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Biomedical subjects

L Gilson

Publications and source records attributed to L Gilson.

At least 19 recordsLinked to original sources
PubMed2002

Geographic patterns of deprivation in South Africa: informing health equity analyses and public resource allocation strategies.

There is a growing interest in the use of small area analyses in investigating the relationship between socioeconomic status and health, and in informing resource allocation decision-making. However, few such studies have been undertaken in low- and middle-income countries (LMICs). This paper reports on such a study undertaken in South Africa. It both looked at the feasibility of developing a broad-based area deprivation index in a data scarce context and considered the implications of such an index for geographic resource allocations. Despite certain data problems, it was possible to construct and compare three different indices: a general index of deprivation (GID), compiled from census data using principal component analysis; a policy-perspective index of deprivation (PID), based on groups identified as priorities within policy documents; and a single indicator of deprivation (SID), selected for relevance and feasibility of use. The findings demonstrate clearly that in South Africa deprivation is multi-faceted, is concentrated in specific areas within the country and is correlated with ill-health. However, the formula currently used by the National Treasury to allocate resources between geographic areas, biases these allocations towards less deprived areas within the country. The inclusion of the GID within this formula would dramatically alter allocations towards those areas suffering from human development deficits. The area in which analysis was undertaken was not, however, sufficiently small to identify pockets of deprivation within the less deprived metropolitan areas. These findings suggest that it is feasible to conduct small area analyses in LMICs but that specific attention needs to be given to the size of the geographic unit used in analysis. In addition, they highlight the importance of considering deprivation in resource allocation mechanisms if vertical equity goals are to be promoted through resource allocation, particularly within decentralized health systems.

Censuses↗
PubMed2001

Strategies for promoting equity: experience with community financing in three African countries.

Although the need for a pro-poor health reform agenda in low and middle income countries is increasingly clear, implementing such policy change is always difficult. This paper seeks to contribute to thinking about how to take forward such an agenda by reflection on the community financing activities of the UNICEF/WHO Bamako Initiative. It presents findings from a three-country study, undertaken in Benin, Kenya and Zambia in 1994/95, which was initiated in order to better understand the nature of the equity impact of community financing activities as well as the factors underlying this impact. The sustained relative affordability gains achieved in Benin emphasise the importance of ensuring that financing change is used as a policy lever for strengthening health service management in support of quality of care improvements. All countries, however, failed in protecting the most poor from the burden of payment, benefiting this group preferentially and ensuring that their views were heard in decision-making. Tackling these problems requires, amongst other things, an appropriate balance between central and local-level decision-making as well as the creation of local decision-making structures which have representation from civil society groups that can voice the needs of the most poor. Leadership, strategy and tactics are also always important in securing any kind of equity gain-such as establishing equity goals to drive implementation. In the experiences examined, the dominance of the goal of financial sustainability contributed to their equity failures. Further research is required to understand what equity goals communities themselves would prefer to guide financing policy.

Benin↗
PubMed2000

Redressing dis-advantage: promoting vertical equity within South Africa.

This paper represents the first attempt to apply vertical equity principles to the South African health sector. A vertical equity approach, which recognises that different groups have different starting points and therefore require differential treatment, appears to offer an appropriate basis for considering how best to redress the vast inequities which exist in post-Apartheid South Africa. Vertical equity principles are applied in critically analysing two areas of recent policy action which are particularly relevant to health sector equity in South Africa, namely public-private sector cross-subsidies and the allocation of government resources between provinces. Despite a strong political commitment to redressing historical inequities, recent government policy actions in these two areas appear to fall short of desirable goals when viewed through a vertical equity lens. In particular, policies since the first democratic elections in 1994 have done little to reduce the extent of government subsidies to the private health sector, which serves a minority of the population. In addition, recent proposals for a Social Health Insurance will allow minimal cross-subsidies between high- and low-income earners and would not adequately redress the currently inequitable public-private cross-subsidies. With respect to the allocation of government resources between provinces, a vertical equity approach would suggest that the most historically dis-advantaged provinces have an even greater claim on government resources than reflected in the current formula, as developed by the Department of Finance. This paper also considers the potential benefits of engaging with societal views in determining what constitutes dis-advantage in the South African context, in order to identify those who should receive priority in resource allocation decisions. It concludes with a review of a number of practical steps that can be taken to draw vertical equity principles into policy action.

Black or African American↗
PubMed2000

Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition.

