Reform and counter reform: how sustainable is New Zealand's latest health system restructuring?

New Zealand's health care sector has undergone almost continual restructuring since the early 1980s. In the latest set of reforms, 21 district health boards (DHBs) have been established with responsibility for promoting health, purchasing services for their populations and delivering publicly owned health services. Boards will be governed by a mix of elected and appointed members, will be responsible for arranging the delivery of primary and community health services, and will own and run public hospitals and related facilities. We clarify the differences and continuities between earlier reforms and the 2000/01 structures, as well as the current reforms' potential strengths and weaknesses. The paper discusses whether the DHB model was the only feasible option for restructuring and whether the dynamics of the new system may lead to further changes, particularly on the purchaser side of the system. Given that DHBs face potential conflict between their purchasing and provision roles, and given the potential advantages that primary care organisations may have as purchasers, we conclude that it is possible that all or part of the purchasing function of DHBs might eventually shift to primary care organisations, leaving the DHBs as hospital-based provider organisations.     

Running on the spot: lessons from a decade of health reform in New Zealand

Over the past 10 years the New Zealand public health system has been the subject of major reforms. This paper describes these reforms and asks what real changes resulted from the decade of restructuring, and what general lessons might be learned from these experiences? The discussion contributes to the ongoing economic debate concerning the role of markets in the health sector. It also highlights some of the more practical issues and problems that are relevant for health policy makers. The New Zealand reforms have been costly, and yet any benefits appear to have been considerably less than expected, especially in terms of efficiency gains. Explanations for this include the possibility that the magnitude of potential efficiency gains had been overestimated, and that any incentives for improving efficiency were weakened by the particular institutional arrangements that were established. Some of the more interesting developments that have occurred in the service delivery area have emerged largely from unplanned responses to the reforms rather than by design. New Zealand's experiences illustrate that, unless due cognizance is taken of the norms and values of those working within a system, structural change is unlikely to bring about the expected responses, nor achieve the desired outcomes. Given the high cost of reform, incremental change, which aims to tackle specific issues, may be a more cost-effective means of securing the desired results.     

From home to hospital and back again: economic restructuring,end of life,and the gendered problems of place-switching health services

Economic restructuring in the health services industry in the USA exemplifies general patterns of economic change propelled by neoliberalism, especially industry privatization, diminished social services, and dependence on "flexible" labor and management regimes. Combined with the widespread entry of women into the labor force, an aging population, and minimal assistance for high quality long-term care at the end of life, these economic and social conditions raise a set of difficult policy questions for health services planning. Set in these broad contexts, this paper situates access to and experience of health services in the home, the hospital, and nursing facility, to demonstrate how economic changes have relocated and redefined health services in ways that distinctively impact how people experience the places where they receive care. This place switching of health services externalizes costs of subacute and "daily life care" (the so-called custodial care) to the sphere of the individual, their family, and communities. The theoretical analysis uses current geographical and philosophical approaches to place and space, and considers the tensions between institutionally managed health care space, and the patient's experience of receiving health services in place. The place/space dilemma of health services provision is examined through several interrelated subjects: long-term care at the end of life, gendered characteristics of care giving, the limitations of Medicare and Medicaid, historical changes in hospital length of stay, the restructuring of nursing practices, and the "no-care zone". The analysis is based on examples of stroke and incontinence care to demonstrate the importance of considering place and space issues in health care planning.     

Social work and health restructuring in Canada and Finland

The health care systems in Canada and Finland are currently in the process of restructuring. Responsibility for care has increasingly shifted to ill persons themselves and to their families and friends. Reduced hospital stays, service privatization and user fees have been implemented to some degree in both countries. These changes are reverberating throughout Finnish and Canadian societies, affecting not only users of health care but also the labour force in health workplaces. Health social workers, at the front line with clients, have experienced new issues which have impacted on their practice with ill persons and their families. In an environment of health care restructuring, they have needed to draw upon their repertoires of knowledge, skills and community networks in order to respond. At the same time, social workers noted that there is a leaner package of health and social service benefits to support patients and families. Social workers have tried to adapt and find new opportunities to practice social work in the changed environment. This small study, initially conducted as a pilot for a larger study, compared the experiences of social workers in Canada and Finland and the perceived impacts of health restructuring on their clients. The findings, seen within the context of changing societal and institutional environments, can help us to better understand some of the impacts of health restructuring on social work and social workers in hospitals and local health centres. Indirectly and directly, these changes also affect clients in the health care system, those whose needs remain uppermost in the delivery of social work services.     

