Background: Decentralizing health sector, division role, power and authority of decision making in public health issue from top to lower structure, is the key means of improving community health status through which health sector reform of one country is achieved. Hence this study is aimed to address Decentralization and Health sector reform in Ethiopia. Objective: To express health sector reform achieved in Ethiopia as a result of decentralization and list all health reform indicators specifically in human resource and finance during the past three decades. Methods and Materials: This study was conducted using four purposely selected reliable reports and articles as a source by focused on the two main reforms activities that have been achieved through health sector decentralization in Ethiopia; Financial health sector and human resource health sector reform in Ethiopia. Because the rest health sector reforms are included under these two main reform activities. To intensify evidences of this study, additional Federal ministry of health annual reports and other documents were used. After important information was extracted and generalized from these documents, vital points of reforms achieved in the past three decades were summarized at the last literature of this study. Overall parts of this study was accomplished between May 11,- 30, 2020 Findings: The major indicators of Ethiopian health care financing reform include: Retaining and using region’s internally generated revenue, Practice of Outsourcing of nonclinical services in public hospitals, introduction of fee waiver and exemption systems, establishment of a private wing in public hospitals and health facility autonomy through establishment of governing bodies. Human resource reform in Ethiopian health sector include Health Extension Program (HEP) improved community health toward family planning, antenatal care, maternal health care, and hygiene and sanitation significantly, between 2005-2010, task-shifting and scaling-up of mid-level health professionals, which intended to delegate tasks to existing or new cadres who receive either less training or narrowly tailored training, utilization of non-teaching hospitals as training centers: health officers and emergency surgical officers, training mid-level professionals with nurse-level entry, focus on mid-level health professionals and local recruitment. Conclusion: Finding of this study concludes that in Ethiopia, in the past three decades, there was significant health sector reform mainly in the two major dimension; toward financial and human resource. Toward financial, it was aimed to improve community health through affordable cost in the continuous line of service access and availability which guarantees health status of the community. Toward Human resource, HEP, the major avenue for reform, played a major role with succeeded brief indicator of community health service.
The COVID-19 pandemic has provided an ultimate testing ground for evaluating the resilience and effectiveness of federal and decentralized systems. The article analyses how the Spanish asymmetrical system of decentralization has responded to the pandemic, focusing on the management developed by the sub-central governments (Autonomous Communities) during the first two waves of the pandemic in 2020. The research, which is both quantitative and qualitative, employs multidisciplinary tools and information sources, analyzing and linking fiscal and budgetary sources with the available statistics and information on health. Although the health, economic and social crisis caused by COVID-19 has highlighted appreciable shortcomings related to the decentralized model of territorial organization - in questions of both regional financing and health management - the research concludes that decentralization has not per se been a handicap when confronting the pandemic in Spain.
Mohammed Shadrul Alam, Shahnoor Islam, AKM Khairul Basher
In Bangladesh, Government is trying to find a perfect health system that best serves its population. Here, we present the results of our study with aim to assess the opinion of various stakeholders about: what are the 1) high-priority areas, 2) moderate priority areas, and 3) low-priority areas to reform the health sectors for Bangladesh. We conducted a cross-sectional, exploratory and anonymous population-based e-survey from February to June, 2021 among individuals aged above 26 years. A semi-structured questionnaire was designed and incorporated into the Google survey tool (Google Forms) and a shareable link was generated and disseminated to physicians, Academicians/ Clinicians of Medical Colleges/ Universities, Health System administrators etc. Respondents were also given space to comment on each topic. Comments & reactions of all respondents were categorized into three main headings. These were 1) high-priority areas, 2) moderate priority areas, and 3) low-priority areas to reform the health sectors for Bangladesh. Out of 483 respondents, 476 respondents (80.5% males and 19.5% female) completed the entire survey. The mean age of respondents is 44.70 SD± 10.07 with age range 26-86 years. About 27% of the respondents were from faculties from