Blockchain Papers

Tanima Goswami, Nibedita Bayen

No abstract is available for this record.

Khanh Phuong Nguyen, The Due Ong, Xinyu Zhang, Tra My · 6 authors

Ensuring sufficient financial resources for improving effective and efficient procurement of vaccines was highlighted by the Immunization Agenda 2030, which is particularly challenging for middle-income countries (MICs) that are ineligible for support from Gavi, the Vaccine Alliance. In response to the broader decentralization of the governance system and decreased international development aid, the central government of Vietnam decentralized the responsibility of financing the Expanded Program on Immunization (EPI) to provincial governments in 2023 but rapidly reversed it considering its following negative consequences, for example, severe vaccine stockouts and the largest decline in childhood immunization coverage in over 20 years. This paper analyzed the consequences closely linked to decentralization in Vietnam, the underlying reasons, and lessons for other MICs. To avoid recurrence, MICs should ensure the primary role of the central government in EPI financing and management, improve the local management capacity, and allocate more resources toward less-developed areas to narrow the intra-country disparities.

Bruno Meessen, Megumi Rosenberg, Grace Marie Ku

BACKGROUND: There are substantial issues with the quality of care (QoC) received by persons living with chronic conditions, particularly in low- and middle-income countries (LMICs). One possible channel to improve QoC is through financing, specifically purchasing arrangements for health services. This has been actively explored in high-income country settings, generating a growing body of scientific knowledge. OBJECTIVE: To understand the potential and the constraints of using purchasing arrangements as a way to improve QoC for chronic conditions in resource-constrained settings. METHODS: A Delphi survey was conducted with 49 international participants with content expertise in chronic care management, health financing, or both, and context expertise in resource-constrained settings including in Small Island Developing States or Fragile and Conflict-Affected States, to assess the possible contribution of purchasing arrangements to QoC for chronic conditions with respect to specific types of care providers (e.g. patients and relatives, community health workers, public health centres), decentralized coordination bodies and purchasing agencies in such settings. RESULTS: There was a high level of consensus among the Delphi panel in favour of considering purchasing arrangements as one of the levers to improve QoC for people living with chronic conditions. Specific directions for action were identified along with their caveats. CONCLUSIONS: The challenge of improving the quality of chronic care in resource-constrained settings is extensive and requires immediate attention. Leveraging purchasing arrangements is one promising channel to strengthen quality chronic care in such settings.

Henry Komakech, Lynn Atuyambe, Fadi El‐Jardali, Christopher Garimoi Orach

BACKGROUND: Low- and middle-income countries face several challenges in providing health services, particularly to displaced populations, during all phases of emergencies. However, little is known about how health services are organized to displaced populations following repatriation. This study examined the organization of health services following the repatriation of South Sudanese refugees from the three West Nile districts of Arua, Adjumani, and Moyo in Uganda. METHODS: We conducted a qualitative case study in three West Nile refugee hosting districts, Arua, Moyo, and Adjumani. We used the World Health Organization Health System Framework, focusing on four blocks: health services, financing, medicines and supplies, and human resources. We conducted in-depth interviews with 32 purposefully selected respondents, including health service providers, district civil leaders, local government staff, and non-government organization staff. The data were analyzed using content analysis. RESULTS: Following repatriation, the district health teams in the three districts assumed overall responsibility for planning, managing, and providing health services. Health services followed an integrated model within a decentralized framework in all three districts. Health services were available in most areas except for former refugee settlements where facilities were either closed or relocated. After repatriation, funding for health services was provided through the government's primary health care grant with minimal support from aid agencies. Districts, however, face several challenges, including shortages of medicines and essential supplies, inadequate health workers, and poor infrastructure. CONCLUSION: Refugee repatriation disrupted health service delivery in the refugee hosting districts, leading to a reduction in funding; inadequate skilled health workers and equipment; and the closure of some facilities. To ensure the continuity of health services, government and aid agencies should plan for repatriation and establish strategies to sustain health services in refugee-hosting areas.

