Price and income elasticities of demand for modern health care: the case of infant delivery in the Philippines.

In the Philippines most women choose to deliver at home despite the presence of modern facilities. Policy-making requires a knowledge of the factors that determine that choice, especially in terms of variables like price and location, which are amenable to policy intervention. Over 2/3 of the babies born in low-income countries are delivered by traditional birth attendants who are uneducated and have no formal training. They are, however, available in rural areas, whereas 70-90% of the modern practitioners are in the cities. Recently efforts have been made to expand modern obstetrical services in developing countries, but few surveys are available documenting the impact of modern facilities on delivery patterns. The present survey collected data from 3075 women who had singleton births on the island of Cebu between 1983 and 1984, as well as data from 48 modern public and private health facilities and 88 modern and traditional health practitioners. For the analysis of these data an economic demand model was built, using the mixed multinomial logit technic to estimate relationships between delivery characteristics, mothers' characteristics, and delivery choice. Money prices were not a significant factor in the choices, but time prices were a significant consideration for the rural sample. Hours of availability were a significant factor for both urban and rural mothers, and availability of drugs was significant for the urban sample. Both rural and urban women preferred delivery by a midwife, trained or not, to delivery by a combination of doctors, nurses, and midwives. With few exceptions, income was not a significant factor, and having insurance (10% of the sample) increased the probability of choosing a modern private practitioner. Money price effects were inelastic; i.e., a price increase by modern facilities would not have much effect on the choice of these facilities, and lowering the price of modern public delivery services would do little to increase demand for them. Locating more public practitioners and facilities in rural areas could effectively increase the use of modern facilities by rural women. Both urban and rural women would increase their use of modern public away-from-home facilities if these facilities would increase their hours of operation. Having drugs available would also increase the use of the public away-from-home facilities. In both urban and rural samples, trained midwives were the practitioners of choice. Among rural women a rise in income would increase the likelihood of their choosing public and private away-from-home deliveries and home deliveries by private practitioners. From the point of view of public policy, the most significant implications of the study are: 1) decreasing travel time for rural women by locating modern facilities and practitioners in rural areas would increase the use of modern delivery services; 2) increasing hours of operation, increasing the availability of drugs, and providing trained midwives at public facilities would increase the use of modern delivery services; 3) decreasing money prices would not increase use of modern public delivery services; and 4) increasing the price for cost recovery would not decrease the use of modern public delivery services.     

Public service ethics in a changing world

The past 25 years have seen profound changes in the management and delivery of public services throughout the UK and elsewhere. Such developments, known as New Public Management (NPM) have taken hold, to a greater or lesser extent, in many OECD countries. These developments have had an impact upon the ethics of public service in a number of different ways. This paper explores four themes arising from these developments, i.e. (1) regulatory regimes and performance; (2) changing organisational structures, relationships and partnerships; (3) the public service ethos and (4) individual virtue.The themes are located within a complex set of mutual relationships involving individuals, organisations, government and society. Ethical behaviour will reflect a balance between these relationships, expressed in decisions taken within a ‘problem space’ characteristic of public services.     

The Audit Commission and Public Services: Delivering For Whom?

This article examines the role of the Audit Commission in the delivery of public services. It charts the changing role of the Audit Commission since its inception in 1983 from that of a financial watchdog to a delivery monitor. Though its impact upon public services generally has increased, its impact is uneven between public services because of their different regulatory regimes. The authors conclude that the public, however defined, has very little influence upon the regulation of public services—despite official rhetoric. Consequently, the role of the public in regulating the delivery of public services represents a relatively excluded and even forgotten dimension, thus undermining claims made by the Audit Commission of acting in the public interest when monitoring the delivery of public services.     

SHELTER STRATEGIES FOR THE URBAN POOR IN DEVELOPING COUNTRIES

Rapid growth in many developing-country cities is strainingthe capacity of their shelter delivery systems. Governmentshave chosen a variety of implicit and explicit policies to amelioratethese strains. However, these policies are not always consistentwith their objectives, often because of a lack of knowledgeof how housing markets actually work and how policies affectand are constrained by market behavior. This paper reviews recentresearch on housing market behavior in developing countries,including the demand for housing and the pattern of housinginvestment across countries, the financing of housing by low-incomehouseholds, and the willingness to pay for secure tenure. Commonhousing policies are then examined, including public housing,sites and services projects, and slum clearance versus upgrading.Rent controls, measures to improve the supply of finance andinfrastructure, and building codes and standards are also discussed.      

The failed implementation of performance management in Irish central government

Ireland's Strategic Management Initiative was launched in 1994 and aimed to improve public services delivery. In line with public sector reforms in other countries, it placed strong emphasis on performance management in public sector organisations. Initiatives stressed the need for strategic planning and performance monitoring. The overall impact of these reforms was disappointing, with the Organisation for Economic Co‐operation and Development reporting in 2008 that the Irish public sector lacked a performance culture. This paper utilizes a series of interviews with senior managers in order to identify why performance management did not gain traction and our contribution highlights the complex contextual factors which undermined this agenda.     

