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.
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.
Background: Health financing is one of the focuses in the National Health System Reform major project in the 2022 Government Work Plan. However, obstacles have been found in health financing in Indonesia, including a lack of promote and preventive financing; less non-governmental involvement; and weak development of national health insurance (JKN) services. Purpose: To understand the principles of health financing for the realization of universal health coverage. This principle uses the concept of Kutzin et al (2017) and Atim et al (2021), namely revenue raising; pooling revenues; purchasing services; benefit design and rationing mechanism; and governance and institutional arrangements, including decentralization. Method: Focuses on the principles of health financing by utilizing secondary data sources through qualitative methods. The data sources were obtained from scientific journals, official government reports, related web pages, and others. Results: The effectiveness of increasing income for health financing cannot yet be measured. Revenue collection was found to overlap with health financing sources. There was a deficit for the JKN budget, and the community was not disciplined in paying contributions in purchasing services and distribution mechanisms. For the principle of decentralization, regional governments still depend on the central government in planning and budgeting health financing. Conclusion: The principles of health financing in Indonesia are not yet optimal in practice. This article contributes to looking at the gaps in information regarding the government's commitment to universal health coverage.
This article analyzes Brazil's Unified Health System (SUS), established by the 1988 Constitution. The article initially presents the previous trajectory of national health policy and the context of democratization in the 1980s, which favored health reform and created a public, universal, and comprehensive health system. It then explores the advances and contradictions recorded in more than three decades of implementation of the SUS. The main advances observed were the creation of institutional mechanisms compatible with the federative arrangement and social participation, political and administrative decentralization, the national expansion of access to health, changes in the health care model, including strengthening primary care, and improvements in health indicators. On the other hand, the persistence of structural problems and disputes between different health agendas, with differences between governments, led to contradictions in financing and public-private relations in health. Despite the differences between countries, the analysis of the Brazilian case provides lessons on the challenges in building universal health systems in Latin America.
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.
Abstract Health system is the backbone of delivering efficient preventive, promotive, curative and rehabilitative services. WHO has identified six building blocks of any health system. These include governance and leadership, infrastructure, workforce, financing, information management and access to essential medicines. Nepal has been striving to strengthen its health system despite several challenges in all WHO building blocks. Inadequate funds, geographical inequalities, insufficient health workforce, weak logistics, suboptimal health information system and inadequate health infrastructure have plagued Nepal health system for long. Natural calamities (e.g. earthquake of 2015) and COVID-19 pandemic overwhelmed the health system. In 2015, Nepal promulgated its new Constitution that devolved and decentralized several powers of generating revenue and exercising authority to sub-national governments viz the states/provinces and local civic bodies. Though functions of health system have been clearly defined at federal, state and local levels in the Constitution, transition of the erstwhile federal health system into new governance and implementation modalities continues to be challenging. There is a strong need to strengthen all building blocks of health system in Nepal at all levels of governance.
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.
The healthcare corruption has aroused heated discussions in China recently.From the beginning of 2023 to the present, at least 155 hospital directors have been investigated that the number is more than twice that of last year.The healthcare corruption was not only a matter of physician morality but also reflected the defects of China's medical system. 1 Since the establishment of China's Urban Employee Basic Medical Insurance (UEBMI) in 1998, China has formed a fragmented health insurance system in urban areas.Fragmentation hindered the mutual aid function of health insurance.Therefore, from 2009 to 2020, China carried out the health financing reform of UEBMI which adjusted the pooling level from the county to the municipal level.However, the increasing financialization of the healthcare system would result in physicians weakening accountability to the public. 2Horizontal integration and vertical management of fiscal power enabled the municipal governments to concentrate and allocate health funding, but the administrative decentralization led to laxity of spending supervision by county governments.This flawed system was a tough test for physicians.Without supervision, physicians might induce patients to increase healthcare services for the purpose of maximizing income. 3Figure 1 was the framework of Unified Pool arrangement in China.The paper aimed to discuss whether the unified pool reform would trigger healthcare corruption.Treating the pooling level adjustment reform of UEBMI as a quasi-experiment, the study tried to interpret the empirical results based on Chinese health insurance regulations, and explored the reasons for the high incidence of healthcare corruption in China.Instead of focusing solely on patients' utilization of healthcare services, the paper considered the behaviors of healthcare provider (eg, hospitals, physicians) and healthcare policy executor (eg, county governments, medical insurance bureau) by a quasi-experiment.The effects of the unified pool reform on outpatient expenditure were examined by using the staggered DID model, and the moderating effects of physician density were examined by using DDD model.The micro data in the study were from the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, 2015, and 2018 The macro data were from China City Statistical Yearbook.The documents were from on the official websites of the municipal-level governments, the Medical Insurance Bureau, and the Human Resources and Social Security Bureau.After excluding the samples with missing information and the samples of municipalities directly under the central government, this paper finally obtained panel data for 4 periods, 573 respondents who were continuously tracked, and a total of 2292 observations.Table 1 showed that the treatment effects on outpatient reimbursement expenditure were significant at a 5% significance level, no matter whether control variables were added.The implementation of unified pool reform would lead to a significant increase in outpatient reimbursement expenditure, rather than copayment expenditure.The treatment effects on outpatient expenses were also mainly caused by the increase in outpatient reimbursement expenditure.We utilized the parallel trend test
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.
