Trends in rural fiscal decentralisation in India’s Karnataka state: a focus on public health

For decades, decentralisation reforms have been seen as a powerful instrument by health policy advocates to improve health sector performance in developing countries. In India, the 73rd Constitutional Amendment introduced in 1992 called for strengthening the fiscal autonomy and service delivery capacity of rural local governments. This paper explores how decentralised governance influences public health sector resource allocation, equity and efficiency in rural Karnataka. For this, the authors analysed administrative data published by the Karnataka state government to create tailored standardised performance measures that capture the degree of local governments’ fiscal discretion in implementing public health programmes from 2011–18 at the district level. The findings highlight sector-specific differences in fiscal autonomy, ranging from high local discretion over funds in the nutrition sector to very limited discretion in the medical and public health sector. They also show that decentralised public health funding is not well-targeted to areas of greatest need in Karnataka

Activity-Based Costing and Inter-District Flows in the New Zealand Public Health Sector

<p>Changes in the New Zealand public health sector in recent years, such as heightened political, economic and social pressures to manage and reduce costs while improving the quality of care in conjunction with stringent health care guidelines, have forced district health boards (DHB) nationwide to reassess their approach to health care provision. This has chiefly involved evaluating current practices or institutions; revising health care systems, including locality of treatment; and assessing established accounting systems and mechanisms (or lack thereof) to understand the source of costs and resource consumption. Acknowledging that patient welfare has always held pre-eminence in the New Zealand public health sector, balancing the dual pressures to enhance the utilisation of limited resources and adhere to social pressures to provide sustained high quality health services has been a difficult exercise for DHBs. In recognition of the potential benefits of activity-based costing (ABC), and the fact that the New Zealand public health sector is severely underrepresented in current literature, this multi-site case study examines how sophisticated costing systems (such as ABC), are being used by DHBs. Using an institutional theory framework, this study posits that DHBs will use sophisticated costing systems to (1) improve cost understanding with the goal of managing and reducing their costs; and (2) contribute to more informed National Prices for Inter-District Flows (IDF), the aim of which is to plan and provide services to meet the directives and outcomes outlined by the Ministry of Health. Overall, the findings are compelling and reveal that costing systems are used on three levels to plan and provide health services, including unsophisticated costing systems that are not formally recognised; moderately sophisticated costing systems (such as CostPro) that are formally recognised; and sophisticated costing systems (such as PPM) that are formally recognised. Furthermore, the findings reveal that DHBs with sophisticated costing systems generate event-level information, which directly influences the calculation of National Prices for IDFs. The findings of this exploratory study also indicate a need to examine the nexus between ABC and IDFs in a New Zealand public health sector context further.</p>

Activity-Based Costing and Inter-District Flows in the New Zealand Public Health Sector

<p>Changes in the New Zealand public health sector in recent years, such as heightened political, economic and social pressures to manage and reduce costs while improving the quality of care in conjunction with stringent health care guidelines, have forced district health boards (DHB) nationwide to reassess their approach to health care provision. This has chiefly involved evaluating current practices or institutions; revising health care systems, including locality of treatment; and assessing established accounting systems and mechanisms (or lack thereof) to understand the source of costs and resource consumption. Acknowledging that patient welfare has always held pre-eminence in the New Zealand public health sector, balancing the dual pressures to enhance the utilisation of limited resources and adhere to social pressures to provide sustained high quality health services has been a difficult exercise for DHBs. In recognition of the potential benefits of activity-based costing (ABC), and the fact that the New Zealand public health sector is severely underrepresented in current literature, this multi-site case study examines how sophisticated costing systems (such as ABC), are being used by DHBs. Using an institutional theory framework, this study posits that DHBs will use sophisticated costing systems to (1) improve cost understanding with the goal of managing and reducing their costs; and (2) contribute to more informed National Prices for Inter-District Flows (IDF), the aim of which is to plan and provide services to meet the directives and outcomes outlined by the Ministry of Health. Overall, the findings are compelling and reveal that costing systems are used on three levels to plan and provide health services, including unsophisticated costing systems that are not formally recognised; moderately sophisticated costing systems (such as CostPro) that are formally recognised; and sophisticated costing systems (such as PPM) that are formally recognised. Furthermore, the findings reveal that DHBs with sophisticated costing systems generate event-level information, which directly influences the calculation of National Prices for IDFs. The findings of this exploratory study also indicate a need to examine the nexus between ABC and IDFs in a New Zealand public health sector context further.</p>

Appraising the Implementation of Complexity Approaches Within the Public Health Sector in Scotland. An Assessment Framework for Pre-Implementation Policy Evaluation

Complexity approaches have gained international attention as potentially effective strategies to address population health challenges. In light of this, the Scottish government (Scot. Gov.) set the implementation of these approaches as the recommended practice for its public health sector organizations. This study evaluates the opportunity and feasibility of implementing complexity approaches in public health Scotland employees' everyday routine by employing a qualitative study that involves 20 stakeholders, representative of different organizations and roles. We made use of an assessment framework based on Soft Systems Methodology (SSm) and Normalization Process Theory (NPT) comprised of five phases: Phase One defines the boundaries, aims, and goals of the issue under study; Phase Two consists of data collection, drawing on the e-Health Implementation Toolkit (e-HIT); Phase Three involves short presentations and breakout group activities to provide information on the new policy; Phase Four employs system thinking tasks to structure debate and builds shared understanding among participants; Phase Five applies NPT to appraise the organizational position around complexity based on information from the preceding steps. We found two main obstacles to implementing complexity approaches: (1) a lack of a shared understanding of the key concepts in complexity and their practical implications; (2) stakeholders' fear of significant disruption to work routines and power relationships. We recommend addressing these issues with appropriate training and customization of goals and tools that may enable complexity approaches to succeed within the Scottish public health context. Our assessment framework allows the recognition of key mechanisms to support how Scotland's Public Health body can enhance the implementation of complexity approaches. The appraisal framework could be used to study early-stage policy implementation in other contexts.

Impact of government budget deficits on public health sector output in Nigeria

The study examined the impact of government budget deficits on the public health sector output in Nigeria over a period of 1980 to 2018. The specifically study sought to: investigate the impact of government budget deficits affect the public health sector output in Nigeria, ascertain the impact of external borrowing on the public health sector output in Nigeria and evaluate the impact of domestic borrowing budget deficits financing on the public health sector output in Nigeria. The methods of data analysis range from argument dickey fuller unit root test, Johansen co-integration test and finally error correction method. The following results were the basic findings of the study: (1) government budget deficits have positive insignificant impact on public health sector output in Nigeria (t – statistics (0.5663) < t0.05 (1.684); (2) external borrowing of financing budget deficits has negative insignificant impact on Health sector output in Nigeria (t – statistics (-1.2746) < t0.05 (1.684) and (3) domestic borrowing of financing budget deficits has positive significant impact on Health sector output in Nigeria (t – statistics (2.1711) > t0.05 (1.684). This study concludes that the budget deficits of government have positive insignificant impact on Health sector output in Nigeria because more budget allocations are put in health recurrent government expenditure than health capital expenditure whereas health capital expenditure is the engine of growth in health sector output. The study recommended that the Federal Government should commence and continue to execute the National Health Act. Allocation’s map-out for the Basic Health Care Provision Fund (BHCPF) should be drawn directly from the National Health Act, which is not less than 1% of the Consolidated Revenue (CRF) Fund of the Federation and is to flow from the FG's share of revenue.