Government stewardship and primary health care in Guatemala since 1996

This article analyzes the role of government stewardship in the expansion of primary health care in post‐conflict Guatemala. By the time the Peace Accords were signed in 1996, the country's primary health care system was scarcely functioning with virtually no services available in rural indigenous areas. To address this gaping void/deficiency, the Ministry of Public Health and Social Assistance (MSPAS) embarked on a progressive expansion of primary services aimed at covering the majority of rural poor. Through a series of legal, policy, and program reforms up to 2014, the MSPAS dramatically expanded primary coverage and greatly improved basic health indicators for the entire population. To succeed in this effort, the MSPAS and its partners needed to simultaneously grow their stewardship capacity to oversee and develop the primary health system. On the basis of recent health systems strengthening literature, we propose a stewardship framework of 6 critical functions and use it to analyze the gains in government capacity that enabled the achievement of many of the country's primary health goals. Of the 6 stewardship functions, “building relationships, coalitions, and partnerships” especially with civil society organizations stands out as one of the keys to MSPAS success.     

Strengthening family planning stewardship with a total market approach: Mali,Uganda, and Kenya experiences

To improve overall market sustainability, governments and their donors are ramping up efforts to strengthen stewardship in developing country health markets. Key stewardship functions include generating intelligence that enable policymakers, ministerial leaders, and program managers to develop evidence‐based policies and strategies to improve the resource management, supply, and use of health products and services. The total market approach (TMA), an analytic and policy framework, generates market intelligence and improves evidence‐based decision‐making, and also strengthens other stewardship functions, such as building and sustaining partnerships, strengthening tools for implementation, aligning government policy with market interventions, and ensuring accountability/transparency. TMA evolved in response to the phase out of donor support for reproductive health (RH) and family planning (FP) programs and the need to improve coordination among public, private, nongovernmental organizations, and civil society to achieve greater equity, health impact, and market sustainability. To assess TMA's role in strengthening the stewardship of RH/FP markets, this article reviews three countries that applied TMA principles: Mali, Uganda, and Kenya. It identifies how TMA processes influenced stewardship functions and assesses to what degree these processes have contributed to concrete actions to improve market efficiency and sustainability.     

Stewardship of health security: The challenges of applying the One Health approach

Experience with the control of epidemics, notably the 2004 outbreaks of avian influenza, has demonstrated that a “One Health approach,” that recognizes that human, animal, and environmental health are interdependent, is the most effective way of dealing with threats from emerging infectious diseases (EID). However, introducing and applying a One Health approach is challenging for many countries. One of the key challenges relates to stewardship. The evolution of the strategies and policies used to introduce and adopt the One Health approach in the detection and response to EID over the period 2005 to 2017 is described at global level and in country case studies of Thailand and Indonesia. Both countries experienced significant outbreaks of H5N1 avian influenza from 2004 and have sought to adopt the One Health approach in their response strategies. The challenges for stewardship of health systems in introducing a One Health approach are described, and key lessons identified in regard to national level agency coordination, engagement of the broader civil society outside government, and developing a reliable, credible, and impartial decision‐making process. The concept of stewardship provides valuable insights for policymakers on how to incorporate a One Health approach into their EID response systems.     

Stewardship of quality of care in health systems: Core functions,common pitfalls,and potential solutions

National Ministries of Health in low‐ and middle‐income countries (LMICs) have a key role to play as stewards of the quality agenda in their health systems. This paper uses a previously developed six‐point framework for stewardship (strategy formulation, intersectoral collaboration, governance and accountability, health system design, policy and regulation, and intelligence generation) and identifies specific examples of activities in LMICs in each of these domains, pitfalls to avoid, and possible solutions to these pitfalls. Many LMICs now have quality strategies with clear vision statements. There are good examples of quality agencies and donor collaboration councils to coordinate activities across different sectors. There are multiple options for accountability, including public reporting, community accountability structures, results‐based payment, accreditation, and inspection. To improve health system design, available tools include decision support tools, task‐shifting models, supply chain management, and programs to train quality improvement staff. Policy options include legislation on disclosure of adverse events, and regulations to ensure skills of health care providers. Lastly, health information tools include patient registries, facility surveys, hospital discharge abstracts, standardized population and patient surveys, and dedicated agencies for reporting on quality. Policy‐makers can use this article to identify options for driving the quality agenda and address anticipated implementation barriers.     