MD. Faisal Ahmed

I am writing in response to “The Urgent Need for Developing a Common Health Insurance Policy in Bangladesh: A Perspective” [1]. The article effectively highlights the pressing need for a universal health insurance system in Bangladesh. However, it largely advocates for conventional solutions that have faced challenges in implementation across low- and middle-income countries. A paradigm shift is necessary—one that moves beyond traditional state-led models to explore decentralized, technology-driven, and behaviorally informed strategies tailored to Bangladesh's economic and social realities. Habib and Molla reports that out-of-pocket healthcare spending amounts to 68.5% of total healthcare costs in Bangladesh which causes financial difficulties for numerous citizens [2]. They suggest raising government funding while improving coverage through existing health programs. Using only state-funded initiatives fails to address the constraints that stem from both fiscal capacity and administrative efficiency issues. A better solution combines mandatory insurance with voluntary options through digital financial access while employing behavioral economics to boost participation rates. The scarcity of health insurance payments stems from people's distrust of financial institutions and their inability to see immediate advantages from coverage. Behavioral economics provides solutions through default enrollment models which require people to actively decline insurance coverage. Mobile banking platforms bKash and Nagad should integrate health insurance services through automatic micro-premium withdrawals which maintain user involvement while avoiding yearly payment requirements. Insurance communication becomes more effective through behavioral alignment when risk protection messages replace long-term health investment messaging. A new approach would be the implementation of health insurance models supported by diaspora communities. The annual remittance amount of over $22 billion in Bangladesh lacks an organized system to direct this money toward healthcare funding. Insurance plans that allow expatriates to pay insurance premiums for family members and support community-based risk funds would enhance healthcare coverage among vulnerable populations. The Philippines and Mexico together with other countries have established successful diaspora-backed healthcare insurance systems which reduced healthcare expenses paid directly by patients to millions of people [3, 4]. Technological integration is also crucial. The article correctly identifies healthcare financing problems yet fails to investigate blockchain-based claims automation and AI-based adaptive pricing solutions. Blockchain technology brings transparency to operations while reducing fraud and streamlines claim settlements through automation to establish system-wide trust [5]. AI-driven underwriting systems allow for risk-based premium adjustments which enables insurance affordability for different income groups according to Rix [6]. Proof-of-concept deployments in Rwanda and Kenya show that these innovations can scale up for emerging markets [7, 8]. Bangladesh needs to prevent implementing models from high-income countries because their economic and institutional structures differ too much from its own. The country needs to prioritize a combined method that includes public-private collaborations with technological enhancements and behavioral economic practices. The implementation of mobile-based microinsurance and remittance-backed financing and blockchain claims processing requires initial testing through pilot programs for framework scalability purposes. The absence of forward-thinking strategies makes universal health coverage efforts stay theoretical instead of becoming practical initiatives. MD. Faisal Ahmed: writing – review and editing, writing – original draft, conceptualization, methodology, investigation, validation, resources, data curation. The author declares no conflicts of interest. Data sharing not applicable to this article as no data sets were generated or analyzed during the current study. No new data were generated or analyzed in this study. All supporting information and references are publicly available as cited in the article.

Resham B. Khatri, Pratik Khanal, Dipendra Singh Thakuri, Prabesh Ghimire · 5 authors

BACKGROUND: Nepal has been undergoing demographic and epidemiological transitions, marked by an increasing burden of non-communicable diseases (NCDs) and injuries. These transitions have led to financial implications, including rising out-of-pocket (OOP) expenses. This study reviews and synthesizes evidence on the status, issues and challenges in health financing system, policies, and programs to achieve universal health coverage (UHC) in Nepal. METHODS: We conducted a scoping review of literature on Nepal's health financing system, policies, and programs. A search strategy was developed using keywords related to two core concepts: health financing and universal health coverage. Grey literature was identified from the web pages of relevant ministries and organizations. A total of 148 studies/policy documents published in Nepali and English up to 31 December 2024 were included. Policies and content related to the health financing system were reviewed to understand the status, issues and challenges of health financing functions, and UHC . A framework-guided deductive content analysis approach was employed, and findings were interpreted using the three UHC components: service coverage, population coverage, and financial coverage. RESULTS: Nepal's health policy documents prioritize financial protection for low-income people and target groups through social health protection programs/schemes. However, multiple social health protection schemes coexist with fragmented risk pooling and low efficiency in health financing. OOP expenditure is high at 54.2%, with 10% of the population facing catastrophic health expenditures. Injuries and chronic morbidities contribute significantly to this burden, with 70% of injury-related and 62% of NCD-related expenses borne through OOP payments. Despite efforts to improve financial risk protection, the National Health Insurance Program (NHIP) suffers from low population coverage (28%), low renewal rate (54%), and financial sustainability issues (as provider payments exceed revenue collection). The UHC service coverage index, though improving, was only 54 out of 100 in 2021 reflecting limited health system capacity and insufficient readiness to address health challenges, including those posed by shifting demographics and the growing burden of NCDs. Nepal's total health expenditure remains around 2% of GDP, with persistent inefficiencies in resource allocation, fiscal decentralization, and budget absorption. CONCLUSIONS: Nepal's health financing policies align with UHC goals, yet critical gaps remain in multiple dimensions . Issues such as inefficiencies, underfunding, and fragmented social health protection schemes limit equitable access to quality health care. Therefore, comprehensive structural reforms-spanning legal, institutional, and policy frameworks-are urgently needed. Key reforms include: (1) merging or harmonizing existing social health protection schemes for efficient pooling and purchasing; (2) enhancing domestic health financing through increased health funding (≥5% of GDP) via payroll contributions, progressive taxation, and earmarked sin taxes; (3) reforming NHIP to mandatory enrollment starting from formal sector, subsidizing premium for informal sector and free coverage for disadvantaged groups, alongside strengthening policy implementation including accrediting of health facilities, ensuring service quality, prioritising and expanding coverage packages with strategic purchasing from all public and private health facilities; and (4) equitable public financing to ensure needs-based allocation across government levels that respond to demographic and epidemiological patterns. Further research is needed to assess hybrid tax and premium based insurance models, strategic purchasing optimization, and digital health innovations for financial sustainability.

Laura Buback, Kyle Daniels, Tiese Etim-Inyang, Monnaphat Jongdeepaisal · 8 authors

Many countries in the Asia Pacific rely on community health workers (CHWs) to care for various health needs. In the Greater Mekong Subregion (GMS), malaria CHWs have been an essential component of malaria elimination. Yet as the malaria burden declines, the role of malaria CHWs in local health systems and communities is changing. There is a need to expand malaria CHW roles to take on the provision of health services beyond malaria. This study sought to understand the process and experience of this role expansion including implementation, financing, policy, and sustainability within the Asia Pacific region. We documented malaria CHW programs that included health services in addition to malaria. We conducted 21 key-stakeholder interviews from thirteen programs in eight countries throughout the Asia Pacific region virtually in English and findings were analyzed using rapid-matrix analysis. Participants were recruited by an online landscaping survey, with an inclusion criterion of five + years' work experience and English speaking. Governments ran five of the thirteen programs; six were international non-governmental organizations (INGOs), and two were academic. Senior staff from programs that have expanded roles of malaria CHWs or integrated CHW programs explained expansion processes, challenges, and opportunities. We found that integration can occur in multiple program domains and does not necessarily occur in all domains simultaneously. We identified entry points for role expansion: integrated policy and financing, planning, assessments, and research. Operational entry points included the selection, training, motivation, management, supervision, and monitoring of CHWs. Enabling factors included decentralized management structures, health system linkages, commodity provision and referral procedures, and community engagement. While there is not a linear or unique path towards integration, we provide considerations for the policy level, practical implementation steps, and enabling factors for countries in the GMS to consider as they move towards sustainable, integrated malaria CHWs.