South African Academic Health--the future challenge

In South Africa, significant changes in Academic Health have taken place since the first democratic elections in 1994. Academic Health came from a separated academic hospital, departmental-based curriculum and research focussed on achievement, and an abundance of money, to a position of integrated service delivery with specific reference to primary health care, separation of service levels, a new integrated curriculum, research focussed according to the need and contract research, and financial constraints with limited budgets. The management of this change is a task challenging the manager in all fields of Academic Health. Leaders need to know their environment and organisation to be able to manage change. Academic Health centres are experiencing major changes as a result of the effects of managed care, reduced rate and growing expenditure on health services. In addition to restructuring of the clinical services, Academic Health centres are being challenged to sustain their academic mission and priorities in the face of resource constraints. In order to tackle these challenges, institutions need physicians in administrative positions at all levels who can provide leadership and thoughtful managerial initiatives. The future challenge for managers focuses on service delivery, research, health education and training, Academic Health management, professionalism and financial management.     

Health policy reform in the People's Republic of China

With very limited resources, China has developed perhaps the world's largest network of health care services. The health status of its peoples has risen dramatically during the past 40 years. The reasons for these achievements are complex and include an ideology of equity for all citizens, the near universal availability of adequate food, education, housing, jobs, and transport, and the universal availability of accessible and affordable treatment and preventive health services. Despite these achievements China is facing new problems. These include the aging of the population, continued growth of the population leading to ever increasing demands on all sectors of the economy including health services, urban-rural inequalities, low productivity in the health services, lack of legal safeguards for health protection, a continued burden of infectious and endemic diseases, weak infrastructure for prevention and primary health care, and an increasing burden of chronic diseases associated with tobacco smoking and atherosclerotic circulatory diseases and trauma due to traffic accidents and occupational hazards. Decentralized management, financial incentives for health workers, privatization of medical practitioners, health legislation, and changes to health insurance arrangements have been introduced as a means of addressing the issues. The outcomes have been uneven, with little or no improvements in some problems and good progress in others. Changes in the health system appear to be reflecting not only health reform measures but also general economic reforms.     

Mandated human services restructuring: a case study in local collaboration from Colorado

The Colorado State Legislature has undertaken an historic restructuring of human services ranging from child welfare, mental health, and nursing services to substance abuse prevention, institutionalization, and health care financing. Significant steps in this process include an overhaul of child welfare legislation, major revisions to legislation affecting group health insurance policies, and a restructuring of the state departments that provide human services. A Democratic Governor and a Republican-dominated legislature have worked together hand-in-hand, although not always harmoniously, in moving these changes forward. This article examines the statewide restructuring of human services in a case study of how the local planning process was carried out in one region of Colorado. A highlight of the case study is the Working Together survey administered to participants of the planning committee midway through the process and again after the Local Area Plan was developed. In addition, lessons are presented from the process instructive for others considering whether to undertake significant organizational restructuring. The lesson section focuses on the local area planning process and how Colorado may have designed and facilitated a more effective process.     

Use of business planning methods to monitor global health budgets in Turkmenistan

After undergoing many changes, the financing of health care in countries of the former Soviet Union is now showing signs of maturing. Soon after the political transition in these countries, the development of insurance systems and fee-for-service payment systems dominated the discussions on health reform. At present there is increasing emphasis on case mix adjusted payments in larger hospitals and on global budgets in smaller district hospitals. The problem is that such systems are often mistrusted for not providing sufficient financial control. At the same time, unless further planned restructuring is introduced, payment systems cannot on their own induce the fundamental change required in the health care system. As described in this article, in Tejen etrap (district), Turkmenistan, prospective business plans, which link planned objectives and activities with financial allocations, provide a framework for setting and monitoring budget expenditure. Plans can be linked to the overall objectives of the restructuring system and can be used to ensure sound financial management. The process of business planning, which calls for a major change in the way health facilities examine their activities, can be used as a vehicle to increase awareness of management issues. It also provides a way of satisfying the requirement for a rigorous, bottom-up planning of financial resources.     

Integrating MCH/FP and STD/HIV services: current debates and future directions

The issue of integrating MCH/FP and STD/HIV services has gained an increasingly high priority on public health agendas in recent years. In the prevailing climate of health sector reform, policy-makers are likely to be increasingly pressed to address the broader concept of "reproductive health' in the terms consolidated at the Cairo International Conference on Population and Development, and the UN Conference on Women in Beijing. Integrated MCH/FP and STD/HIV services could be regarded as a significant step towards providing integrated reproductive health services, but clarity of issues and concerns is essential. A number of rationales have emerged which argue for the integration of these services, and many concerns have been voiced. There is little consensus, however, on the definition of "integrated services' and there are few documented case studies which might clarify the issues. This paper reviews the context in which rationales for "integrated services' emerged, the issues of concern and the case studies available. It concludes by suggesting future directions for research, noting in particular the need for country-specific and multi-dimensional frameworks and the appropriateness of a policy analysis approach.     