Special Issue on electronic media,markets and civil society in East and Southeast Asia: Introduction

Abstract

The government of Hong Kong has been trying to reform the territory's health care financing system since the early 1990s and is finally on the verge of succeeding. The objective of this paper is to assess the reform efforts and explain the causes of repeated failures and eventual success. It will argue that the government's fortunes changed only after it abandoned the core reform goal and decided to pursue peripheral objectives. It will explain the abandonment with reference to the peculiar political system in Hong Kong that makes it difficult for the government to adopt substantial policy reforms in the face of even moderate opposition. The reason for the government's policy incapacity is the existence of liberalism in a non-democratic setting, which allows the government to neither suppress opposition nor mobilize popular support. This has been illustratively evident in its health care reforms when its proposals to improve the system's fiscal sustainability invariably met an early death because they imposed costs on employers, the population or both. The current proposal has fared better not only because it addresses a simpler peripheral problem but also because it offends almost no one and pleases many among the powerful.     

Government-to-Government Contracting: Stewardship,Agency, and Substitution

ABSTRACT

This paper provides empirical evidence detailing the distinctive nature of service delivery provided through contracts with other governments. The results of a survey of Ohio city and county managers both confirm and stand in contrast to implications derived from stewardship theory. Consistent with stewardship, our data demonstrate that contracts with public sector service partners generate less intensive monitoring by contracting governments than do services contracted with private entities. In contrast to stewardship theory, we find that contracting governments do not use other governments for services requiring intensive monitoring. In an era of accountability and results-oriented management, reliance on trust may not satisfy constituents who seek evidence of effective service delivery. The inability of the contracting government to affect another government's service delivery reduces the attractiveness of that government as a contracting partner. If the tools of stewardship prove to be inadequate, the imposition of carrots and sticks appropriate for a principal-agent relationship could undermine the trust central to stewardship. Given these tensions, it is not surprising that governments are contracting less with other governments.     

Federalism and suitable housing for the frail elderly: A comparison of policies in Canada and the United States

Abstract

The frail elderly have special multidimensional housing needs beyond affordability, including shelter that is more adaptive to reduced function and offers supportive services. Suitable housing for this population comprises three policy areas—housing, health care, and social services. In a federal system, development and implementation of policies in these areas involves participation of several levels of government and the nongovernmental sector. This paper uses federalism as a conceptual framework to examine and compare these policy areas in Canada and the United States.

In both countries, general national housing policies—relying heavily on the nongovernmental sector and characterized by joint federal‐provincial programs in Canada and by important local government roles and age‐specific programs in the United States‐have benefited the elderly. The effects of such policies on the frail elderly, however, have been less positive because of the general lack of essential human services and, to a lesser degree, health care that enables them to live outside institutions. This is especially true in the United States, where health care policy is fragmented and is dominated by a private insurance system, partial federal financing of health insurance for the elderly, and tense federal‐state relations in financing health care for the poor. Although Canadian policies and programs operate autonomously and more uniformly within a national health plan, neither country has a universal, comprehensive long‐term care system. Geographically diverse patterns of social services, funded by grants to states and provinces and the nonprofit sector, are common to both countries. However, the United States has inadequately funded age‐specific programs and has relied on a growing commercial service provision. Housing outcomes for frail elders are moving in the right direction in both countries; however, Canada seems to be better positioned, largely because of its health care system. As increased decentralization continues to characterize the three policy areas that affect suitable housing for frail elders, the United States can learn from Canada's negotiated federalism approach to more uniform solutions to merging housing and long‐term care.     

Local government decentralization and the health sector in Tanzania

An evaluation of primary-level healthcare undertaken in Tanzania 1989-91 found that district health managers felt powerless to address health care performance weaknesses, although the district is the unit to which government management functions have been decentralized. In order to understand the managers views, this article analyses the pattern of decentralization within the health system from their perspective. It reviews the hislorical development of government structures and the theory and practice of decentralization within Tanzania. The matrix of accountability for health care has become very confusing, with multiple and cross-cutting flows of authority within and between levels of the system. District health managers have limited authority to take management action, such as managing resources, in ways that would begin to address problems of inefficiency and poor quality of care within primary care. District health management also suffers from weak resource allocation and financial management piocedures. The main obstacles preventing more effective management are: resource constraints; conflicts between the demands for central control and local discretion; limited institutional capacity; and political and cultural influences over the implementation of decentralization. Evaluation of past experience suggests that future policy influencing the organizational structure of government health services must be developed cautiously, recognizing the critical importance of complementary action to develop both institutional capacity and political and economic support for the health system.     

The quest for a better performing health system: Public expertise and corporate management recipes in France

Though the government pledged to cut the public deficit from 7.7% of the gross domestic product in 2010 to 3% by 2013, thereby responding to EU Normative power, health expenditures continue to rise, because public demands are higher and more social problems are handled in the health care setting. With French budget deficit threatening France's credit rating, novel instruments were needed. These included corporate management recipes (e.g., pay for performance contracts, patient volume targets, and management by objectives), new compensation mechanisms (e.g., activity‐based accounting and a nationwide scale of health care costs) and far‐reaching laws (e.g., the 2009 HPST bill). Our approach investigates some critical elements of the French health care system. We focus on primary (e.g., family physicians and General Practitioners) and secondary (e.g., hospital and specialty) care. We explore how policies such as the standardization of health services, the regrouping of health policy decisions within the larger Regional Health Agencies, affected citizens' engagement and physicians' autonomy. A French welfare elite pursued a hybrid strategy, regulating quasi‐markets of care providers in a postcompetitive government, while creating supportive conditions for a vibrant private hospital sector. Reforms also emphasized evidenced‐based policy, outputs‐rather than outcome‐measurement, and performance evaluation in a bid to streamline the delivery of health services.     