Costase Ndayishimiye, Richard Nduwayezu, Christoph Sowada, Katarzyna Dubas‐Jakóbczyk

Results-based healthcare financing policies have been adopted in countries worldwide, including those with limited resources. We conducted a retrospective, semistructured interview study to evaluate healthcare providers' experiences with Rwanda's performance-based financing (PBF) policy and the factors influencing its implementation. Guided by the health policy evaluation model-context, content, process, and actors-as a deductive framework supplemented by inductive coding, we analysed data from 21 participants (doctors, n = 13; nurses, n = 5; midwives, n = 3). Providers described PBF as a key motivator, supplementing incomes, increasing accountability, and fostering teamwork to meet performance targets. PBF was credited with improving patient outcomes, particularly in incentivized services; however, concerns arose regarding disparities in service prioritization. Key facilitators of and barriers to the implementation of PBF were identified, providing insights into its operational dynamics. Strong political commitment and integration into national strategies, such as Imihigo, along with decentralization through district steering committees, were key contextual enablers, enhancing the program's flexibility and alignment with local priorities. The content factors centred on a two-tiered contracting system, combining national accreditation processes with individual performance incentives. Process factors supporting PBF were characterized by decentralized evaluations, audits, and multilevel communication, which collectively bolstered accountability mechanisms. The engagement and capacity of stakeholders were highlighted as crucial to the success of PBF. Nonetheless, significant barriers, such as payment delays, manual documentation, untimely evaluations, insufficient training, limited provider participation in decision-making, and the exclusion of patients as stakeholders, were identified. These findings offer practical recommendations for policymakers aiming to improve or adapt provider payment mechanisms in similar contexts.

Brittany Hagedorn, Jeremy Cooper, Benjamin Loevinsohn, Valentina Martufi

BACKGROUND: To improve service delivery of Nigeria's primary health care (PHC) system, the government tested two approaches for facility-level financing: performance-based financing (PBF) and decentralized facility financing (DFF). Facilities also had increased autonomy, supervision, and community oversight. We examine how the intervention approach and funding level affected breadth of services and structural quality. METHODS: We use health facility surveys previously collected in 2014 and 2017, covering three years of implementation, in which districts were randomly assigned PBF or DFF and compared to matched districts in control states. We use log-linear regressions and non-parametric statistics to estimate the effect size of the financing approach and level of funding per capita. RESULTS: Service availability was highest in PBF facilities, while DFF also outperformed control on most measures. Results showed that structural readiness and service offerings both increased with more funding, especially under DFF. DFF and PBF facilities were better equipped to provide services that they claimed to offer, which was not the case for controls. Overall, PBF outperformed DFF, partially explained by funding levels. The rate of offering complimentary services followed a pattern of easiest-to-hardest to deliver. CONCLUSION: PBF and DFF both improved the breadth and structural quality of services, although DFF performance was more sensitive to funding levels. Improvements were observed at relatively low levels of funding, but larger investments were associated with better performance. Most DFF facilities exceeded the performance of higher-funded controls, implying that funding was more valuable in the context of autonomy, increased supervision, and community oversight.

Silvia Landa, Elisha Y. Sanoussi, Ezechiel Mahamane, Kairou Oudou Bilo Mahamadou · 6 authors

Water, sanitation, hygiene, waste management, and other environmental health services are critical for safe health systems, but global access is lacking. Adequate financing is a key barrier, and understanding resource allocation can help identify solutions in resource-limited contexts. We conducted a qualitative case examining resource allocation in rural Niger. Our objectives were to understand resource allocation processes, key actors and their roles, and contextual factors that influenced resource allocation. We interviewed thirty-three healthcare workers, community leaders, and government officials. We found that resource allocation followed formal and informal processes. Formal processes encompassed annual budgets and monthly supplies through government channels, while informal processes depended on healthcare workers' out-of-pocket expenses, unpaid labor, in-kind community support, healthcare facility revenue, and contributions from non-governmental and United Nations agencies, and the diaspora. Informal resource allocation was critical to fill the gap when formal processes were slow or insufficient. Resource allocation was highly decentralized with minimal influence of national policies and legal frameworks at the local level. Key contextual factors influencing resource allocation included politicization of budgets at the commune level, sometimes leading to inefficiency or inequity. We observed that healthcare facility actors who were most knowledgeable of needs often held the least decision-making power. We concluded that informal processes were complementary to formal processes, not conflicting. In contexts where government funding is severely limited, informal mechanisms may be the only viable short-term option to ensure the availability of services, demonstrating greater flexibility and adaptability. However, ultimately informal processes are an interim solution that should be explored to ensure service delivery without undermining long-term government systems strengthening. We recommend that funders commit to long-term initiatives promoting local government democratic decision-making, account for local actors' capacities and incentives, and acknowledge dynamic formal and informal resource allocations to optimize investments and trade-offs.