This paper summarizes eight country studies of inequality in the health sector. The analyses use household data to examine the distribution of service use and health expenditures. Each study divides the population into "income" quintiles, estimated using consumption expenditures. The studies measure inequality in the use of and spending on health services. Richer groups are found to have a higher probability of obtaining care when sick, to be more likely to be seen by a doctor, and to have a higher probability of receiving medicines when they are ill, than the poorer groups. The richer also spend more in absolute terms on care. In several instances there are unexpected findings. There is no consistent pattern in the use of private providers. Richer households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicate that intuition concerning inequalities could result in misguided decisions. It would thus be worthwhile to measure inequality to inform policy-making. Additional research could be performed using a common methodology for the collection of data and applying more sophisticated analytical techniques. These analyses could be used to measure the impact of health policy changes on inequality.

Data Collection↗
PubMed1999

Health sector development: from aid coordination to resource management.

Aid coordination has assumed a prominent place on health policy agendas. This paper synthesizes the findings of research undertaken to explore the changing practices of aid coordination across a number of countries. It begins by reviewing the key issues giving rise to increased attention to aid coordination in the health sector. The second section describes, assesses and compares the strengths and weaknesses of the dominant mechanisms or instruments which were found to be employed to coordinate health sector aid in the case studies. From this analysis, four factors become clear. First, in many countries, coordination mechanisms have been introduced as a part of an incremental process of trying out different approaches--there is no one model that stands out at any one time. Secondly, some instruments function largely for consultation, predominantly coordinating inputs, while others are more directive and operational, and are used to manage inputs, processes and outputs. Third, many of the mechanisms have not excelled, although, fourth, it is difficult to judge the effectiveness or impact of aid coordination. It is therefore argued that concern with the effectiveness of aid coordination arrangements must give way to a broader analysis of the processes, outputs and outcomes governing the use of both external and domestic resources, focusing on institutional characteristics, the distribution and nature of influence among the actors, and the interests which they pursue through the aid regime. These factors varied considerably across the countries indicating that aid management is context dependent and subject to continuing changes. Finally, the paper looks at the findings in the light of the introduction of sector-wide approaches.

Budgets↗
PubMed1999

Small fish in a big pond? External aid and the health sector in South Africa.

Since a new government was elected in 1994, South Africa has become a favoured nation for the many bilateral and multi-lateral agencies providing aid to developing countries. Despite several relatively large pledges of 'transition support', however, external resources constitute less than 2% of the annual government budget. This non-dependence has established a degree of equilibrium in a relationship normally regarded as highly unequal in other African countries. Although international donors funded the antiapartheid movement in South Africa prior to 1994, the new government inherited a chaotic administration that had little institutional experience of conventional development aid. Many of the new cadres entering government had not been exposed to the workings of government, let alone donor, bureaucratic processes. It is not surprising, therefore, that in the first few years after 1994, the aid relationship was characterized by low disbursements, unrealistic expectations and a degree of conflict. Since 1997, however, aid supported projects have started to become more visible. Within the broad objective of supporting transformation of the health system, one of the key areas of donor support is managerial capacity development, particularly of district, hospital and provincial health structures. These initiatives tend to be poorly coordinated, a problem compounded by a quasi-federal system in which provinces have large amounts of autonomy. The contribution of donor aid to strengthening the health system could be enhanced by the establishment of a clear national framework to guide the many externally supported projects building managerial skills and systems.

Financing, Organized↗
PubMed1999

Managing external resources in the health sector: are there lessons for SWAps (sector-wide approaches)?

Drawing on the case studies presented in this issue, from Bangladesh, Cambodia, Mozambique, Zambia and South Africa, and examples from other countries, this paper asks what general conclusions can be drawn about the management of external resources, and specifically what lessons could inform the future implementation of sector-wide approaches (SWAps) in the health sector. Factors constraining the management of aid by ministries of health are grouped under three themes: context and timing, institutional capacities and the interplay of power and influence in negotiations over aid. Two factors, often underplayed, were found to be important in facilitating management of resources: the inter-relationship of formal and informal relationships, and the extent to which incremental changes are tolerated. The main conclusion is that coordination and management of external resources is inherently unstable, involving a changing group of actors, many of whom enjoy considerable autonomy, but who need each other to materialize their often somewhat different goals. Managing aid is not a linear process, but is subject to set-backs and crises, although it can also produce positive spin-offs unexpectedly. It is highly dependent on institutional and systemic issues within both donor and recipient environments. In promoting sector-wide approaches the key will be to recognize context-specific conditions in each country, to find ways of building capacity in ministries of health to develop and own the future vision of the health sector, and to negotiate a realistic package that is explicit in its agreed objectives. The paper ends with identifying crucial actions that will enable ministries of health to take the lead role in developing and implementing SWAps.