THE STATES' ROLE IN HEALTH CARE COST CONTAINMENT*

Under the Social Security Act of 1935, the federal government expanded its involvement in maternal and child health care programs through grants-in-aid to state and local health departments. The Medicaid legislation of 1965 vastly enlarged federal expenditures, and state responsibilities. State performance was frequently criticized, especially in health care cost containment. Recently, the states have initiated several efforts to link cost containment and the quality of health care.     

What motivates adherence to medical recommendations? The procedural justice approach to gaining deference in the medical arena

Although it is within their long‐term interest, patients often fail to follow health care recommendations made by medical experts. This failure results in the widespread occurrence of preventable health problems and a significant increase in health care costs. Taking a new approach to confronting this issue, this paper examines whether the procedural justice model, which has been useful in explaining cooperation with legal and managerial authorities, can provide a basis for increasing patients' willingness to voluntarily adhere to health care recommendations. Three studies tested and supported this proposition. Study 1 experimentally manipulated physicians' procedural fairness or unfairness to explore its influence on patients' acceptance of doctors' recommendations. Study 2 used patients' reports about the fairness of their personal physicians and linked those evaluations to their willingness to follow their doctor's recommendations. Finally, study 3 explored the role of general procedural justice judgments in promoting willingness to accept health policies when they are advocated by private doctors and government health care authorities. The results of all three studies support the argument that when health care authorities use fair procedures, patients are more likely to accept their recommendations. Importantly, this procedural justice effect is distinct from, and in some cases stronger than, the influence of competence.     

Trust and verification: balancing agency and stewardship theory in the governance of agencies

ABSTRACT

Many government services are delivered by (partially) autonomous agencies. Governments need effective measures for contracting, steering, and monitoring agencies and to balance control and trust. In the literature, control-based agency theory and trust-based stewardship theory have often been portrayed as alternative and competing approaches. In empirical studies in public administration, however, these approaches often find mixed and contradictory results. Against this background, this article analyzes how a combination of trust- and control-based approaches, explicitly founded on agency and stewardship theory, can help explain when participants find a given governance regime to be most satisfactory. A survey instrument is developed which, for the first time, fully measures the rich concept of stewardship theory in conjunction with agency theory. The analysis of the governance of Dutch agencies shows that government indeed combines governance solutions from both theoretical camps and illuminates under which conditions this combination is most satisfactory.     

National Childhood Vaccine Injury Act of 1986: Using Tax Revenues to Assure Vaccine Availability

The National Childhood Vaccine Injury Act of 1986 was funded with an earmarked tax in an attempt to prevent a perceived crisis that was developing in the United States regarding the availability and affordability of vaccines for life-threatening childhood illnesses. The federal government felt compelled to intervene in a perceived failure of the private marketplace. In short, the inability of several pharmaceutical firms to obtain liability insurance due to high damage awards forced them to leave the marketplace or self-insure. This article details the history of the vaccine tax policy issues and updates the experiences of the financing mechanism. As the federal government attempts to broaden its role in the health care delivery system, the possibility of similar interventions exist.     

Contracting for Indigenous Health Care: Towards Mutual Accountability

In Australia and other industrialised countries, governments contract with the non‐government sector for the provision of primary health care to indigenous peoples. Australian governments have developed policies and funding programs to support this health sector, but the current arrangements are unduly complex and fragmented. The results of our study show that the complex contractual environment for Aboriginal Community‐Controlled Health Services (ACCHSs) and their funders is an unintended but inevitable result of a quasi‐classical approach to contracts applied by multiple funders. The analysis in this article highlights potential policy and program changes that could improve the effectiveness of funding and accountability arrangements, based on the use of an alliance contracting model, better performance indicators and greater clarity in the relative roles of national and jurisdictional governments.     