Sakshi Jain, Sameen Ahsan, Dylan Walters, Geoffrey Kinyua · 8 authors

This paper aims to emphasize the significance of creating subnational nutrition action plans in regions with high variation in nutrition challenges and evaluates their projected return on investment in Kenya. Despite steady progress, undernutrition in Kenya remains high, costing the country an estimated US$ 4.2 billion or 7% of its GDP annually. Under Kenya's decentralized government system, numerous counties developed sectoral County Nutrition Action Plans (CNAPs) in 2018 to identify and prioritize essential nutrition actions to target undernutrition at the subnational level. In this paper, the authors present findings from county investment cases (CICs) in five counties - Nandi, Busia, Makueni, Vihiga, and Elgeyo Marakwet-including the costs, health impacts, and benefit to cost ratios of implementing high-impact nutrition interventions. Data was collected on the target coverage and cost of interventions prioritized in each county's CNAPs for the 2018 to 2022 period. A monetized DALY approach, using the value of a statistical life methodology was used for cost-benefit analysis and the Optima Nutrition tool was used for cost-effectiveness analysis. The estimated cumulative impact of the five CNAPs was projected as 1,800 child and 115 maternal deaths averted; preventing and treating 19,000 cases of stunting and 4,700 cases of wasting in children under five and averting 67,000 cases of anaemia in pregnant women and adolescent girls. The county-level benefit-cost ratios range from $5:1 to $14:1 (at a default 3% discount rate). This analysis demonstrates that localized subnational plans can be advantageous for policymaking and prioritization to better address subnational disparities in undernutrition and offer a high return on investment.

UrbanBirth Collective

While maternal mortality decreased during the Millennium Development Goals era, it remains unacceptably high, with stagnation in reductions possible due to shocks such as COVID-19. Most women in low- and middle-income countries already receive antenatal care and over half give birth in health facilities. In cities, use of health facilities for childbirth is near universal (>90%). Cities present complex challenges in ensuring pregnant women receive equitable, high-quality care. The UrbanBirth Collective is a portfolio of projects in sub-Saharan African cities seeking to address an important knowledge gap: how to adapt urban healthcare systems and lived environments to improve maternal and perinatal well-being? Its key focus is care during labour, childbirth, and the early postnatal period, when most poor maternal and perinatal outcomes occur. Our starting projects focus on harnessing open source data to examine and compare cities on the continent, including in-depth case studies of three cities: Grand Conakry (Guinea), Grand Nokoué metropolitan area (Benin), and Lubumbashi (Democratic Republic of the Congo), where we will capture and analyse three main dimensions of the dynamics: maternal health service provision; maternal healthcare use by women; and the complex, nonlinear interactions between the provision and use of care within the spatial, social, and political ecosystem of a city. By comparing these three cities, we shall propose a generalisable model which can be validated and applied in other cities in sub-Saharan Africa. The growth of cities demands increasing attention on future-proofing them with the capacity to develop, implement, and continuously adapt a coherent strategy for the provision of equitable maternal and newborn care. Our ambition is to contribute to reaching zero preventable maternal deaths in cities. To achieve these goals through understanding specific contexts and facilitating the adoption and application of research findings and recommendations, we will collaborate closely with local stakeholders, including healthcare workers, community leaders, and policymakers.

Esteban Ortiz‐Prado, Isaac Alexander Suárez Sangucho, Wilson Ricardo Cañizares Fuentes, Jorge Vásconez-González · 5 authors