medical colleges /medical universities and 1.7% were health system administrators. The high prioritized areas where the majority (>60%) of our respondents strongly agreed upon, for instance, good governance, structural referral system should be establishment, and reformation of existing health care procurement & purchasing policy. The moderate prioritized areas where 50 - 60% of our respondents strongly agreed upon, such as securing sustainable financing for health care, further development of existing health infrastructure, and establishment of Health Academy of planning and development (HAPD). The low prioritized areas where less than 50% of our respondents strongly agreed upon, such as decentralization and autonomous health system, public health-oriented infection prevention and control (IPC) program, and implement the national health insurance system (NHIS) under a separate authority etc. Good governance in health departments & health care provider organizations are essential elements for health sector reform. Health sector reform should be sustained, purposeful, planned and evidence-based and fundamental change addressing significant, strategic dimensions of health systems. J Bangladesh Coll Phys Surg 2022; 40: 84-94
BACKGROUND: This article addresses how health institutions operate in Algeria. It deals with the problem of the management of health institutions in Algeria between centralization and decentralization. This means are there spaces for health institutions in the formulation of local health policies? Algeria seeks to establish local health institutions in response to current demographic growth. AIM: This study evaluates the Algerian legislature’s success in developing a legal framework for the administrative organization of health care institutions. METHODS: This comparative study focuses on legal texts, using data from the national statistical office, the World Bank, and the official Algerian news agency. RESULTS: The study finds a close relationship between free health services and the dominance of central health authorities that finance all public health institutions, including residents’ medical expenses, screening, surgery, and rehabilitation. Non-resident patients are compensated for treatment by state insurance funds (CNAS and CASNOS). There are no charitable hospitals. Therefore, civil society and humanitarian, charitable institutions are invited to launch initiatives regarding charitable hospitals, because they will contribute to relieving pressure in public health institutions and will also help in promoting public health in Algeria. The Ministry of Health controls central health services. CONCLUSION: Algerian health law mixes central and decentralized management but does not encourage local health institutions to seek funding and administrative independence. Algeria’s health system needs to be reformed.
While the health grants to local governments recommended by Fifteenth Union Finance Commission in the wake of Covid 19 pandemic lays emphasis on the trust-based approach to local governments and decentralization of health, the danger of Mission Creep can undo the potential and effectiveness of the grants to strengthen the primary health care sector. Lack of sensitization towards local governments; the misconception that local governments and its stakeholders are illiterate, weak and corrupt entities; absence of an institutional monitoring mechanism to conduct a follow-up of the recommendations made by the respective Finance Commissions; lack of co-ordination between various Ministries of union and state governments; and the erosion of cooperative federalism can all contribute to health grants falling prey to the vicious cycle of Mission Creep Syndrome.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Decentralization reforms through Direct Health Facilities Financing (DHFF) have empowered Health Facility Governing Committees (HFGCs) to participate in different governance aspects to improve service delivery at the facility level. However, there is little research on how empowered HFGCs perform in the context of the DHFF. The purpose of this study was to evaluate the functionality of HFGCs under DHFF in Tanzanian primary health care facilities that had variation of performance in 2018. To collect both qualitative and quantitative data, the study used a cross-section design. The study had a sample size of 280 respondents, who were chosen using a multistage cluster sampling technique from 32 primary health care facilities that were practicing DHFF. Data was collected via a closed-ended structured questionnaire, in-depth interviews with chairpersons of HFGCs, and Focus Group Discussions. To examine the functionality of HFGCs, researchers used descriptive and theme analysis. In the 2018-star rating assessment, the study discovered that HFGCs functioned well in both high and low-performing health facilities. When HFGCs from high-performing health facilities were compared to HFGCs from low-performing health facilities, it was discovered that HFGCs from the high-performing health facilities had comparatively high functionality. The functionality of HFGCs in Tanzania has thus been impacted by the DHFF context.