COMBATING HEALTHCARE COST INFLATION WITH CONCERTED ADMINISTRATIVE ACTIONS IN A CHINESE PROVINCE

This article defies the traditional notion that cost inflation in healthcare could hardly be curbed without the significant revision of economic incentive scheme, but demonstrates the possibility of containing cost inflation with concerted administrative actions in the Chinese context. It examines the case of Fujian Province that embarked on a health bureaucracy‐led policy reform without an alteration of economic levers but mainly using administrative tools to combat cost escalation. Through clearly defined, well designed, targeted and concerted administrative measures, effective cost containment is attainable in China's healthcare sector, at least in the short run. If combined well with the powerful economic instruments, administrative tools would be able to augment their effects in cost containment, provided with the government's possession of hospital ownership. At the heart of Fujian's case are the reassertion of the government stewardship, the reconstruction of the collapsed accountability mechanisms, the reconfiguration of policy instruments, and the revision of administrative incentives, rather than the decreased costs per se. Copyright © 2011 John Wiley & Sons, Ltd.     

Interagency information sharing: Expected benefits,manageable risks

The sharing of program information among government agencies can help achieve important public benefits: increased productivity; improved policy-making; and integrated public services. Information sharing, however, is often limited by technical, organizational, and political barriers. This study of the attitudes and opinions of state government managers shows that more than 8 in 10 judge information sharing to be moderately to highly beneficial. It also reveals specific concerns about the inherent professional, programmatic, and organizational risks. The study proposes a theoretical model for understanding how policy, practice, and attitudes interact and suggests two policy principles, stewardship and usefulness, to promote the benefits and mitigate the risks of sharing.     

Market imperfections,government imperfections,and policy mixes: policy innovations in Singapore

Proper roles for government and market in addressing policy problems may be assessed by considering the duality between market imperfections and government imperfections. The potential of government interventions or market mechanisms as core policy instruments can be eroded by fundamental deficiencies deeply rooted in either government or market as social institutions. The impacts of such deficiencies are much more extensive than postulated by the existing theories. Analysis here, based on policy innovations in land transport and health care in Singapore, suggests how policy mixes might become the norm of response for addressing policy problems found in a range of sectors. The analytical framework presented may help to distinguish among different policy mixes according to their effectiveness, but also provides some useful guiding principles for policy design.     

Reputational impact of Covid-19 pandemic management on World Health Organization among Indian public health professionals

Organizational reputation is critical for successful stakeholder engagement. A crisis can affect the organizational reputation and alter stakeholder perception about organizations. The current study investigates the impact of the Covid-19 pandemic and its management on the World Health Organization's (WHO's) reputation among Indian public health professionals (PHPs). The study applies the situational crisis communication theory (SCCT) model to investigate the reputational impact of the pandemic on WHO among the study subjects. The study results indicate that most Indian PHPs attribute the current Pandemic to WHO. Their current reputation has dropped compared to their earlier reputation among Indian PHPs. The same is reflected in their behavioral intent, with the PHP's willingness to follow WHO guidelines on public health issues significantly reduced. The study also finds empirical support for the SCCT Model.     

National health insurance: Some lessons from the Canadian experience

In the current American debate over national health insurance an examination of the Canadian governmental experience is very instructive. Canada is enough like the United States to make the effects of Canadian health insurance policies rather like a large natural experiment. The Canadian experience—universal government health insurance administered by the ten provinces with some fiscal and policy variations—can be used to predict the impact in the United States of proposed national health insurance plans on the medical care system, and the reaction of mass publics and national policymakers to these effects.The central purpose of the Canadian national health insurance was to reduce and hopefully eliminate financial barriers to medical care. In this it succeeded. But it also produced results which Canadian policymakers never anticipated: essentially unexpected side-effects on cost, quality, organization, and manpower distribution of the particular national health insurance program adopted. It should be cause for concern, the article concludes, that most of the prominent American national health insurance proposals resemble the Canadian program in failing to provide a single level of government with both the means and incentives to curb the inflationary effects of national health insurance. The lesson from Canada is that unless the system has very strong anti-inflationary mechanisms and incentives built into it, national health insurance will feed the fires of medical inflation despite great formal governmental authority to control it.     

The weakness of strong policies and the strength of weak policies: Law,experimentalist governance,and supporting coalitions in European Union health care policy

The experience of European Union (EU) health care services policy shows the importance of supporting coalitions in any effort to effect policy change and the extent to which the presence or absence of such coalitions can qualify generalizations about policymaking. EU health care services law is substantively liberalizing and procedurally driven by the courts, with little legislative input. But the European Court of Justice (ECJ) has been much better at establishing an EU competency in law than in causing policy development in the EU or member states. Literature on courts helps to explain why: courts are most effective when they enjoy supporting coalitions and the ECJ does not have a significant supporting coalition for its liberalizing health care services policy. Based on interview data, this article argues that the hard law of health care services deregulation and the newer forms of health care governance, such as the Open Method of Coordination and the networks on rare diseases, depend on supporting coalitions in member states that are willing to litigate, lobby, budget, decide cases, and otherwise implement EU law and policy. Given the resistance that the Court has met in health care sectors, its overarching deregulatory approach might produce smaller effects than expected, and forms of experimentalist governance that are easy to deride might turn out to have supporting coalitions that make them unexpectedly effective.