Developing Countries↗
PubMed1997

The lessons of user fee experience in Africa.

This paper reviews the experience of implementing user fees in Africa. It describes the two main approaches to implementing user fees that have been applied in African countries, the standard and the Bamako Initiative models, and their common objectives. It summarizes the evidence concerning the impact of fees on equity, efficiency and system sustainability (as opposed to financial sustainability), and the key bottlenecks to their effective implementation. On the basis of this evidence it then draws out three main sets of lessons, focusing on: where and when to implement fees; how to enhance the impact of fees on their objectives; and how to strengthen the process of implementation. If introduced by themselves, fees are unlikely to achieve equity, efficiency or sustainability objectives. They should, therefore, be seen as only one element in a broader health care financing package that should include some form of risk-sharing. This financing package is important in limiting the potential equity dangers clearly associated with fees. There is a greater potential role for fees within hospitals rather than primary facilities. Achievement of equity, efficiency and, in particular, sustainability will also require the implementation of complementary interventions to develop the skills, systems and mechanisms of accountability critical to ensure effective implementation. Finally, the process of policy development and implementation is itself an important influence over effective implementation.

Africa↗
PubMed1997

User fee policies to promote health service access for the poor: a wolf in sheep's clothing?

An international survey of health service user fee and exemption policies in 26 low- and middle-income countries assessed whether user fee policies were supported by measures that protect the poor. In particular, it explored whether governments were introducing a package of supportive measures to promote service improvements that benefit disadvantaged groups and tackle differential ability to pay through an effective series of exemptions. The results show that many countries lack policies that promote access for disadvantaged groups within user fee systems and quality improvements such as revenue retention at the health care facility and expenditure guidelines for local managers. More significant policy failures were identified for exemptions: 27 percent of countries had no policy to exempt the poor; in contrast, health workers were exempted in 50 percent of countries. Even when an official policy to exempt the poor existed, there were numerous informational, administrative, economic, and political constraints to effective implementation of these exemptions. The authors argue that user fee policy should be developed more cautiously and in a more informed environment. Fees are likely to exacerbate existing inequities in health care financing unless exemptions policy can effectively reach those unable to pay.

Africa↗
PubMed1996

Who should be doing what in the international health: a confusion of mandates in the United Nations?

Since 1945 at least five United Nations organisations have become substantially involved in international health activities. This has led to considerable confusion among policy makers, scholars, and UN staff over distinct and appropriate mandates. Interviews with staff an a historical analysis have shown that while formal mandates have been complementary, effective mandates have led to an unclear delineation of activities. The process of translating formal into effective mandates have been influenced by the decentralised nature of the UN, lack of a master plan for its activities, the considerable growth in the policy agenda and the shift towards a multisectoral approach to health. The identification of each organisation's comparative advantage, at both the global and country levels, is one way of understanding what each organisation does best and perhaps should be doing. There is a need for improved mechanisms to define effective mandates, taking into account comparative advantages, if the mandates of UN organisations are appropriate to meet future challenges in international health.

Global Health↗
PubMed1996

A triple burden for health sector reform: 'post'-conflict rehabilitation in Uganda.

While conflict continues to threaten health development in many countries, relative peace has been secured in others. The transition from war to peace carries important political and economic opportunities for the reappraisal of social policy in general, and of health policy in particular. The health systems of countries recovering from prolonged periods of conflict often carry a double burden: the inheritance of an inappropriate and unaffordable health system developed in the pre-conflict era, and the particular, long-term effects of conflict on health and health services. This paper reports on the particular policies designed to rehabilitate the Ugandan health system, and argues that they exacerbated, rather than alleviated, the health crisis inherited in 1986. In this way they posed a third burden. By analyzing the context and process of policy formulation in the immediate post-conflict period, it explores the rationale which lay behind the adoption of these policies and identifies potential strategies for strengthening policy development in these unstable, resource-poor and health-deprived situations.

Civil Disorders↗
PubMed1995

Management and health care reform in sub-Saharan Africa.

Recent discussions of health care reform in sub-Saharan Africa have centered on the potential of alternatives to public financing and provision of health care to address efficiency and resource weaknesses. This paper informs these discussions by reporting an overview of the findings of a detailed evaluation of the efficiency and quality of public and non government primary level health services in Tanzania, a sub-Saharan leader in health policy development since the 1960s and used here as an exemplar country for the region. The paper discusses the management actions necessary to address the performance weaknesses identified and considers the possible contribution alternative financing strategies might make in addressing the weaknesses. However, financing reforms will not by themselves address the performance failures; health care reform packages must allow for financing, organizational and management development.

