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商品の説明
内容説明
Health systems in low- and middle-income countries: an economic and policy perspective outlines the key aspects and issues concerning health systems of low- and middle-income countries, recognising the current global context within which these systems operate and the dynamics of this context. It brings together a set of renowned authors to tackle the issues that face population health and health care in the twenty-first century. The focus is predominantly low- and middle-income countries, with a distinct meeting of economic and policy perspectives, and grounding analysis of key issues within the broader international context. The book therefore provides a unique and comprehensive analysis of health systems, with a very different and unique 'flavour' in the field. It should have wide appeal to those engaged in health and health care, including health professionals, researchers and students, as well as those outside traditional health professions but with increasing interest within health issues, such as trade policy makers, researchers and students.
著者について
Richard Smith has been a Health Economist for some 20 years, following undergraduate and postgraduate studies in economics at the University of York. Upon leaving York in 1991, he worked in Sydney, Cambridge, Bristol, Melbourne and Norwich, before joining the School in May 2007. He is also an Honorary Professor of Health Economics at the Universities of Hong Kong and East Anglia, and is an Associate Fellow at The Royal Institute of International Affairs, Chatham House.
Richard has worked in a number of areas of health economics, most recently upon developing the application of macro-economics to health, the economics of globalization and health, and aspects of trade in health goods, services, people and ideas. His current interests are broadly in the interaction and interface between a nation's health system and other systems - both within the nation (e.g. tourism, travel and leisure sectors) and between different countries (e.g. through movement of health professionals).
Kara Hanson received degrees from McGill University, the University of Cambridge and Harvard University, and has worked at the London School of Hygiene since 1997. She has over 20 years' experience in the field of health economics, combining research and policy advice at the country and international levels.
Kara's research has focused mainly on the economics of financing and organising health services in low- and middle-income countries. She has particular interests in the private sector and the role it can play in expanding coverage of essential health interventions, especially in the supply of malaria treatment and prevention. She has also made contributions in the areas of human resources, health financing, and the economics of hospitals. She is co-Research Director of a health systems research consortium funded by the UK Department for International Development, and leads a number of multi-country research programmes in the economics of malaria.
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Health Systems in Low- and Middle-Income Countries: An Economic and Policy Perspective
2012/5/31
形式:ペーパーバック
The articles in this volume, edited by Richard D. Smith and Kara Hanson, use the tools of political economy to analyze health system performance. The exposition is aimed at non-specialists, and the chapter endnotes include useful citations to the literature. Many of the articles have an exploratory or pioneering quality, and the reader feels the excitement of walking on new ground. On the other hand, the quality of the articles is quite uneven, and a few of the tables and charts were carelessly prepared. Brief comments on the individual articles are provided below.
Chapter 1 What is a "Health System"? (R. Smith and K. Hanson)
This chapter provides an introduction to health systems, including health sector organizations, political and economic institutions, and global flows of capital and technology. It introduces some aspects of "systems thinking": "loop thinking," which conceptualizes causality as an ongoing event with feedback loops, rather than as a linear, one-time occurrence; and a focus on adaptive actors who change their behavior by learning from previous outcomes.
Chapter 2 Health Systems and Institutions (L. Gilson)
This article surveys five health system frameworks or models, which can be distinguished by their scope and approach. Those with a narrow scope focus more exclusively on health sector organizations: that is, organizations whose primary purpose is to improve health status. Those with a wider focus include other political and economic institutions such as households and regulatory bodies. Those with an inventory approach aim primarily to identify or list health system components. Those with a relational approach focus more attention on how components interact and influence one another. [After reading all of the articles in the volume, one sees that much more is known about system components than about the causal relationships between them: investigating causes is where the action is for researchers.]
The article then surveys wider organizational and systems theory that can be applied to health systems. Gilson distinguishes three views of organizational behavior:
* Mechanical - Assumes that people follow rules and procedures in a predictable way. Reform is approached through restructuring, decentralization, etc.
