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

The Welfare State in India: From Segmented Approach to Systems Approach in Social Protection

Social protection in India is segmented with multiple programmes applying different targeting methods to design and implementation, providing varied benefits and covering different groups of the population. Such approach to social protection has policy implications for not only India but also for other emerging countries following similar path. A shift to a systems approach to social protection is required to provide comprehensive coverage over the life course of an individual while improving equity and efficiency. In this article, we introduce the welfare state in India, provide a comparative analysis of various programmes, challenges posed by the segmented approach to social protection including barrier to emergency responses and some reforms to consider to move to a systems approach to social protection. We highlight how integrating and consolidation of programmes in the same area, leveraging digital technology and unique identification number, creation of a single database, etc., can speedup progressive universalism.

Trade-offs between efficiency, equality, and equity in restoration for flood protection

Conservation decision-makers and practitioners increasingly strive for efficient and equitable outcomes for people and nature. However, environmental management programs commonly benefit some groups of people more than others, and very little is known about how efforts to promote equality (i.e., even distributions) and equity (i.e., proportional distributions) trade-off against efficiency (i.e., total net outcome per dollar spent). Based on a case study in the Brigalow Belt Bioregion, Australia, we quantified trade-offs between equality, equity, and efficiency in planning for flood protection. We considered optimal restoration strategies that allocate a fixed budget (1) evenly among beneficiary sectors (i.e., seeking equality among urban residents, rural communities, and the food sector), (2) evenly among Local Government Areas within the Brigalow Belt (i.e., seeking spatial equality), and (3) preferentially to areas of highest socioeconomic disadvantage (i.e., seeking equity). We assessed equality using the Gini coefficient, and equity using an index of socioeconomic disadvantage. At an AUD10M budget, evenly distributing the budget among beneficiary sectors was 80% less efficient than ignoring beneficiary groups, and did not improve equality in the distribution of flood protection among beneficiary sectors. Evenly distributing the budget among Local Government Areas ensured restoration in four areas that were otherwise ignored, with a modest reduction in efficiency (12-25%). Directing flood protection to areas of highest socioeconomic disadvantage did not result in additional reductions in efficiency, and captured areas of high disadvantage for the rural and urban sectors that were missed otherwise. We show here that different ways of targeting equity and equality lead to quite different trade-offs with efficiency. Our approach can be used to guide transparent negotiations between beneficiaries and other stakeholders involved in a planning process.

Equity and Efficiency of Medical and Health Resource Allocation in Western China Based on Health Resources Agglomeration Degree and Malmquist Index

Background: There is unequal distribution and low utilization efficiency of medical and health resources among regions in China for regional inequality social and economic development. The social and economic development in western China is relatively backward nationwide. The quantity and quality of medical and health resources have become a social problem in western China. This study aims to evaluate the equity and efficiency of health resource allocation in western China. Methods: The research data are extracted from China Statistical Yearbook ( 2009 – 2019 ). We choose the health resource agglomeration degree ( HRAD ) theory and Malmquist index to evaluate the equity and efficiency of health resource allocation in western China. The HRAD shows the impact of demographic and geographic factors on health resource aggregation. Results: From the latest data in 2019, the equity of medical and health resources allocation based on geographical area in Inner Mongolia, Tibet, Qinghai and Xinjiang is poor. The equity of medical and health resources allocation based on population allocation in Yunnan, Tibet, Gansu, Qinghai, Ningxia and Xinjiang is poor. From 2009 to 2019, the equity of health resource allocation in western China are poor nationwide. The total factor productivity of Tibet, Qinghai, Ningxia and Xinjiang was less than 1, which were 0.994, 0.984, 0.974 and 0.994, respectively. The allocation of medical and health resources in western China is unfair. Conclusion: The government should pay attention to the horizontal flow of medical and health resources when investing in medical and health resources. Population and geographical factors should be taken into account when allocating health resources. The total factor productivity in the western region is greatly affected by the technological progress rate. We should increase investment in medical and health technology, and effectively optimize the equity and efficiency of medical and health resource allocation.

Health needs assessment

This chapter begins with a consideration of the technical processes used for conducting health needs assessment. The relationship between health needs assessment and health economics is then examined and the philosophy of utilitarianism and its influence on health economics is explored. Cost utility analysis and its links to studies of quality of life are described and the important relationships between equity and efficiency are considered. The chapter then proceeds to explore the political and philosophical issues attaching to health needs assessment. This leads to an elaboration of the concept of justice derived from the work of Sen. Using ideas about the importance of human capabilities an argument is developed about the relational approach to understanding justice. The relational as against the individualistic position is found to provide a novel and useful way of describing health need and of attempting to meet that need. It also provides a set of precepts about the ways that services might be configured.