In the past three decades, Ecuador's health system has faced frequent ministerial turnover, often appointing leaders with limited training in public health policy and management. Although many ministers have strong clinical backgrounds, their lack of public health expertise has hindered a cohesive vision, raising concerns about the leadership's capacity to tackle the nation's complex health challenges effectively. The Ministry of Health is responsible for upholding the right to health, promoting health, preventing diseases, overseeing surveillance, and providing integrated care. It also develops clinical protocols and management guidelines, delivers health services, and conducts studies comparing national and international health management best practices [5,6]. To adequately fulfill these responsibilities, a master's degree in public health should be the minimum requirement for those considered for the position of Minister of Health. While ministers are indeed supported by technical personnel, they must have enough training to understand technical matters and not be overly reliant on staff or influenced by conflicts of interest [7]. Advanced public health training equips leaders with essential knowledge about financing, management, cost-effectiveness, and health communication, enabling them to evaluate and implement comprehensive health policies [8,9].A health minister requires both managerial skills to oversee health services and advocacy skills to ensure that potential effects on population health are integrated into the work of other government departments and ministries [10]. Helath Ministers require strong knowledge of epidemiology and public health preparedness, highlighted by challenges from global health crises like COVID-19. However, the Ministry faces internal issues impacting ministerial effectiveness, including overlapping responsibilities in regulations, unclear accountability, fragmented technical programs, and departments prioritizing specific professions over broader functions [11]. Furthermore, governance within the health sector is heavily influenced by institutional power dynamics. This lack of governance can severely hinder the performance of the Ministry of Health, contributing to systemic failures [12,13].Over the past 30 years in Ecuador, most health ministers have lacked advanced degrees or experience in key areas such as public health, epidemiology, or health systems management (see Table 1). This absence of qualifications hinders effective public health leadership, which demands an integrated, evidence-based approach to address social, environmental, and behavioral health determinants [1][2][3][4].Although the primary role of a health minister is to manage and oversee the national health system, their responsibility also extends to proposing public policies that can be evaluated through tangible improvements in health indicators, such as infant mortality. We believe that this is a significant issue for health governance.Therefore, we conducted an analysis based on the significant reductions in infant mortality during specific periods, identifying the ministers in charge and the outcomes associated with their tenure, highlighting changes that could reflect the impact of effective leadership and policy implementation (Figure 1). In Ecuador, significant milestones in public health were achieved, particularly before the year 2000. Key figures during their tenure led important vaccination campaigns and successfully managed the 1991 cholera outbreak, reducing infant mortality and advancing the Comprehensive Family and Community Health Program [14]. Between 1990 and 2006, the country saw critical reforms, such as the decentralization of health management to municipalities, the formation of Cantonal Health Councils, and the proposal of Universal Health Insurance in 2005-2006 [15]. However, in 2009, these decentralization efforts were reversed with the re-centralization of the health management system [16], undoing much of the progress that had been made.During 2014, the introduction of new food labeling regulations, which made nutritional information more accessible and positioned Ecuador as a global reference in non-communicable disease prevention was an important contrbution. However, this period was also marked by controversial decisions, including the closure of the National Institute of Hygiene and Tropical Medicine, the elimination of the National Service for the Eradication of Malaria (SNEM), and the shutdown of vaccine production in Ecuador [17]. Despite these public health initiatives, the reduction in infant mortality rates (IMR) during this period was less pronounced compared to other periods. While some improvements were made, the IMR did not decrease as significantly as might have been expected, highlighting a period where public health outcomes did not fully align with the scale of reforms introduced.[Insert Table 2 here ] The COVID-19 pandemic highlighted Ecuador's severe shortage of public health expertise, resulting in one of the world's highest excess death rates. Health ministers, often lacking local experience, communication skills, and disease management knowledge, struggled to provide clear public health messaging. This was worsened by significant mismanagement and corruption, including inflated prices for essential medications and supplies, which deepened the crisis [19,20].Corruption has long plagued the health sector, with some ministers facing serious allegations. For example, several scandals have involved the procurement of ambulances and other essential supplies at inflated prices, breaching public procurement laws [21][22][23].Ecuador's health leadership has historically been marked by high ministerial turnover, driven by political interests. This instability, coupled with instances of corruption and controversial policies, has hindered effective public health initiatives and created fragmented health policies. While some achievements exist, persistent leadership issues have led to high malnutrition rates and ineffective campaigns on issues like traffic accidents and drug abuse, contrasting sharply with the successes of neighboring countries like Peru.Appointing leaders focused solely on clinical medicine without a robust public health background poses several risks:• Fragmented Policies: Lacking public health foundations can lead to ineffective, fragmented policies [4,24,25].• Curative Bias: Overreliance on treatment instead of prevention perpetuates unsustainable healthcare costs [26].• Insufficient Emergency Preparedness: COVID-19 underscored the need for leaders skilled in epidemiology and crisis management [27][28][29].To better manage Ecuador's health system, technical skills and public health experience should be prioritized over political considerations in minister selection. Ideal candidates would possess:• Advanced public health qualifications.• Proven experience in public health policy formulation and evaluation.• Active public health research engagement.• Strong leadership and communication skills to articulate a public health vision and make informed, evidence-based decisions.Recent ministers have lacked communication competencies, resulting in fewer public health campaigns and diminishing the perception of health ministers as public health advocates.Selecting health ministers is a nuanced task influenced by social, political, and contextual variables, particularly in developing nations like Ecuador. However, the logic and some of the evidence underscores that this process must be approached thoughtfully, prioritizing technical expertise over political considerations, to ensure sustainable public health progress. While the public often expects a Minister of Health to be an effective administrator, adept at managing public procurement and addressing operational challenges, what Ecuador urgently requires is a leader with expertise in prevention, health promotion, and ensuring equitable access to healthcare services. These competencies are often lacking in physicians focused on curative, private-sector roles. This commentary highlights systemic issues, not as a complaint but as a reflection on persistent shortcomings.For example, despite a 25-year national malnutrition prevention program, Ecuador still has one of the region's highest malnutrition rates. Even during economic booms, investment favored hospital infrastructure over essential primary healthcare. This manuscript urges Ecuadorian authorities to address these issues and adopt the recommended steps for strengthening national health leadership, shifting towards a comprehensive public health focus for sustainable health improvements.

Ahmad Shirjang, Leila Doshmangir, Mohammad Bazyar, Vladimir Sergeevich Gordeev

BACKGROUND: Demographic transitions, societal changes, and evolving population health needs are placing increasing pressure on healthcare systems, necessitating ongoing reforms. Primary health care (PHC) is a foundational component of Universal Health Coverage (UHC) and sustainable health systems. Many countries have undertaken PHC reforms aimed at improving population health. This review explores the objectives, implementation mechanisms, challenges, and outcomes of these reforms. METHODS: We conducted a systematic review of studies sourced from five databases (PubMed, Scopus, Proquest, Embase, and Science Direct), applying the World Health Organization's Health Systems Framework for deductive content analysis. The PRISMA guidelines were followed to ensure transparency and rigour in summarizing the published literature. RESULTS: A total of 147 types of interventions were identified, with most targeting service delivery and financing. Key reform objectives included expanding access to care, improving financing and payment systems, scaling up family physician programmes, increasing government health expenditure, leveraging private sector capacities, and strengthening the PHC workforce. These interventions resulted in expanded public health coverage, enhanced access to PHC, increased utilization of services among low-income populations, broader social insurance coverage, and improved service quality, contributing to better community health outcomes. CONCLUSION: The success of PHC reforms depends on their alignment with political, social, and cultural contexts, as well as consideration of the social determinants of health. Strong governmental support, managerial stability, decentralization, and regional capacity building are essential for sustainable implementation. Reforms should be gradual, supported by accurate forecasting, adequate and sustainable resources, and evidence-based strategies, drawing on international experiences.