* Economic - People are self-serving and individualistic. They respond to incentives and other market-oriented reforms.
* Socio-cultural - Individual behavior is influenced by social ties. Institutional control and reform efforts are based on norms and values.
Chapter 3: Measuring and evaluating performance (E. Nolte and M. McKee)
This chapter surveys a number of health systems performance indicators and performance measurement frameworks. Performance measurement gets a lot of attention, but it is a recent innovation, and there is not a large body of evidence showing that performance measurement produces better outcomes. At the same time, performance measurement is a costly undertaking that takes resources away from provision of health services. So both costs and benefits of performance measurement systems need to be weighed.
Chapter 4: Revenue collection and poling arrangements in financing (D. McIntyre and J. Kutzin)
Health financing systems have three functions:
* Revenue collection.
* Pooling. (Risk pooling reduces uncertainty of health expenditures and can subsidize health care for the poor and for relatively unhealthy individuals.)
* Purchasing.
The central argument of the chapter is that "... in order to achieve equitable, efficient, and sustainable universal coverage, it is necessary to reduce fragmentation between funding pools. From an equity perspective, there is wide agreement that individuals and households should contribute to funding healthcare according to their ability to pay, and should benefit from health services according to their need for healthcare. This requires that the health systems promotes both income and risk cross-subsidies, from the healthy to the poor and the healthy to the ill respectively." (p. 78)
Chapter 5: Delivering health care services: incentives and information in supply-side innovations (K. Hanson)
This chapter discusses principal-agent theory and informational asymmetries in the health field. Principal-agent theory suggests that principals (who contract for services) and agents (who provide them) may not have the same interests; since it is costly for principals to monitor the performance of agents, agents will to some degree advance their own interests over the interests of the principals who hire them. According to Hanson, informational asymmetries arise because health outcomes are difficult to measure, the mechanisms through which inputs are transformed into outcomes (e.g., "health") is poorly understood, and health care providers have better knowledge of the need for health services and their quality than consumers. These informational asymmetries, in light of principal-agent theory, suggest that health care providers appropriate more resources for their use than they could obtain in purely competitive markets.
Chapter 6: Human resources and the health sector (B. McPake)
McPake focuses on the role that international migration of health professional plays in depleting the health care work force in developing countries, but she provides relatively little information on the magnitude of the problem. She suggests that low-income countries work on "push" factors influencing migration (e.g., low pay, poor working conditions, lack of complementary resources, limited career opportunities, and general societal conditions [poor educational opportunities for children, political and economic instability, high unemployment, and violence]). She suggests that high income countries compensate low-income countries for their loss of investment in training when health workers emigrate, but there are no examples are given where high-income countries have agreed to do this. [Aid flows, however, help compensate for these losses.]
Chapter 7: Pharmaceuticals and the health sector (P. Yadav, R. Smith, and K. Hanson)
Very large, risky investments in product development are required in the pharmaceutical industry, and investors demand correspondingly high returns. Market potential is correlated with investment but disease burden is not. Attempts to correct these market failures include product development partnerships (partnerships between profit and non-profit organizations to develop drugs for neglected diseases), advance market commitments, orphan drug acts (tax credits and other incentives for drugs with limited market potential), and priority review vouchers (which allow manufacturers to request expedited safety and efficacy reviews).
I was surprised to read that "there is a clear conflict between TRIPS [the Trade-Related Aspects of Intellectual Property Rights agreements] and public health; by their nature, the monopoly rents afforded by patents are reflected in the final product's pricing, acting as a barrier to affordability." (p. 165) Yes, medicines under patent are more expensive than generic medicines. But if there was less protection for intellectual property, what would happen to investment in R&D? And how would that affect public health?
Chapter 8: The health system and international trade (R. Smith)
Smith focuses on negative consequences of cross-border flows: they increase communication of disease, marketing of unhealthy lifestyles, and environmental degradation through industrialization. But cross-border flows also increase the availability of funding to health systems in developing countries and provide new pharmaceuticals and technology.
