care are outlined. General practitioners in the United Kingdom would do well to pay attention to the effects of market reform occurring in general practice among their American counterparts.

The insulation of Canada’s healthcare system from trade treaty obligations is crucial to the legitimacy of Canada’s trade policy. Legal analysis has suggested, however, that competitive and for-profit delivery of the kind contemplated by the Kirby Report and some provinces may make healthcare more vulnerable to challenges under NAFTA and GATS. The Government of Canada has tried to counter this interpretation by stressing the importance of public financing as the principal criterion for exemption of healthcare from trade treaties, but now the potential for private financing of essential medical services indicated by the Supreme Court’s decision in Chaoulli v. Quebec has made that line of argument look risky as well. It is apparent that Canada failed to anticipate the possible interactions of domestic, international and constitutional law when it made commitments in the area of private health insurance at the WTO in 1997. Accordingly, the time has come to acknowledge the fragility of the boundary between health and trade policies, to take the risks and costs associated with trade treaty obligations fully into account when undertaking healthcare reform and to strengthen the separation between private and public health insurance.

OBJECTIVE: To explore issues family physicians face in providing community-based palliative care to their patients in the context of a changing health care system. DESIGN: Focus groups. SETTING: Small (< 10,000 population), medium-sized (10,000 to 50,000), and large (> 50,000) communities in Nova Scotia. PARTICIPANTS: Twenty-five men and women physicians with varying years of practice experience in both solo and group practices. METHOD: A semistructured approach was used, asking physicians to reflect on recent palliative care experiences in order to explore issues of care. MAIN FINDINGS: Five themes emerged from the discussions: resources needed, availability of family support, time and money supporting physicians' activities, symptom control for patients, and physicians' emotional reactions to caring for dying patients. CONCLUSION: With downsizing of hospitals and greater emphasis on community-based care, the issues identified in this study will need attention, particularly in designing an integrated service delivery model for palliative care.

Objective:

To apply a policy-analysis framework to the athletic training educational reform policy that will be fully implemented by January 2004.

Data Sources:

Policy analysis is not a specific science. No one framework exists for conducting all policy analyses. I used literature from the education, policy analysis, and athletic training fields as data sources to provide background and to create a framework from which to conduct the policy analysis.

Data Synthesis:

Once the policy-analysis framework was selected, I began data synthesis, using several athletic training sources in support of the findings. The tension among the myriad stakeholders in this policy is clear. Although many see the benefits of accreditation, some experience hardships from the imposed policy.

Conclusions/Recommendations:

Of the 4 possible alternatives suggested, following the route currently under implementation (Committee on Accreditation of Health Education Programs accreditation) was the most agreeable solution. The goals as stated by the policy makers are attained by the policy. However, issues within the accreditation process itself need to be addressed. Of the many stakeholders in the reform effort, some will see little gain and have many hardships imposed on them. As the policy is implemented, unintended implications will likely arise, as with any new policy. Thus, I recommend that the National Athletic Trainers' Association develop a system dedicated solely to reducing the hardships faced by many of its members as the policy is implemented.

Background

Chronic disease is a major global challenge. However, chronic illness and its care, when intruding into everyday life, has received less attention in Asia Pacific countries, including Australia, who are in the process of transitioning to chronic disease orientated health systems.

Aim

The study aims to examine experiences of chronic illness before and after the introduction of Australian Medicare incentives for longer consultations and structured health assessments in general practice.

Methods

Self-help groups around the conditions of diabetes, epilepsy, asthma and cancer identified key informants to participate in 4 disease specific focus groups. Audio taped transcripts of the focus groups were coded using grounded theory methodology. Key themes and lesser themes identified using a process of saturation until the study questions on needs and experiences of care were addressed. Thematic comparisons were made across the 2002/3 and 1992/3 focus groups.

Findings

At times of chronic illness, there was need to find and then ensure access to 'the right GP'. The 'right GP or specialist' committed to an in-depth relationship of trust, personal rapport and understanding together with clinical and therapeutic competence. The 'right GP', the main specialist, the community nurse and the pharmacist were key providers, whose success depended on interprofessional communication. The need to trust and rely on care providers was balanced by the need for self-efficacy 'to be in control of disease and treatment' and 'to be your own case manager'. Changes in Medicare appeared to have little penetration into everyday perceptions of chronic illness burden or time and quality of GP care. Inequity of health system support for different disease groupings emerged. Diabetes, asthma and certain cancers, like breast cancer, had greater support, despite common experiences of disease burden, and a need for research and support programs.

Conclusion

Core themes around chronic illness experience and care needs remained consistent over the 10 year period. Reforms did not appear to alleviate the burden of chronic illness across disease groups, yet some were more privileged than others. Thus in the future, chronic care reforms should build from greater understanding of the needs of people with chronic illness.

SYNOPSIS

There is growing recognition that health and health care at school can significantly impact children's health. From childhood obesity interventions to new immunization mandates, schools are at the forefront of child health discussions. The 2008 presidential campaign and the renewed focus on health-care reform raise the possibility that in 2009 school health will play a larger role in health policy conversations than previously.