BACKGROUND: The shift in the global burden of disease from communicable to noncommunicable was a factor in mobilizing support for a broader post-Millennium Development Goals (MDGs) health agenda. To curb these and other global health problems, 193 Member States of the United Nations (UN) became signatories of the Sustainable Development Goals (SDGs) and committed to achieving universal health coverage (UHC) by 2030. In the context of the coronavirus disease 2019 (COVID-19) pandemic, the importance of health systems governance (HSG) is felt now more than ever for addressing the pandemic and continuing to provide essential health services. However, little is known about the successes and challenges of HSG with respect to UHC and health security. This study, therefore, aims to synthesize the evidence and identify successes and challenges of HSG towards UHC and health security. METHODS: We conducted a structured narrative review of studies published through 28 July 2021. We searched the existing literature using three databases: PubMed, Scopus and Web of Science. Search terms included three themes: HSG, UHC and health security. We synthesized the findings using the five core functions of HSG: policy formulation and strategic plans; intelligence; regulation; collaboration and coalition; and accountability. RESULTS: A total of 58 articles were included in the final review. We identified that context-specific health policy and health financing modalities helped to speed up the progress towards UHC and health security. Robust health intelligence, intersectoral collaboration and coalition were also essential to combat the pandemic and ensure the delivery of essential health services. On the contrary, execution of a one-size-fits-all HSG approach, lack of healthcare funding, corruption, inadequate health workforce, and weak regulatory and health government policies were major challenges to achieving UHC and health security. CONCLUSIONS: Countries, individually and collectively, need strong HSG to speed up the progress towards UHC and health security. Decentralization of health services to grass root levels, support of stakeholders, fair contribution and distribution of resources are essential to support the implementation of programmes towards UHC and health security. It is also vital to ensure independent regulatory accreditation of organizations in the health system and to integrate quality- and equity-related health service indicators into the national social protection monitoring and evaluation system; these will speed up the progress towards UHC and health security.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
User committees, such as Health Facility Governing Committees, are popular platforms for representing communities and civil society in holding service providers accountable. Fiscal decentralization via various arrangements such as Direct Health Facility Financing is thought to strengthen Health Facility Governing Committees in improving accountability in carrying out the devolved tasks and mandates. The purpose of this study was to analyze the status of accountability of Health Facility Governing Committees in Tanzania under the Direct Health Facility Financing setting as perceived by the supply side. In 32 different health institutions, a cross-sectional design was used to collect both qualitative and quantitative data at one point in time. Data was collected through a closed-ended questionnaire, an in-depth interview, and a Focus Group Discussion. Descriptive statistics, multiple logistic regression, and theme analysis were used to analyze the data. According to the findings, Health Facility Governing Committees' accountability is 78%. Committees have a high level of accountability in terms of encouraging the community to join community health funds (91.71%), receiving medicines and medical commodities (88.57%), and providing timely health services (84.29%). The health facility governance committee's responsibility was shown to be substantially connected with the health planning component (p = 0.0048) and the financial management aspect (p = 0.0045). This study found that the fiscal decentralization setting permits Committees to be accountable for carrying out their obligations, resulting in improved health service delivery in developing nations.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Abstract Background In Lower and Middle‐Income Countries (LMICs), decentralization has dominated the agenda for reforming the organization of service delivery (LMICs). The fiscal decentralization challenge is a hard one for decentralization. As they strive to make decisions and use health facility funding, primary healthcare facilities encounter the obstacles of fiscal decentralization. LMICs are currently implementing fiscal decentralization reforms to empower health facilities and their Health Facility Governing Committees (HFGCs) to improve service delivery. Given the scarcity of systematic evidence on the impact of fiscal decentralization, this study examined the functionality of HFGCs and their associated factors in primary healthcare facilities in Tanzania that were implementing fiscal decentralization through Direct Health Facility Financing (DHFF). Methods To collect both qualitative and quantitative data, a cross‐sectional approach was used. The research was carried out in 32 primary healthcare facilities in Tanzania that were implementing the DHFF. A multistage sample approach was utilized to pick 280 respondents, using both probability and nonprobability sampling procedures. A structured questionnaire, in‐depth interviews, and focus group discussions were used to gather data. The functionality of HFGCs was determined using descriptive analysis, and associated factors for the functioning of HFGCs were determined using binary logistic regression. Thematic analysis was used to do qualitative research. Result HFGC functionality under DHFF has been found to be good by 78.57%. Specifically, HFGCs have been found to have good functionality in mobilizing communities to join Community Health Funds 87.14%, participating in the procurement process 85%, discussing community health challenges 81.43% and planning and budgeting 80%. The functionality of HFGCs has been found to be associated with the planning and budgeting aspects p value of 0.0011, procurement aspects p value 0.0331, availability of information reports p value 0.0007 and Contesting for HFGC position p value 0.0187. Conclusion The study found that fiscal decentralization via DHFF increases the functionality of HFGCs significantly. As a result, the report proposes that more effort be placed into making financial resources available to health facilities.
