IHSP has been developing new approaches to analyzing the performance of health care through better
understanding of health care organization, with a particular focus on ambulatory care. Professor Berman is
collaborating with colleagues Profs. Hsiao, Roberts, and Reich at HSPH on a comprehensive approach to health
sector reform. This approach involves planning changes to five health system "control knobs" - one of which is
organization. Berman and Roberts have developed the concepts of "macro" and "micro" organization of health care,
as shown in the following figure:
Macro organization refers to the structure and functioning of the provider market, while micro organization
refers to the characteristics internal to health care providers, both individuals and larger providers like
Analyzing the organization of provision
IHSP has been developing new methods for analyzing the organization of health care provision, the first step
in designing and implementing reforms to change organization. Guidelines for the assessment of the role of
private health care providers, (Publication Link: DDM No. 9. Assessing the Private Sector: Using Non-Government
Resources to Strengthen Public Health Goals) were developed through USAID's Data for
Decision Making Project. They were used to carry out two national private health care assessments, one in
Kenya, (Publication Link: DDM No. 20. Kenya: Non-Governmental Health
Care Provision) and one in Zambia, (Publication Link: DDM No. 19, Zambia: Non-Governmental Health Care Provision). These studies showed that private providers are a major source of services for many important health
problems in African countries with diverse markets, like Kenya and that they are rapidly emerging in countries
where they have been banned, as in Zambia. A regional conference in Africa reviewed these and other studies and
called from much more systematic efforts in Africa to understand the emerging private sector and develop new
regulation and financing strategies in response, (Publication Link: DDM No. 21.1. Conference Report Summaries: Private Providers Contributions to Public Health in Four African
Countries, Nairobi, Kenya, November 28, 1994 - December 1, 1994).
A more comprehensive methodology has now been developed by Prof. Berman and applied in studies in Egypt and
Poland. In Egypt, an analysis at the national level of the organization of ambulatory care provision highlighted
the important role of private physician practices in meeting acute health care needs nationally. It also showed
that government hospitals play a larger role in ambulatory care services that government health centers and
clinics, despite the widespread development of these facilities in recent years, (Publication Link: DDM No. 82. Understanding the Supply Side: A Conceptual Framework for Describing and Analyzing the Provision of Health
Care Services With an Application to Egypt).
In Poland, a "provider market analysis" highlighted the large role now played by private providers in Krakow,
Poland's second largest city. This study also provided for the first time a comprehensive picture of the public
and private ambulatory care market, which will in the future be financed by Poland's new social health insurance
system, (Publication Link: DDM No.73. Provision of Ambulatory Health Services in
Poland: A Case Study from Krakow).
Other approaches to reforms in health care organization
IHSP researchers have also looked at the implementation of new organization strategies in developing
countries. A five country analysis (Kenya, Zimbabwe, India, Indonesia, and Ghana) of experience with giving
government hospitals greater autonomy showed that autonomy programs in lower income countries are difficult to
implement. Governments are often reluctant to provide true authority to hospitals in key areas like personnel
and function that would enable them to operate more efficiently and to be more responsive to community needs. (Publication Link: DDM No. 32-2. Recent Experiences with Hospital
Autonomy in Developing Countries -- What Can We Learn?). Dr. Paul Campbell of IHSP has also led an effort to
adapt managed care concepts to Zimbabwe's non-profit medical aid schemes, which are struggling with stagnant
finances and the rising costs associated with emerging diseases, (Publication Link: DDM No. 84. Applying Managed Care Concepts and Tools in Zimbabwe).
Please click here for more information on
Decentralization in Making Health Care Work Better.
1Major Applied Research 4, Technical Paper 1, A Model for Analyzing Strategic Use of
Government Financing to Improve Health Care Provision.
Peter Berman and Mukesh Chawla, April 1999