An equity and efficiency integrated grid-to-level 2SFCA approach: spatial accessibility of multilevel healthcare

Background Equity of healthcare spatial access is essential for the health outcomes of medical investments and the welfare of populations, and efficiency of medical resource allocation is important for obtaining a supply-demand equilibrium with lower cost and higher outputs with limited inputs. However, the literature that involves both equity and efficiency in its analysis of healthcare spatial allocation is rare, and the spatial accessibility of multilevel healthcare is difficult to measure by traditional methods in a large region with diversified population distribution. Methods To assist in solving these issues, this paper aims to build an equity and efficiency integrated analytical framework by proposing a new “GTL-2SFCA” approach to analyze the spatial accessibility of multilevel healthcare; maximum and minimum floating catchments of different levels of healthcare were assigned to ensure a combination of universal search coverage and efficient hospitalization behavior simulation. Results The analytical framework was applied and tested in Hubei, China. Almost half of the residents (47.95%) and townships (44.98%) have access to both public general hospitals (PGHs) and primary healthcare centers (PHCs) services, 36.89% of the residents enjoy only one sufficient service, either PGHs or PHCs, and the remaining residents (15.16%) are faced with the risk of lacking access to both services. The results reveal that there are core-periphery effects of multilevel healthcare throughout Hubei and isolate clusters that have adequate access in the western region. The polarization effect of higher-level healthcare and the polycentric pattern of lower-level healthcare coexist. The multilevel healthcare shortage was identified in some areas in boundary and peripheral regions. Conclusions This study integrates equity and efficiency into the GTL-2SFCA framework, enriches the FCA series methodologies and provides a more operational solution for evaluating the access of residents in more sophisticated spatial units to each level of healthcare. By more significantly differing and quantifying the catchment area and distance decay effect, this methodology avoids overestimating or underestimating accessibility and discovers some imperceptible spatial inequities. This study has application value for researchers and decision-makers in other scenarios and regions with significant heterogeneity in medical resources and where the population has greater mobility.

Observaciones y perspectivas sobre las modalidades de educación básica en América Latina en la era pandémica y pospandémica

La crisis sanitaria de covid-19 ha llevado a que el modelo educativo en muchos países, incluidos los latinoamericanos, pase a la modalidad remota. Este artículo tiene como objetivo explorar la transición de la presencialidad a la virtualidad a lo largo de la pandemia, así como sus implicaciones para las posibilidades y disponibilidades pedagógicas en la era pospandémica mediante un análisis de la modalidad de la educación básica en América Latina basándose en un estudio de caso del programa educativo a distancia en México: Aprende en Casa. Las conclusiones sugieren que el sistema mexicano de educación básica ha experimentado tres etapas de transformación ante la pandemia. Sin embargo, también observamos que en el proyecto Aprende en Casa existen varias deficiencias, vinculadas principalmente a la falta de garantía de equidad y eficiencia educativa. Se finaliza concluyendo que, con la finalidad de abordar los retos en la educación básica tanto en México como en toda la región latinoamericana, hace falta una visión hacia un enfoque integral, atendiendo la diversidad de las condiciones socioeconómicas. The Covid-19 health crisis has led to a shift in the educational model in many countries to the remote mode, including Latin American countries. This article aims to analyse the modality of basic education in Latin America based on a case study of the distance education programme in Mexico: Learning at Home. In this article, the objective is to explore the transition from face-to-face education to virtual mode, as well as its implications for pedagogical and public proposals in the post-pandemic era. The findings suggest that the Mexican basic education system has undergone three stages of transformation in the face of the pandemic. However, we also note that there are several shortcomings in the Learning at Home project, mainly linked to the lack of guarantee of educational equity and efficiency. We conclude that in order to address the challenges in basic education not only in Mexico, but also in the Latin American region as a whole, a new vision towards a comprehensive approach is needed, taking into account the diversity of socio-economic conditions.

Balancing Equity and Efficiency in the Allocation of Health Resources—Where Is the Middle Ground?

The notion of equity in health service delivery has been embodied in several of the Global Sustainable Development Goals (SDGs), especially the aspiration for universal health coverage (UHC). At the same time, escalating healthcare costs amidst dwindling resources continue to ignite discussions on the efficiency aspect of healthcare delivery at both operational and system levels. Therefore, health planners and managers have had to grapple with balancing the two, given limited resources and sophisticated population health needs. Undoubtedly, the concepts of equity and efficiency have overarching importance in healthcare. While efficiency dictates an ‘economical’ use of the limited healthcare resources, equity advocates their fair and ethical use. Some have leaned on this to argue that one has to be forgone in search of the other. In search of a ‘middle ground’, this paper explores the conceptual underpinnings of equity and efficiency in the context of healthcare resource allocation with some empirical examples from high-income and low- and middle-income settings. We conclude by arguing that equity and efficiency are, and ought to be, treated as complementary rather than conflicting considerations in distributing health resources. Each could be pursued without necessarily compromising the other—what matters is an explicit criterion of what will be ‘equitable’ in ensuring efficient allocation of resources, and on the other hand, what options will be considered more ‘efficient’ when equity objectives are pursued. Thus, equity can be achieved in an efficient way, while efficiency can drive the attainment of equity.

Universal Metrics for Climate Change Adaptation Finance? A Cautionary Tale

Climate change adaptation is receiving ever more attention in the literature and in practice. Since available funds are not meeting adaptation needs, the question of how to allocate scarce resources becomes pressing. Universal adaptation metrics promise to facilitate the allocation process ex ante and the evaluation of projects ex post. Two such metrics have been proposed recently: Saved Wealth (SW), measured in terms of money, and Saved Health (SH), gauged in terms of disability adjusted life-years (DALYs). The paper analyzes this SWSH approach and shows that it is replete with unresolved conceptual and normative-ethical problems, which are exemplary for universal metrics seeking to combine concerns for equity and efficiency at once. The paper’s aim is to uncover these issues, and its conclusion is modest: universal metrics such as SW and the DALY have to be designed and used with great caution and further research is necessary.