Health sector in Indonesia faces many complex challenges. The enactment of the new regional government legislation has resulted in a decentralization policy design that requires the regional government to cover all the health issues. Besides, the policy on health issues is also influenced by the many changes of national strategic environment. Many findings indicate apprehensive situations in the health sector. Some of the problems include health financing, health personnel, and health regulations. Thus, it is recommended that each regional government develop a Regional Health System (RHS) as the implementation of health policy.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Abstract Background: Decentralization has dominated the agenda for the reforms of the organization of service delivery in Lower and Middle-Income Countries (LMICs). Decentralization faces a formidable challenge of fiscal decentralization in primary healthcare facilities. Of now, LMICs are implementing fiscal decentralization reforms to empower health facilities and their Health Facility Governing Committees (HFGCs). Given the paucity of the impact of fiscal decentralization, this study was conducted to assess the functionality of HFGCs and their associative factors in primary health care facilities implementing fiscal decentralization through Direct Health Facility Financing (DHFF) in Tanzania. Methods: A cross-sectional design was employed to gather both qualitative and quantitative data. The study was conducted in 32 selected primary health facilities implementing DHFF in Tanzania. Probability and nonprobability sampling procedures were employed, in which a multistage sampling procedure was used to select 280 respondents. Data were collected through a structured questionnaire, in-depth interviews and focus group discussions. Descriptive analysis was employed to determine the functionality of HFGCs and binary logistic regression was employed to determine associated factors for the functionality of HFGC. Qualitative analysis was done through thematic analysis. Result: HFGC functionality under DHFF has been found to be good by 78.57%. Specifically, HFGCs have been found to have good functionality in mobilizing communities to join Community Health Funds 87.14%, participating in the procurement process 85%, discussing community health challenges 81.43% and planning and budgeting 80%. The functionality of HFGCs has been found to be associated with the planning and budgeting aspects p-value of 0.0011, procurement aspects p-value 0.0331, availability of information reports p-value 0.0007 and Contesting for HFGC position p-value 0.0187. Conclusion: The study has revealed that fiscal decentralization through DHFF significantly improves the functionality of HFGCs. Therefore, the study recommends more effort be put into facilitating the availability of finances to the health facilities.
Health care is the most important activity and human kind is dealing with its organization for centuries. Public health policies and functional health care systems have as their primary objectives the preservation and improvement of public health. Problems of intensive aging of the population, continuous growth of health spending, ensuring sustainable financing of health systems and efficient use of resources are present in all world health systems. Health care system reforms have become a global phenomenon for the last twenty years of the last century. The goal of this review paper is to point out the importance and need for timely modifications of the strategy of the health care optimization plan in Serbia by 2035, so that the health care system of Serbia would be ready to respond to potential global health crises in the future. The Plan for optimizing the health care institutions network by 2035 as a key document of the Master Plan will be briefly presented with an analysis of key parameters of health care effectiveness and above all improvement of the implementation of basic principles of health care - uniformity and availability of health services on the territory of Republic of Serbia. In order to present future key changes in the health system, it is necessary to take into account the current situation, as well as the potential consequences of the global pandemic of COVID-19 virus on health systems. Databases were used for analysis: WHO, OECD, World Bank Reports. The tendency of increasing the share of health care costs in GDP, with the problems of efficient use of health care resources, is becoming the most important reason for reforming health insurance and health care in almost all countries in the world. Numerous researches of eminent experts in the field of economy and finance indicate that the introduction of compulsory health insurance with a clearly defined package of health conditions is the most rational choice in the implementation of the World Health Organization project: "Health for all in the 21st century". A health system could be said to be effective if it provides health care of maximum quality in terms of medical outcome, with minimal costs in relation to the allocated funds. Health care systems around the world today face very similar problems, and the COVID-19 pandemic has shown how "vulnerable" it is not only the health system but all of humanity when faced with such challenges.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Abstract Users Committees such as Health Facility Governing Committees (HFGCs) are one of the popular mechanisms used to represent communities and civil societies in holding service providers into account. This study embarked on assessing the status of accountability of HFGCs under the DHFF context in Tanzania as experienced by the supply side (HFGCs members). A cross-sectional design was employed in collecting both qualitative and quantitative data at one point in time in 32 selected health facilities. A closed-ended questionnaire, in-depth interview and FGDs were employed to collect data. Data were analyzed through descriptive statistics and Multiple logistics regression, and thematic analyses. The study found high accountability of HFGCs by 78%. specifically, HFGCs have high accountability in mobilizing the community to join community health funds 99.71%, receiving medicines and medical commodities 88.57% and timely health services 84.29%. It was reviled that the accountability of the health facility governance committee was significantly associated with the health planning aspect (p=0.0048) and financial management aspect (p=0.0045). This study concluded that the fiscal decentralization context empowers HFGCs to be accountable in accomplishing their responsibilities hence improving health service delivery in developing countries. This study recommends more efforts to be directed in supporting HFGCs addressing challenges of managing health facilities works and mobilization of resources from other stakeholders.