During the transition from a planned economy to a decentralized, market socialist economy, the Chinese healthcare system has evolved from a centralized, egalitarian public system (1949-1979) to one which is largely self-governed and can be characterized as 'public identity, private behavior' healthcare system (1980-1999). With blurring of the distinction between public and private governing systems, and a shift in norms towards profit orientation, major concern has arisen about the extent of high cost, high volume services being offered through excessive entrepreneurial practices. This thesis is concerned with the regulatory strategies and options to reach 2010 health reform objectives of equity and efficiency under a mixed public/private market. While possible lessons can be drawn from established economies and transitional economies, China faces some unique challenges, given the diverse market structures and fragmented healthcare system across the country, and the underdeveloped framework for the rule of law. The thesis reviews policy documents from 1949 to 2004 and draws from interviews with senior health policy-makers and hospital directors in three different locations, in order to explore the role of the state in market regulation, the effectiveness of technical and social regulations, and how policy implementation and regulatory compliance occur. The research has found that the dynamics of the healthcare system are shaped by the financing arrangements for healthcare and the absence of arms-length governance of hospitals by health departments. Without an effective state health financing tool, nor mature market institutions, China is not able to use neither performance-based regulation nor technology-based regulation. China has adopted a management-based regulatory strategy but the absence of effective governance structure hinders effective regulation. If the reform objectives of improving healthcare quality while costs are to be attained, China will need to develop purchasing tools to alter the current perverse incentives for provider behavior. Government will also need to work with civil society organizations to develop tools for clinical governance, such as clinical audit for risk management and hospital accreditation programs. To do so requires establishing arms-length governance mechanisms between health departments and hospitals, and appropriate corporate governance structures within hospitals. Specifically, MOH needs to establish a technical policy think tank to investigate all the policy issues arising from the announcement of the 1997 health reform, including coordination with other line ministries and provincial authorities, and formulation and implementation of a policy research agenda, in order to attain a market-based governance system for health by 2010.
The adoption of decentralization by devolution in Tanzania has enabled the implementation of a Direct Health Facility Financing (DHFF) program in the facilities. While copious gains have been reported under DHFF, there are also notable failures to improve health service provision. This study aims to explore the experience of implementing the DHFF program in the rural areas of the Kigoma District Council. An exploratory qualitative study was conducted in Primary Health Care (PHC) facilities of the Kigoma District Council. A purposive sampling technique was used to draw 21 key informants including leaders of health facilities and members of the Health Facility Governing Committees (HFGC). Key Informant Interviews (KII) were used to solicit information from the study participants. Content analysis technique was used to analyze data collected from study participants. Our findings present enablers and barriers in the implementation of DHFF. Successful implementation of DHFF was enabled by the availability of formal training and supportive supervision, adherence to DHFF guidelines, availability of planning guidelines at the health facility, functionality of the HFGC, and adherence to the procurement process. A low sense of ownership of the program, delays and insufficient fund disbursement, shortage of health workers, and inadequate knowledge of DHFF program implementation emerged as the barriers that impeded successful program implementation. Evaluating the implementation experience of the DHFF program requires policymakers at the national level to devise a mechanism for the timely disbursement of funds, reinforcing capacity building to increase the autonomy of health facilities in their daily operations. Furthermore, structural and operational barriers warrant further operational and implementation research.
Anosisye Mwandulusya Kesale, Eliza Mwkasangula, Mikidadi Muhanga, Christopher P. Mahonge
The governance of epidemics is very critical for curbing and responding to several infectious epidemics. This study was conducted to explore the experience of the Health Facility Governing Committees (HFGCs) on the governance strategies they adopted to levarage the COVID 19 epidemic in their primary health facilities in Tanzania. An exploratory qualitative design was employed to study the governance strategies adopted by HFGCs during the COVID19. In this study, fourteen (14) HFGC chairpersons and ninety one (91) HFGC members with experience regulating primary health centers during a COVID 19 pandemic were involved. The study included four (4) governance response metrics that were discovered to be commonly used by HFGCs. These included coordinating responders, providing health information, explaining health hazards, and conducting out health interventions. Despite variations in implementation strategies, only two (2) governance response measures, coordinating responders and implementing, were found to be consistently applied by the majority of HFGCs. The nature of the governance path chosen by the Tanzanian government has been found to have influenced the slow reaction of primary health care governance actors such as HFGCs. Despite being empowered by Direct Health Facility Financing, COVID 19 presented challenges to several HFGCs. Though observed to be autonomous and expected to make judgments based on their circumstances, higher-level governance actors' opinions and actions on epidemics influenced the practices of local-level governance actors, including HFGCs. Indeed, for the HFGCs' potential to be realized, they must be empowered in ways other than fiscal and political decentralization. Other aspects of empowering governance actors, such as capacity building and education level, should be considered in order for them to completely realize their potential.