Chapter 9 The health system and external financing (A. Vassall and M. Martinez-Alvarez)
This chapter surveys a number of issues associated with aid to health sectors in developing countries: absorptive capacity, fragmentation of assistance programs, unpredictability of aid flows, and weak governance.
Chapter 10 The health system and wider social determinants of health (R. Loewenson and L. Gilson)
In large part, this chapter is a critique of economic and political inequality and a discussion of how those inequalities lead to inequality in health outcomes.
Chapter 11 The health system and global changes (R. Smith)
This is an overview of how changes in demographics, global governance, the environment, and technology will impact on the health sector and health outcomes.
Chapter 12 Global health diplomacy: the "missing pillar" of health system strengthening (R. Smith and K. Hanson)
This chapter argues that health system strengthening in developing countries has neglected development of negotiation skills and advocacy for the involvement of health professionals in international negotiations.
In sum, this book adds value by drawing attention to relationships between the health sector and other political and economic institutions: it thus provides a wider perspective than the mainstream health literature, which focuses on the health sector more narrowly. Some of the authors are a little bit strident in advancing their views, but they are careful to distinguish between opinion and evidence, which is in short supply in this young field. There is a lot of work to be done here.
Chapter 1 What is a "Health System"? (R. Smith and K. Hanson)
This chapter provides an introduction to health systems, including health sector organizations, political and economic institutions, and global flows of capital and technology. It introduces some aspects of "systems thinking": "loop thinking," which conceptualizes causality as an ongoing event with feedback loops, rather than as a linear, one-time occurrence; and a focus on adaptive actors who change their behavior by learning from previous outcomes.
Chapter 2 Health Systems and Institutions (L. Gilson)
This article surveys five health system frameworks or models, which can be distinguished by their scope and approach. Those with a narrow scope focus more exclusively on health sector organizations: that is, organizations whose primary purpose is to improve health status. Those with a wider focus include other political and economic institutions such as households and regulatory bodies. Those with an inventory approach aim primarily to identify or list health system components. Those with a relational approach focus more attention on how components interact and influence one another. [After reading all of the articles in the volume, one sees that much more is known about system components than about the causal relationships between them: investigating causes is where the action is for researchers.]
The article then surveys wider organizational and systems theory that can be applied to health systems. Gilson distinguishes three views of organizational behavior:
* Mechanical - Assumes that people follow rules and procedures in a predictable way. Reform is approached through restructuring, decentralization, etc.
* Economic - People are self-serving and individualistic. They respond to incentives and other market-oriented reforms.
* Socio-cultural - Individual behavior is influenced by social ties. Institutional control and reform efforts are based on norms and values.
Chapter 3: Measuring and evaluating performance (E. Nolte and M. McKee)
This chapter surveys a number of health systems performance indicators and performance measurement frameworks. Performance measurement gets a lot of attention, but it is a recent innovation, and there is not a large body of evidence showing that performance measurement produces better outcomes. At the same time, performance measurement is a costly undertaking that takes resources away from provision of health services. So both costs and benefits of performance measurement systems need to be weighed.
Chapter 4: Revenue collection and poling arrangements in financing (D. McIntyre and J. Kutzin)
Health financing systems have three functions:
* Revenue collection.
* Pooling. (Risk pooling reduces uncertainty of health expenditures and can subsidize health care for the poor and for relatively unhealthy individuals.)
* Purchasing.