Noncommunicable diseases (NCDs) are leading causes of death globally and in Nigeria they account for 29% of total deaths. Nigeria's health system is decentralized. Fragmentation in governance in federalised countries with decentralised health systems is a well-recognised challenge to coherent national health policymaking. The policy response to the rising NCD burden therefore requires strategic intent by national and sub-national governments. This study aimed to understand the implementation of NCD policies in Nigeria, the role of decentralisation of those policies, and to consider the implications for achieving national NCD targets. We conducted a policy analysis combined with key informant interviews to determine to what extent NCD policies and strategies align with Nigeria's decentralised health system; and the structure and process within which implementation occurs across the various tiers of government. Four inter-related findings emerged: NCD national policies are 'top down' in focus and lack attention to decentralisation to subnational and frontline care delivery levels of the health system; there are defective coordination mechanisms for NCD programmes which are underpinned by weak regional organisational structures; financing for NCDs are administratively burdensome and fragmented; and frontline NCD service delivery for NCDs are not effectively being integrated with other essential PHC services. Despite considerable progress being made with development of national NCD policies, greater attention on their implementation at subnational levels is needed to achieve more effective service delivery and progress against national NCD targets. We recommend strengthening subnational coordination mechanisms, greater accountability frameworks, increased and more efficient funding, and greater attention to integrated PHC service delivery models. The use of an effective bottom-up approach, with consideration for decentralization, should also be engaged at all stages of policy formulation.
INTRODUCTION: Faced with the coronavirus disease (COVID-19) pandemic, governments worldwide instituted lockdowns to curtail virus spread. Health facility closures and travel restrictions disrupted access to antiretroviral (ARV) therapy for people living with HIV. This report describes how HIV programs in Indonesia, Laos, Nepal, and Nigeria supported treatment continuation by introducing home delivery of ARVs. METHODS: Staff supporting the programs provided accounts of when and how decisions were taken to support ARV home delivery. They captured programmatic information about home delivery implementation using an intervention documentation tool. The 4 country experiences revealed lessons learned about factors favoring successful expansion of ARV home delivery. RESULTS: Three of the countries relied on existing networks of community health workers for ARV delivery; the fourth country, Indonesia, relied on a private sector courier service. Across the 4 countries, between 19% and 51% of eligible clients were served by home delivery. The experiences showed that ARV home delivery is feasible and acceptable to health service providers, clients, and other stakeholders. Essential to success was rapid mobilization of stakeholders who led the design of the home delivery mechanisms and provided leadership support of the service innovations. Timely service adaptation was made possible by pre-existing differentiated models of care supportive of community-based ARV provision by outreach workers. Home delivery models prioritized protection of client confidentiality and prevention measures for COVID-19. Sustainability of the innovation depends on reinforcement of the commodity management infrastructure and investment in financing mechanisms. CONCLUSION: Home delivery of ARVs is a feasible client-centered approach to be included among the options for decentralized drug distribution. It serves as a measure for expanding access to care both when access to health services is disrupted and under routine circumstances.