The public and private sectors in health: economic issues

Major changes in the public/private mix of health services are occurring in many countries. These changes may be analysed by examining the financing and provision of services and subsidization of the purchase of the factors of production. The public sector and not-for-profit and for-profit elements of the private sector must be viewed as separate entities in such analyses due to their differing objectives, motives and form of operation. The issues to be dealt with by countries in finding the public/private mix which is appropriate for their health system and achieves their objectives include efficiency, quality, regulation, equity and consumer choice and satisfaction. The recommendations for action for countries include: promoting collaboration between private and public sectors; testing different public/private mix models; identifying appropriate expansion paths for private sector services; improving information for policy and planning decisions; enhancing management capacity; and, reviewing programme and project support. International agencies also have a role in this process by supporting countries through the provision of technical assistance, financial aid, promoting policy reviews, and facilitating the sharing of information and experiences among countries concerning these public/private mix issues.     

'It makes me want to run away to Saudi Arabia': management and implementation challenges for public financing reforms from a maternity ward perspective

Poor practice by health care workers has been identified as contributing to high levels of maternal mortality in South Africa. The country is undergoing substantial structural and financial reforms, yet the impact of these on health care workers performance and practice has not been studied. This study, which consisted of an ethnography of two labour wards (one rural and one urban), aimed to look at the factors that shaped everyday practice of midwives working in district hospitals in South Africa during the implementation of a public sector reform to improve financial management. The study found that the Public Financing Management Act, that aimed to improve the efficiency and accountability of public finance management, had the unintended consequence of causing the quality of maternal health services to deteriorate in the hospital wards studied. The article supports the need for increased dialogue between those working in the sexual and reproductive health and health systems policy arenas, and the importance of giving a voice to front-line health workers who implement systems changes. However, it cautions that there are no simple answers to how health systems should be organized in order to better provide sexual and reproductive health services, and suggests instead that more attention in the debate needs to be paid to the challenges of policy implementation and the socio-political context and process issues which affect the success or failure of the implementation.     

Community and long-term facility care in Canada

By 1969, federal/provincial agreements had resulted in universally-insured access to hospital and medical services for all Canadians. In the absence of similar agreements for community and long-term care, each province has designed, implemented, and modified its own policies and programs during the last three decades. However, the communal values and the universal access to hospital and medical services which underpinned the national health plan influenced these policies and programs. Over time, the provincial programs have become more similar to each other but significant differences remain. However, all the provincial programs combine the assessment and delivery of short- and long-term community care and almost all combine the assessment of need for community care with that for long-term facility care placement. This article examines the development and changes in the community care and long-term facility care sectors in Canada over the recent past. Despite financial constraints which have resulted in the downsizing of hospitals and reductions in the ratio of long-term beds to the population aged 75 and over, community care budgets have increased substantially during this time. The article also discusses the major issues now confronting Canadian policy-makers and planning in regards to these programs and explores the potential impact of factors such as changes in funding and the organization and delivery of other health care services on long-term care.     

Maternal health services--the developing world

Women in developing nations run 100 to 200 times the risk of dying in pregnancy and childbirth compared to women in affluent countries. The vast majority of these deaths are preventable. We examine 3 models of health development for their potential impact on maternal mortality. Although universal primary maternal health care would be ideal, resource limitations render its implementation impractical in many regions. The nonavailability of transport and referral services limits the impact of community-based programs. Selective primary health interventions have some role, but more costly and complex services are required to deal with hemorrhage, the complications of illegal abortion and to provide operative deliveries. Public health workers should focus on intersectoral programs at the community level which mobilize women around health issues. Sustainable development has the greatest potential to produce lasting changes in the risks of childbearing.     

Managing competition in the countryside: Non-profit and for-profit perceptions of long-term care in rural Ontario

This paper contributes to the current debates surrounding private delivery of health care services by addressing the distinctive challenges, constraints and opportunities facing for-profit and non-profit providers of long-term care in rural and small town settings. It focuses on the empirical case of Ontario, Canada where extensive restructuring of long-term care, under the rubric of managed competition, has been underway since the mid-1990s. In-depth interviews with 72 representatives from local governments, public health institutions and authorities, for-profit and non-profit organisations, and community groups during July 2003 to December 2003 form the platform for a qualitative analysis of the implications of managed competition as it relates to the provision of long-term care in the countryside. The results suggest that the introduction and implementation of managed competition has accentuated the problems of service provision in rural communities, and that the long-standing issues of caregiving in rural situations transcend the differences, perceived or otherwise, between for-profit and non-profit provision. Understanding the implications of market-oriented long-term care restructuring initiatives for providers, and their clients, in rural situations requires a re-focussing of research beyond the for- versus non-profit dichotomy.     