Costs and Cost Analysis↗
PubMed1995

AinS and a new family of autoinducer synthesis proteins.

In Vibrio fischeri, the autoinducer N-3-oxohexanoyl-L-homoserine lactone (AI-1) governs the cell density-dependent induction of the luminescence operon via the LuxR transcriptional activator. The synthesis of AI-1 from bacterial metabolic intermediates is dependent on luxI. Recently, we found a second V. fischeri autoinducer molecule, N-octanoyl-L-homoserine lactone (AI-2), that in E. coli also activates the luminescence operon via LuxR. A locus independent of luxI was identified as being required for AI-2 synthesis. This 2.7-kb ain (autoinducer) locus was characterized by transposon insertion mutagenesis, deletion and complementation analysis, and DNA sequencing. A single 1,185-bp gene, ainS, was found to be the sole exogenous gene necessary for the synthesis of AI-2 in Escherichia coli. In addition, a V. fischeri ainS mutant produced AI-1 but not AI-2, confirming that in its native species ainS is specific for the synthesis of AI-2. ainS is predicted to encode a 45,580-Da protein which exhibits no similarity to LuxI or to any of the LuxI homologs responsible for the synthesis of N-acyl-L-homoserine lactones in a variety of other bacteria. The existence of two different and unrelated autoinducer synthesis genes suggests the occurrence of convergent evolution in the synthesis of homoserine lactone signaling molecules. The C-terminal half of AinS shows homology to a putative protein in Vibrio harveyi, LuxM, which is required for the synthesis of a V. harveyi bioluminescence autoinducer. Together, AinS and LuxM define a new family of autoinducer synthesis proteins. Furthermore, the predicted product of another gene, ainR, encoded immediately downstream of ainS, shows homology to LuxN, which is similarly encoded downstream of luxM in V. harveyi and proposed to have sensor/regulator functions in the bioluminescence response to the V. harveyi auto inducer. This similarity presents the possibility that AI-2, besides interacting with LuxR, also interacts with AinR under presently unknown conditions.

4-Butyrolactone↗
PubMed1995

The structural quality of Tanzanian primary health facilities.

Structural quality is a key element in the quality of care provided at the primary level, which aims to offer health care interventions of proven efficacy. This assessment of the structural quality of Tanzanian primary health services indicated serious weaknesses in the available physical infrastructure, as well as supervision and other support, both for government and nongovernmental services and for dispensary and first referral-level services. Addressing these weaknesses is likely to require some additional funding and review of the functions of different groups of health care facilities within the primary care system. Although district health management teams have an important role to play in tackling the weaknesses, the existing division of management responsibilities indicates that they can only do so with the support of the regional and national levels of the health management structure. Study methods might be adapted to facilitate improved supervision and management.

Catholicism↗
PubMed1994

Community satisfaction with primary health care services: an evaluation undertaken in the Morogoro region of Tanzania.

Satisfaction is an important element of the quality of health care, often determining patient willingness to comply with treatment and influencing the effectiveness of care. However, few specific assessments of patient satisfaction in developing countries have been undertaken. This paper presents findings from such a study, carried out in Tanzania and primarily undertaken through the use of qualitative interviewing techniques. The study illustrates the perceived problems of the care available, such as structural and inter-personal skill failings, both of which were seen to influence drug availability and maternal services--key weaknesses of the available care. Health centres were perceived to be little better than dispensaries. Although church health care was generally perceived to be better than government care, there was considerable variation in community judgements and clear signs of poor quality church care. The use of villagers' own words and experiences brought into sharp focus the problems they experience in relation to health care and allow planning lessons are identified.

Adult↗
PubMed1994

The potential of health sector non-governmental organizations: policy options.

Non-governmental organizations (NGOs) have increasingly been promoted as alternative health care providers to the state, furthering the same goals but less hampered by government inefficiencies and resource constraints. However, the reality of NGO health care provision is more complex. Not only is the distinction between government and NGO providers sometimes difficult to determine because of their operational integration, but NGOs may also suffer from resource constraionts and management inefficiencies similar to those of government providers. Some registered NGOs operate as for-profit providers in practice. Policy development must reflect the strengths and weaknesses of NGOs in particular settings and should be built on NGO advantages over government in terms of resource mobilization, efficiency and/or quality. Policy development will always require a strong government presence in co-ordinating and regulating health care provision, and an NGO sector responsive to the policy goals of government.

Delivery of Health Care↗