Peter Binyaruka, John Maiba, Dastan Mshana, Agnes Gatome-Munyua · 5 authors

Primary care facilities' autonomy and the factors that influence it are understudied. Direct facility financing (DFF) is gaining popularity in low- and middle-income countries as a modality to finance primary care facilities. Tanzania has introduced DFF with the objectives of streamlining resource allocation, fostering fiscal decentralization, and granting autonomy to health facilities for enhanced service readiness and responsiveness. This study aims to contribute evidence on primary care facilities' autonomy to execute DFF funds and the factors influencing this autonomy.Qualitative interviews and group discussions were conducted with health workers, managers, and community representatives from two councils to understand their perceptions of the autonomy of primary care facilities under DFF and remaining bottlenecks to effective budget execution. Data were analyzed using thematic content analysis to explore factors that influence facility autonomy to execute DFF funds.Primary care facilities are well informed on financial management and have adequate autonomy to execute DFF funds. However, several factors constrain their autonomy, including delays in funds disbursement, complex procurement and approval processes, rigid spending caps, restrictions on reallocations, and weaknesses in financial management capacity.DFF is a promising modality for health financing that supports health system goals. However, various challenges continue to hinder the autonomy of frontline service providers to fully execute DFF funds. To improve DFF budget execution, policy makers in Tanzania and elsewhere should consider reforms to better align public financial management and health financing.

Mohsin Raza Khan, Muhammad Arsalan Nazir, Sabeen Afzal

PURPOSE: This study aims to analyze the challenges in financing the healthcare system of Pakistan and develop a comprehensive health financing strategy aimed at achieving universal health coverage (UHC). DESIGN/METHODOLOGY/APPROACH: The paper utilizes World Health Organization (WHO) framework on health financing to build the argument. It uses qualitative research design involving focus group discussions and in-depth interviews with key stakeholders, including Federal Board of Revenue, Ministry of Finance, Planning Commission, development partners, academia and health ministries at federal and provincial levels, as well as social health insurance entities. FINDINGS: The research findings highlight several critical issues within Pakistan's healthcare system: Firstly, health spending is inadequate to provide financial protection to 24 million people. Secondly, the available health funding is allocated in clusters and caters primarily to specific groups, which exacerbates inequities in healthcare provision. Thirdly, the existence of multiple purchasing agents who operate concurrently to buy health services results in duplication and wastage of resources. Fourthly, the public financial management system, intended to support the swift distribution of public funds to health facilities, is not aligned with the requirements of the health system. Lastly, the devolved health setup has led to governance issues in managing the health sector. ORIGINALITY/VALUE: This study fills a significant gap in the literature on health financing within Pakistan and proposes a unique empirical approach using WHO's framework in a decentralized healthcare context. It also provides actionable recommendations for policymakers to develop strategies that improve the effectiveness of public financial management and health service delivery.

Sergio Flores, Anna Sarkadi

BACKGROUND: Historically marked by a high infant mortality rate, Sweden's healthcare reforms have successively led to a robust, decentralized universal child health system covering over 97% of the population 0-5 years. However, inequities in health have become an increasing problem and the public health law explicitly states that health inequities should be reduced, resulting in various government initiatives. This study examines the experiences of Central Child Health Services (CCHS) teams during the implementation of the Child Health Services Accessibility Agreement between the State and the regions starting in 2017. The agreement aimed to enhance child health service accessibility, especially in socio-economically disadvantaged areas, but broadly stated guidelines and the short-term nature of funding have raised questions about its effectiveness. The aim of this study was to understand the experiences of CCHC teams in implementing the Child Health Services Accessibility Agreement, focusing on investment decisions, implementation efforts, as well as facilitators and barriers to using the funds effectively. METHODS: CCHC teams were purposefully sampled and invited via email for interviews, with follow-ups for non-respondents. Conducted from January to October 2023, the interviews were held digitally and recorded with individuals familiar with the agreement's implementation within these teams. Both authors analyzed the transcripts thematically, applying Braun and Clarke's framework. Participants represented a cross-section of Sweden's varied healthcare regions. RESULTS: Three main themes emerged from the thematic analysis: "Easy come, easy go," highlighting funding uncertainties; "What are we supposed to do?" expressing dilemmas over project prioritization and partner collaboration; and "Building castles on sand," focusing on the challenges of staff retention and foundational program stability. Respective subthemes addressed issues like fund allocation timing, strategic decision-making, and the practical difficulties of implementing extended home visiting programs, particularly in collaboration with social services. CONCLUSIONS: This study uncovered the challenges faced in implementing the Child Health Services Accessibility Agreement across different regions in Sweden. These obstacles underline the need for precise guidelines regarding the use of funds, stable financing for long-term project sustainability, and strong foundational support to ensure effective interprofessional collaboration and infrastructure development for equitable service delivery in child health services.