The New Zealand experience: integrating management development into a rapidly changing health system

New Zealand has seen sweeping changes in recent years in its economic and social policies. Central to these has been the concept of better management in all phases of government activity with an emphasis upon performance, outcomes, and efficiency in achieving economic and social goals. There has been a massive reform of the health sector with restructuring of the Department of Health, devolution of most health delivery responsibilities to fourteen geographically defined area health boards, and the implementation of the principle of general management throughout the system. National health goals have been formulated to be implemented largely through area health boards. These developments have had important effects on educational programs in health services management, public health, and health policy. Collaboration through a New Zealand network of providers has been developed and a rapid growth in those seeking education and training programs has occurred. Education and training inputs are seen to be a major factor in the successful implementation of the major transformational change in New Zealand health systems.     

Co‐located welfare advice in general practice: A realist qualitative study

General practitioners (GPs) engage with patients about a variety of social issues distinct from direct clinical work (“non‐health” issues), such as health‐related benefits and debt. Co‐located welfare advice services could provide support to practices but have usually been considered in terms of patient rather than practice outcomes. We aimed to develop an initial programme theory for how the provision of co‐located advice supports specific practice outcomes, and to identify salient barriers and enabling factors. Twenty‐four semi‐structured interviews with general practice staff, advice staff and service funders in two UK urban localities were conducted between January and July 2016. Data were thematically analysed and a modified Realist Evaluation approach informed the topic guide, thematic analysis and interpretation. Two outcomes are described linked to participant accounts of the impact of such non‐health work on practices: reduction of GP consultations linked to non‐health issues and reduced practice time spent on non‐health issues. We found that individual responses and actions influencing service awareness were key facilitators to each of the practice outcomes, including proactive engagement, communication, regular reminders and feedback between advice staff, practice managers and funders. Facilitating implementation factors were: not limiting access to GP referral, and offering booked appointments and advice on a broader range of issues responsive to local need. Key barriers included pre‐existing sociocultural and organisational rules and norms largely outside of the control of service implementers, which maintained perceptions of the GP as the “go‐to‐location”. We conclude that co‐location of welfare advice services alone is unlikely to enable positive outcomes for practices and suggest several factors amenable to intervention that could enhance the potential for co‐location to meet desired objectives.     

Expanding contraceptive choice: findings from Brazil

This article presents findings from a participatory action research project in a municipality in southern Brazil that models a new and holistic approach to broadening women's contraceptive choices. The project encourages a collaborative process between researchers, community members, and public health managers to diagnose service-delivery problems, to design and implement interventions, and to evaluate their effectiveness. Findings from the baseline evaluation revealed major constraints in availability of and access to family planning and reproductive health services for women, as well as severe deficiencies in quality of care. Interventions designed to address these weaknesses, bound by the limited resources of the public sector, focused on training, restructuring of providers' roles and service-delivery patterns, the management process, the creation of a referral center, and the introduction of injectables, vasectomy services, and a program for adolescents. Evaluation results show the project's considerable impact in broadening reproductive options, although not all issues, especially those related to sustainability, have been resolved.     

Unhealthy European health policy.

The European Union claims that the defense of its welfare state is one of today's most important challenges. This article analyzes whether the European governments and the European Union really pursue a policy that strengthens their health and social security systems, or one that is in itself a threat to health and social security. After a summary of the origin and evolution of the European health systems, the authors pinpoint underlying reasons for reform and demonstrate how, since the 1990s, the European Union has built a strict financial and political straitjacket, forcing these systems to carry out privatization and cutbacks. Reform measures can be divided into three interdependent categories: (1) the increasing influence of governments on health care organization, to enable restructuring; (2) measures aimed at reducing public expenses, including higher financial contributions by patients and restrictions on the range of services provided; and (3) measures that establish competition and hidden or open privatization of services and insurance systems. Through these mechanisms public expenses are reduced while private health care expenses (and private profits) rise freely. Ongoing European health care reforms thus struggle with the contradictions between responding to growing collective needs and securing or increasing private profits.     

Informal and formal health care systems for the rural elderly.

The preceding sections have been an attempt to touch on a broad spectrum of issues related to the health care of older persons living in the rural United States. This article was intended to be an overview of research issues and, as a consequence, we have been unable to go into great depth in any one area of inquiry; we have certainly not included all of the research questions on areas where present knowledge is incomplete. In broad terms, we suggest that future rural health services research on the elderly be concentrated on the following five major categories of inquiry: --A better understanding of the location and distribution of the elderly in rural America --A better understanding of the life conditions affecting the health of the rural elderly --A better understanding of the health status of the rural elderly --A better understanding of the development, delivery, and impact of health services for the rural elderly, and --A better understanding of the methodological and theoretical difficulties of studying the health and health care of the rural elderly.