The central argument of the chapter is that "... in order to achieve equitable, efficient, and sustainable universal coverage, it is necessary to reduce fragmentation between funding pools. From an equity perspective, there is wide agreement that individuals and households should contribute to funding healthcare according to their ability to pay, and should benefit from health services according to their need for healthcare. This requires that the health systems promotes both income and risk cross-subsidies, from the healthy to the poor and the healthy to the ill respectively." (p. 78)
Chapter 5: Delivering health care services: incentives and information in supply-side innovations (K. Hanson)
This chapter discusses principal-agent theory and informational asymmetries in the health field. Principal-agent theory suggests that principals (who contract for services) and agents (who provide them) may not have the same interests; since it is costly for principals to monitor the performance of agents, agents will to some degree advance their own interests over the interests of the principals who hire them. According to Hanson, informational asymmetries arise because health outcomes are difficult to measure, the mechanisms through which inputs are transformed into outcomes (e.g., "health") is poorly understood, and health care providers have better knowledge of the need for health services and their quality than consumers. These informational asymmetries, in light of principal-agent theory, suggest that health care providers appropriate more resources for their use than they could obtain in purely competitive markets.
Chapter 6: Human resources and the health sector (B. McPake)
McPake focuses on the role that international migration of health professional plays in depleting the health care work force in developing countries, but she provides relatively little information on the magnitude of the problem. She suggests that low-income countries work on "push" factors influencing migration (e.g., low pay, poor working conditions, lack of complementary resources, limited career opportunities, and general societal conditions [poor educational opportunities for children, political and economic instability, high unemployment, and violence]). She suggests that high income countries compensate low-income countries for their loss of investment in training when health workers emigrate, but there are no examples are given where high-income countries have agreed to do this. [Aid flows, however, help compensate for these losses.]
Chapter 7: Pharmaceuticals and the health sector (P. Yadav, R. Smith, and K. Hanson)
Very large, risky investments in product development are required in the pharmaceutical industry, and investors demand correspondingly high returns. Market potential is correlated with investment but disease burden is not. Attempts to correct these market failures include product development partnerships (partnerships between profit and non-profit organizations to develop drugs for neglected diseases), advance market commitments, orphan drug acts (tax credits and other incentives for drugs with limited market potential), and priority review vouchers (which allow manufacturers to request expedited safety and efficacy reviews).
I was surprised to read that "there is a clear conflict between TRIPS [the Trade-Related Aspects of Intellectual Property Rights agreements] and public health; by their nature, the monopoly rents afforded by patents are reflected in the final product's pricing, acting as a barrier to affordability." (p. 165) Yes, medicines under patent are more expensive than generic medicines. But if there was less protection for intellectual property, what would happen to investment in R&D? And how would that affect public health?
Chapter 8: The health system and international trade (R. Smith)
Smith focuses on negative consequences of cross-border flows: they increase communication of disease, marketing of unhealthy lifestyles, and environmental degradation through industrialization. But cross-border flows also increase the availability of funding to health systems in developing countries and provide new pharmaceuticals and technology.
Chapter 9 The health system and external financing (A. Vassall and M. Martinez-Alvarez)
This chapter surveys a number of issues associated with aid to health sectors in developing countries: absorptive capacity, fragmentation of assistance programs, unpredictability of aid flows, and weak governance.
Chapter 10 The health system and wider social determinants of health (R. Loewenson and L. Gilson)
In large part, this chapter is a critique of economic and political inequality and a discussion of how those inequalities lead to inequality in health outcomes.
Chapter 11 The health system and global changes (R. Smith)
This is an overview of how changes in demographics, global governance, the environment, and technology will impact on the health sector and health outcomes.
Chapter 12 Global health diplomacy: the "missing pillar" of health system strengthening (R. Smith and K. Hanson)
This chapter argues that health system strengthening in developing countries has neglected development of negotiation skills and advocacy for the involvement of health professionals in international negotiations.
In sum, this book adds value by drawing attention to relationships between the health sector and other political and economic institutions: it thus provides a wider perspective than the mainstream health literature, which focuses on the health sector more narrowly. Some of the authors are a little bit strident in advancing their views, but they are careful to distinguish between opinion and evidence, which is in short supply in this young field. There is a lot of work to be done here.
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