This article explores the proposition that both school health and national health policy will benefit from closer attention to the role of school health within the U.S. health system. It offers a Maryland case study to suggest both the opportunities and operational challenges of linking school health to the larger community health system.

There is a growing but still fragile understanding that competition and integration are not necessarily in conflict and can be used together. In one version, this might mean using competition to drive improvements in performance in planned care, and promoting integration to do so in relation to unplanned care and care for people with complex needs. In another, it entails arguing that competition between integrated systems might offer the best of all worlds, if policies can be designed to support evolution in that direction. This paper suggests that a bundle of policy interventions is needed to support the evolution of integrated systems of care. It examines how policies might be crafted to make this happen; How to avoid the wrong kind of integration to develop; and, how can policy-makers enable competition between integrated systems.

Little is known about African-American physicians' health system experience or their opinions on health reform. In an attempt to obtain socioculturally relevant data quantifying these experiences and opinions, the National Medical Association administered a 38-question, 80-item survey instrument in August 1993. The questionnaire was completed by 236 physicians. The results indicate that African-American physicians feel health care is a right and that the health system needs fundamental change. Although there was no consensus on the type of health reform needed, approximately 35% cited availability and access to care to be the greatest problem facing the system with high costs of care (18.2%) ranking second. Unique findings in the survey indicated respondents felt that the needs and concerns of most African Americans will not be fairly addressed in the reform of the health-care system, that African-African physicians are not included in the formation of health-care policies, and that African-American physicians are facing high levels of professional and healthcare system racial discrimination. More than 99% of African-American physicians reported some degree of racial discrimination in the practice of medicine including peer review, obtaining practice privileges at hospitals, hospital staff promotions, Medicaid and Medicare reimbursements, malpractice suits, private insurance oversight and reimbursements, and referral practices of white colleagues. These findings have profound health policy, health financing, and health service delivery implications and should be included in debates and deliberations on health reform.

Background

In the transition from a planned economy to a market-oriented economy, China’s state funding for health care declined and traditional coverage plans collapsed, leaving China’s poor exposed to potentially ruinous health care costs. In reforming health care for the 21st century, equity in health care financing has become a major policy goal. To assess progress towards this goal, this paper examines the equity characteristics of health care financing in a province of northwestern China, comparing the equity performance between urban and rural areas at two different points in time.

Methods

Analysis of whether health care financing contributions were progressive according to income were made using the Kakwani index for each of the four health care financing channels of general taxes, public and private health insurance, and out-of-pocket payments. Two rounds of surveys were conducted, the first in 2003 (13,619 individuals in 3946 households) and the second in 2008 (12,973 individuals in 3958 households). Household socio-economic, health care payment, and utilization information were recorded in household interviews.

Results

Low-income households have undertaken a larger share of the health care financing burden in recent years, reflected by negative Kakwani indices, which indicate a regressive system. We found that the indices for general taxation were −0.0024 (urban) and −0.0281 (rural) in 2002, and −0.0177 (urban) and −0.0097 (rural) in 2007. Public health insurance presented different financing distributions in urban and rural areas (urban: 0.0742 in 2002, 0.0661 in 2007; rural: –0.0615 in 2002,–0.1436 in 2007.). Out-of-pocket payments were progressive but not equitable. Public health insurance coverage has expanded but financing equity has decreased.

Conclusions

Health care financing policies in China need ongoing reform. Given the inequity of general consumption taxes, elimination of these would improve financing equity considerably. Optimizing benefit packages in public health insurance is as important as expanding coverage, both for health care financing and for utilization management as well. Although they are progressive, out-of-pocket payments are not equitable in China and have the effect of excluding the poor from health care as they cannot afford to pay for medical care and so withdraw from treatment.

Background

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.

Methods

The study findings were generated by triangulating both qualitative and quantitative methods of data collection and analysis among policy technocrats, health managers and groups of health providers. Quantitative surveys were conducted with over 700 individual health workers in both Bangladesh and Uganda and supplemented with qualitative data obtained from focus group discussions and key interviews with professional cadres, health managers and key institutions involved in the design, implementation and evaluation of the reforms of interest.

Results

The reforms in both countries affected the workforce through various mechanisms. In Bangladesh, the effects of the unification efforts resulted in a power struggle and general mistrust between the two former workforce tracts, family planning and health. However positive effects of the reforms were felt regarding the changes in payment schemes. Ugandan findings show how the workforce responded to a strong and rapidly implemented system of decentralisation where the power of new local authorities was influenced by resource constraints and nepotism in recruitment. On the other hand, closer ties to local authorities provided the opportunity to gain insight into the operational constraints originating from higher levels that health staff were dealing with.

Conclusion

Findings from the study suggest that a) reform planners should use the proposed dynamic responses model to help design reform objectives that encourage positive responses among health workers b) the role of context has been underestimated and it is necessary to address broader systemic problems before initiating reform processes, c) reform programs need to incorporate active implementation research systems to learn the contextual dynamics and responses as well as have inbuilt program capacity for corrective measures d) health workers are key stakeholders in any reform process and should participate at all stages and e) some effects of reforms on the health workforce operate indirectly through levels of satisfaction voiced by communities utilising the services.