Ermyas Birru, Melino Ndayizigiye, George Wanje, Tholoana A. Marole · 14 authors

BACKGROUND: Lesotho experienced high rates of maternal (566/100,000 live births) and under-five mortality (72.9/1000 live births). A 2013 national assessment found centralized healthcare management in Ministry of Health led to fragmented, ineffective district health team management. Launched in 2014 through collaboration between the Ministry of Health and Partners In Health, Lesotho's Primary Health Care Reform (LPHCR) aimed to improve service quality and quantity by decentralizing healthcare management to the district level. We conducted a qualitative study to explore health workers' perceptions regarding the effectiveness of LPHCR in enhancing the primary health care system. METHODS: We conducted 21 semi-structured key informant interviews (KII) with healthcare workers and Ministry of Health officials purposively sampled from various levels of Lesotho's health system, including the central Ministry of Health, district health management teams, health centers, and community health worker programs in four pilot districts of the LPHCR initiative. The World Health Organization's health systems building blocks framework was used to guide data collection and analysis. Interviews assessed health care workers' perspectives on the impact of the LPHCR initiative on the six-health system building blocks: service delivery, health information systems, access to essential medicines, health workforce, financing, and leadership/governance. Data were analyzed using directed content analysis. RESULTS: Participants described benefits of decentralization, including improved efficiency in service delivery, enhanced accountability and responsiveness, increased community participation, improved data availability, and better resource allocation. Participants highlighted how the reform resulted in more efficient procurement and distribution processes and increased recognition and status in part due to the empowerment of district health management teams. However, participants also identified limited decentralization of financial decision-making and encountered barriers to successful implementation, such as staff shortages, inadequate management of the village health worker program, and a lack of clear communication regarding autonomy in utilizing and mobilizing donor funds. CONCLUSION: Our study findings indicate that the implementation of decentralized primary health care management in Lesotho was associated a positive impact on health system building blocks related to primary health care. However, it is crucial to address the implementation challenges identified by healthcare workers to optimize the benefits of decentralized healthcare management.

Alyson Lipsky, Molly W. Adams, Chinyere Okeke

Achieving universal health coverage (UHC) requires commitment from a wide range of actors, including policy makers, civil society, and academics. In low- and middle-income countries, creating momentum among stakeholders can be challenging with competing priorities and limited funding. Advocacy coalitions—groups of like-minded organizations coalescing to achieve a common goal—have been used to achieve UHC; however, the effectiveness of advocacy coalitions for UHC is not well understood. This policy brief reviews literature on how social network analysis (SNA)—a method “effective in helping to understand how the stakeholders view one another, share information, cooperate, and take joint action”—has been used in low- and middle-income countries to evaluate UHC advocacy coalitions (Abbot et al., 2022). These findings were validated using experiences from coalition members in Nigeria advocating for UHC. The literature suggests that factors contributing to network success include network cohesion, decentralized network structure, collective action, strong transparency and trust between actors within an advocacy network, and clear communication and collaboration around advocacy objectives and the roles of all involved. The interviews suggest these themes are present in Nigeria as well. Using SNA thinking to conduct interviews in Nigeria, the authors highlighted specific strengths and areas of growth for advocacy coalitions for UHC. La réalisation de la couverture santé universelle (CSU) nécessite l'engagement d'un large éventail d'acteurs, notamment les décideurs politiques, la société civile et les universitaires. Dans les pays à faible et revenu intermédiaire, susciter un élan parmi les parties prenantes peut être difficile avec des priorités concurrentes et un financement limité. Les coalitions de plaidoyer - des groupes d'organisations partageant les mêmes idées se regroupant pour atteindre un objectif commun - ont été utilisées pour réaliser la CSU ; cependant, l'efficacité des coalitions de plaidoyer pour la CSU n'est pas bien comprise. Ce document politique passe en revue la littérature sur la manière dont l'analyse des réseaux sociaux (ARS) - une méthode "efficace pour aider à comprendre comment les parties prenantes se perçoivent mutuellement, partagent des informations, coopèrent et prennent des mesures conjointes" - a été utilisée dans les pays à faible et revenu intermédiaire pour évaluer les coalitions de plaidoyer pour la CSU (Abbot et al., 2022). Ces résultats ont été validés à l'aide des expériences des membres de la coalition au Nigéria plaidant en faveur de la CSU. La littérature suggère que les facteurs contribuant au succès du réseau comprennent la cohésion du réseau, la structure décentralisée du réseau, l'action collective, une transparence et une confiance solides entre les acteurs au sein d'un réseau de plaidoyer, et une collaboration autour des objectifs de plaidoyer et des rôles de tous les intervenants. Les entretiens suggèrent que ces thèmes sont également présents au Nigéria. En utilisant la pensée de l'ARS pour mener des entretiens au Nigéria, les auteurs ont mis en évidence des forces spécifiques et des domaines de croissance pour les coalitions de plaidoyer pour la CSU.

Anosisye Mwandulusya Kesale

Background: Decentralization is implemented at the local level to increase community participation in improving service delivery. Majority of developing countries are implementing Fiscal decentralization in primary healthcare through various approaches such as Direct Health Facility Financing, among other things, to empower Community governance structures to govern Primary Health Facility operations to improve the responsiveness of health service delivery and achieve Universal Health Coverage. One of the primary functions of these governance committees is to oversee health workers in their health facilities. Aims: This aimed at assessing how empowered governance committees govern health workers in their facilities under fiscal decentralization. Methods: To collect data for this study, an explanatory qualitative design with phenomenology traditions was used. To select the area of study, health facilities, and participants, a purposeful sampling procedure was used. Data were gathered through interviews and Focus Group Discussions to explore committee participation in governing health workers in primary care. Thematic analysis was used to analyze the collected data. Result: The findings of the study suggest that community governance committees' participation in governing health workers under fiscal decentralization remains limited. Majority of the committees have found to have low limited participation in governing different aspects of health workers. The majority of the committees have discovered that hiring casual workers such as security guards and cleaners is more important than other functions. Conclusion: The study implies that lower and middle-income countries' willingness to implement fiscal reforms at the local level and empower communities to take the lead in governing health workers still there are very limited specific powers granted to them to govern health workers. Therefore, capacity building to the governance actors is critical if we are to achieve the benefit of fiscal decentralization.