The Upside to Fiscal Challenges: Innovative Partnerships Between Public and Private Sector

The first U.S. public‐private partnerships, or P3s as they are now called, began over 200 years ago. These contractual arrangements between government entities and private companies for the delivery of services or facilities have long been used for water/wastewater, transportation, urban development, and the provision of social services. And the use of such partnerships is increasing because they provide an effective means for meeting public needs, maintaining a high level of public control, improving the quality of services, and increasing the cost‐effectiveness of traditional delivery methods. Although outsourcing of public services is sometimes used to accomplish many of the same goals, P3s are likely to be a solution when public funds are not available and when:

• ? Capital is required to upgrade the infrastructure and so achieve a lower cost, or higher quality, of services.
• ? The contract horizon in the P3 transaction is sufficiently long for the investor/operation to recoup investment dollars and a rate of return.
• ? City residents make payments for the service provided, creating the revenue stream for private profits.
• ? The private partner in the P3 has a low cost of capital, often attributable largely to a large and sophisticated balance sheet.

This article uses examples of several recent P3 contracts to illustrate their role in shifting risk and increasing collaboration between the public and private sectors.     

Welfare and technology in the network society—Concerns for the future of welfare

The last decade of explosive innovation thanks to the growth of information and communication technologies (ICT) has left the public sector, and particularly the provision of welfare services, largely unchanged. Where socialising, commerce, information finding, entertainment and travel have all undergone profound structural transformations, the workings of government have not seen a similar shift. To be sure, the pace of decision-making has been sped up, as it has elsewhere, by Blackberries, and a small number of services are delivered online. But these services are still based around their offline equivalents, and usually aim simply at cutting the costs associated with their delivery by moving online. While this will continue to be a key motivation for the digitisation of government, other more fundamental developments are set to take place which will herald new online-only services, and which will encourage radical decentralisation of power.The first part of this paper will look at the private sector's experience over the past decade for clues as to why the public sector has moved relatively slowly, and likely directions of development in coming years. We will also here present evidence from our own forecasts of the likely narrowing of the digital divide. The next two sections will then deal with future developments in more detail, firstly looking at ICT's future role in welfare service delivery, and secondly at the ways in which it might be used for greater citizen engagement, and the reshaping of power structures that will result from this. The final section will examine some conflicts that arise from this reorientation away from the centre.     

VISION AND PRACTICE OF E-GOVERNMENT: AN EMPIRICAL STUDY

With the internet expanding rapidly in the 1990s, most of the reform agendas of Western countries embedded information technologies in their vision for change (Heeks, 1999; and Holmes, 2001). Existing studies into the diffusion of e-government has mainly centred on the USA and exposed a limited diffusion of digital delivery systems. This paper focuses on e-government by way of the adoption and use of ICT and internet for the delivery of information and services and explores the extent to which local governments endorse the e-government agenda by looking at the strategies and policies of municipalities and their actual use of e-government for the delivery of services and information. The paper utilizes data from a survey conducted during the winter of 2005-2006, addressed to the Chief Information Officers at Italian MUs with a population greater than 40,000. The results show that despite a certain degree of endorsement in terms of strategies for e-government, the use of e-government for the delivery of services is still quite limited.     

Medición de la intensidad en el uso de las tecnologías de la información y la comunicación en Escandinavia

One characteristic of the processes related to technological innovation in the Scandinavian countries is the high participation level of public and private agents. The objective of this strategy is to assimilate knowledge and to spread it out in the best possible way. Thus, in this article we identify the profile of ICT users; we try to establish how important they are for these countries, their good use of these technologies and how they impact on their communication processes. The results derived from the research prove that: 1) Swedish and Danish homes are a reference when it comes to the utilization of ICTs, 2) Finnish companies lead the way in the adoption of ICTs, followed by Danish and Swedish companies; 3) When it comes to provision and implementation of public services on a technological platform, the leading countries are Denmark, Finland and Sweden; and 4) When it comes to the utilization of ICTs in infrastructures, the EU leadership is headed by Sweden and Denmark, far ahead from the other Member States.     

Tracking Resource Use in a Welfare Organization: Needs, Costs and Co-production

Public sector welfare organizations are situated at the sharp end of resource allocations in society and must cope in an environment where demand frequently far exceeds supply. In consequence, the resource problem of meeting the need for social welfare is never fully resolvable and evaluations of the ways in which scarce resources are used within the public sector are of critical importance for public policy. This paper draws on an empirical study of a welfare service for homeless young people in order to illustrate, first, the cost implications of two different approaches to service delivery (one more superficial – termed 'people-processing'; one more in depth – termed, 'people-changing') and, second, how the characteristics of the clients served (in particular, their ability to fully engage with the service termed –'co-production') can have a marked impact on the cost of the services delivered to them.     

Delivering Public Services Through Digital Television

Digital television (DTV) is central to the future electronic delivery of public services in the UK. Central government has been actively promoting the use of DTV in the public sector, for example in policy statements and by funding pilot schemes to be implemented at the local level. Although DTV technology is at an early stage, this article provides an important opportunity to assess the nature of the platform as a state–of–the–art mechanism for delivering services and the factors that are likely to be central to its success.     

Using Relational and Transactional MCSs to Manage the Delivery of Outsourced Public Services: Evidence from Twelve Cases in the USA

The successful management of the purchaser–provider relationship is essential for the effective delivery of public services, and entails the use of both transactional and relational approaches. We herein analyse the degree and complementarity of transactional and relational management control systems in the management of purchaser–provider relationships for the successful delivery of public services using evidence from 12 US case studies. We demonstrate that transactional and relational management control systems are controlled differently in order to improve contracting efficiency. We also show how a combination of these management control systems offers a framework for structured public accountability and service flexibility.     

Managing employees in aged care: live the principles

Aged care services are a large recipient of public money in many developed countries and are primarily provided by nonprofit organizations in Australia. This paper reports on an investigation into the impacts of the psychological contract for nurses in nonprofit aged care. The results highlight the importance of nonprofit organizations fulfilling their obligations and living their principles. Aged care nurses who perceive breaches to their psychological contract are likely to de-identify from the organization.     

Weak Links in the Chain: A Diagnosis of Health Policy in Poor Countries

Recent empirical and theoretical literature sheds light on thedisappointing experience with implementation of primary healthcare programs in developing countries. This article focuseson the evidence showing two weak links in the chain betweengovernment spending for services to improve health and actualimprovements in health status. First, institutional capacityis a vital ingredient in providing effective services. Whenthis capacity is inadequate, health spending, even on the rightservices, may lead to little actual provision of services. Second,the net effect of government health services depends on theseverity of market failures—the more severe the marketfailures, the greater the potential for government servicesto have an impact. Evidence suggests that market failures arethe least severe for relatively inexpensive curative services,which often absorb the bulk of primary health care budgets.A companion paper, available from the authors (seep. 219), offersa perspective on how government funds can best be used to improvehealth and well-being in developing countries. It gives an alternativeview of appropriate public health policy, one that focuses onmitigating the characteristic market failures of the sectorand tailoring public health activities to the government's abilityto deliver various services.      

Debate: Cutback management through public procurement

The policy of contestability has become an important policy in relation to the delivery of public services. This article describes the theoretical underpinnings of contestability and its application to public services in the UK. It discusses the necessary conditions for achieving effective contestability and extending the application of contestability in public service provision.     

Institutional structures of financial sector supervision,their drivers and historical benchmarks

This paper studies institutional structures of prudential and business conduct supervision of financial services in 98 high and middle income countries over the past decade. It identifies possible drivers of changes in these supervisory structures using the panel ordered probit analysis. The results show that (i) more developed, small open economies with better public governance tend to integrate their supervision, especially the prudential one; (ii) more financially developed countries integrate more their supervision; however, greater development of the non-bank financial system leads to less integrated prudential supervision but not business conduct supervision; (iii) the lobbying power of concentrated and highly profitable banking sectors significant hinders business conduct integration; (vi) countries that experienced financial crises integrate their supervisory structure relatively more and (v) greater central bank independence could cause less integration of prudential supervision, but not necessarily of business conduct supervision.     

Agricultural Extension: Good Intentions and Hard Realities

What considerations lead policymakers to invest in agriculturalextension as a key public responsibility, and what factors andagency incentives explain differences in extension system performance?To help answer these questions, this article provides a frameworkoutlining farmers' demand for information, the public goodscharacter of extension services, and the organizational andpolitical attributes affecting the performance of extensionsystems. This conceptual framework is used to analyze severalextension modalities and their likely and actual effectiveness.The analysis highlights the efficiency gains that can come fromlocally decentralized delivery systems with incentive structuresbased on largely private provision, although in most poorercountries extension services will remain publicly funded.      

ANIMAL HEALTH SERVICES: FINDING THE BALANCE BETWEEN PUBLIC AND PRIVATE DELIVERY

Growing fiscal deficits and greater awareness of the huge economiccost of often-inefficient government activities have renewedinterest in transferring the delivery of important servicesfrom the public to the private sector in developing countries.This article, drawn from a longer study, offers a frameworkfor determining the appropriate roles of the public and privatesectors in delivering animal health services, such as veterinarysurveillance, disease vector control, vaccination, clinicaltreatment of sick animals, inspection of livestock products,and veterinary research and extension. The profitability and therefore the supply of private veterinaryservices is governed by several factors arising from economiesof scale, such as the size of the livestock enterprises in thelocality, the nature of potential or actual diseases, and thetypes of animals raised in the production systems. Thus, inareas where private veterinary work is unprofitable or whereother types of market failure occur, economic or social concernsmay make some type of public intervention necessary. The transferof animal health services from the public to the private sectormust be done selectively, and government support may be neededto ensure the success of such transfers.      

Creativity, Leadership and Change

The Department for Education and Employment's (DfEE) Permanent Secretary asks what needs to be done to deliver better public services. What are the priorities for modernization and how can these be achieved? He explains that the civil service has often under-valued management, skimped on management development, left project managers inadequately trained and recognized, and failed to reward effective service delivery. Improving delivery therefore requires a major cultural shift. He discusses four key issues: creativity, leadership, delivery, and community ownership.