Dr Abubakar Yakubu Anadavi, Adah Patrick Eneojo, Dr Emmanuel Bola Jonah K

The epidemiologic approach was used to conduct the cross-sectional survey to observe and identify supply-side risks qualitatively and quantitatively linked to the determinants of the outcomes for Basic Health Care Provision Fund (BHCPF) implementation. The data analysis was conducted on survey datasets obtained from the stratified random sampling based on Integrated Supportive Supervision survey, (n=127) that received Decentralized Facility Financing (DFF) not after the 30th of September, 2022 from a population of 220 PHCs eligible for DFF) . Evaluative research is crucial to improving systems and services at 220 BHCPF designated sites, to ensure that strengths are rewarded, weaknesses observed compared to the expectations for outcomes in the intervention linked to risk factors compared to SDGs targets

Yusuf Hassan Wada, Kenneth Okoineme, Jennifer Anyanti, Dayyabu Yusuf · 7 authors

People living in vulnerable conditions have often been neglected or have a low coverage in health insurance which exacerbate poverty, vulnerability and social exclusion. This necessitates building and implementing insurance coverage that fully integrates social protection systems and community-based social care that prioritise the needs of the most vulnerable. To that end, we propose a decentralized system of sustainable financing and management of the vulnerable group fund that is performance driven with multi-stakeholder accountability systems premised on integrated data management. Integrating these elements will ensure that some of the existing gaps in the basic healthcare provision fund implementation in Nigeria are addressed with the following fundamental building blocks for the vulnerable group fund. These recommendations will help governments, resource partners and relevant stakeholders to consider in formulating strategies for operationalizing the vulnerable group funds and decreasing health inequalities among the population. In addition to implementation of this to accelerate universal health coverage and social protection, this will help to mitigate the currents challenges that exacerbate the inequality gaps, and build more resilient health and social protection systems, including the systems within humanitarian crises settings.

Miriam Nkangu, Julian Little, Raywat Deonandan, Roland Pongou · 5 authors

OBJECTIVES: The study applies the principal-agent approach to explore providers' experiences before and after the introduction of performance-based financing (PBF) in Cameroon, challenges and facilitators in the implementation process, and mechanisms in place to ensure sustainability. METHODS: The study was an in-depth qualitative study whose goal was to provide multiple descriptions of experiences and insights from a principal-agent analysis perspective. Purposive sampling was used to identify the key characteristics of the participants relevant to the study. A snowballing technique was used to further identify eligible participants. Only healthcare providers who were exposed to the previous system and could reflect on and provide meaningful data that captured the everyday experiences before and after the implementation of PBF were included. Data were collected from three districts in the Southwest region of Cameroon from May 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. RESULTS: A total of 17 interviews and 3 focus group discussions (24 participants) were conducted with healthcare providers and key stakeholders involved in PBF. The respondents described a range of changes that they had experienced since the introduction of PBF. Each of these changes was categorized as either positive or negative. Positive changes were framed into 14 dominant categories: motivation, negotiations, innovation, resource allocation, autonomy, decentralization, transparency, improved quality of care, separation of function, performance, equity considerations, opportunity to recruit, participation in decision-making, and improved access to and utilization of maternal health services. The main challenges (negative experiences) reported were framed into nine categories: management of change, retention issues, conflict of interest, poor understanding of the PBF concept, resistance to change, verification challenges, delays in payment of PBF incentives, data entry and documentation, and challenges in meeting the equity considerations of the poor and vulnerable. Despite the challenges, providers preferred the decentralized approach to the centralized system. CONCLUSION: PBF is a national strategy for achieving universal health coverage in Cameroon, and the experiences of providers provide a vital guide to refine national policy. The introduction of PBF has provided positive changes to providers' quality of care when compared to the previous system. Addressing the delays in PBF payments will help to overcome the challenges to implementation and provide opportunities for health facilities to be more efficient and improve their performance. Despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal).

Fortune Benjamin Effiong, Chiemela Prosper Ogbonna, Prosper Ifunanya Agughalam, Miracle O. Okwukwu · 7 authors

Universal health coverage (UHC) is aimed at ensuring that individuals and communities have affordable access to essential health care services without facing financial hardship. Achieving UHC and the third sustainable development goal of the United Nations requires that health systems transition from a vertical, top-down, curative approach toward one that puts people at the core of health care services, such as community-centered health interventions. Nigeria operates a decentralized health care system with the least focus on primary health care, making access to quality, and affordable health care for several citizens a challenge as the major percentage of the Nigerian population relies on primary health care services. The limited number of health care workers, the poor economic state, the inadequate health financing structures and high illiteracy rates have led to challenges such as low health service availability, hesitancy to utilize health interventions, high out-of-pocket expenditure rates, and health misinformation. These can be effectively tackled at the community level by revamping primary health care services, adequate and sustainable health financing, establishing Ward Development Committees, and the involvement of community stakeholders in health policy implementation. Employing such community-based approaches will ensure continuous progress of the Nigerian health care system toward UHC.