Madhulika Khanna, Benjamin Loevinsohn, Elina Pradhan, Opeyemi Fadeyibi · 10 authors
BACKGROUND: Health system financing presents a challenge in many developing countries. We assessed two reform packages, performance-based financing (PBF) and direct facility financing (DFF), against each other and business-as-usual for maternal and child healthcare (MCH) provision in Nigeria. METHODS: We sampled 571 facilities (269 in PBF; 302 in DFF) in 52 districts randomly assigned to PBF or DFF, and 215 facilities in 25 observable-matched control districts. PBF facilities received $2 ($1 for operating grants plus $1 for bonuses) for every $1 received by DFF facilities (operating grants alone). Both received autonomy, supervision, and enhanced community engagement, isolating the impact of additional performance-linked facility and health worker payments. Facilities and households with recent pregnancies in facility catchments were surveyed at baseline (2014) and endline (2017). Outcomes were Penta3 immunization, institutional deliveries, modern contraceptive prevalence rate (mCPR), four-plus antenatal care (ANC) visits, insecticide-treated mosquito net (ITN) use by under-fives, and directly observed quality of care (QOC). We estimated difference-in-differences with state fixed effects and clustered standard errors. RESULTS: PBF increased institutional deliveries by 10% points over DFF and 7% over business-as-usual (p<0.01). PBF and DFF were more effective than business-as-usual for Penta3 (p<0.05 and p<0.01, respectively); PBF also for mCPR (p<0.05). Twenty-one of 26 QOC indicators improved in both PBF and DFF relative to business-as-usual (p<0.05). However, except for deliveries, PBF was as or less effective than DFF: Penta3 immunization and ITN use were each 6% less than DFF (p<0.1 for both) and QOC gains were also comparable. Utilization gains come from the middle of the rural wealth distribution (p<0.05). CONCLUSIONS: Our findings show that both PBF and DFF represent significant improvements over business-as-usual for service provision and quality of care. However, except for institutional delivery, PBF and DFF do not differ from each other despite PBF disbursing $2 for every dollar disbursed by DFF. These findings highlight the importance of direct facility financing and decentralization in improving PHC and suggest potential complementarities between the two approaches in strengthening MCH service delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT03890653 ; May 8, 2017. Retrospectively registered.
expenses for hospitalized patients with chronic liver disease (CLD) poses an economic challenge on affected household in the form of catastrophic health expenditure (CHE), distress financing and impoverishment. OOP Expenses data for hospitalized CLD patients from Bangladesh is scarce. This study aimed to estimate the OOP expenses and resulting CHE, distress financing and impoverishment among hospitalized patients with CLD. This cross-sectional study was conducted among conveniently selected 107 diagnosed CLD patients admitted at Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) aged 18 years and above. Data were collected from the respondents using a semi-structured questionnaire through face to face interview during discharge from hospital. Out of pocket expenditure for chronic liver disease in selected hospitals was Bangladeshi Taka (BDT) 19,262. Direct medical, direct nonmedical and indirect cost was BDT 16,240; 2,165 and 1,510, respectively. Investigation cost and medicine cost contributed to 48.48% and 31.81% of the total OOP expenses, respectively. At 10% threshold level, 29% of the respondents were affected by CHE. 64.5% of the respondents were facing distress financing due to OOP expenses. Among the respondents, 1.9% slipped below the international poverty line of $1.90 (BDT 161.10, in 2019).There was statistically significant (p < 0.05) difference among the mean OOP expenses for different etiological types of chronic liver disease. The study concluded that it requires establishing a more accessible and affordable decentralized health care system for CLD treatment along with the implementation of financial risk protection.
Noemia Liege Maria da Cunha Bernardo, Luciano Soares, Silvana Nair Leite
The decentralization of the Brazilian health system required that municipalities took responsibility for the local Pharmaceutical Policy and Services (PPS) system. This article presents and analyses an innovative experience of diagnosis of municipal PPS as a sociotechnical system. We adopted a multi-methods approach and various data sources. Sociotechnical theory was the framework of the methodology of evaluation and design of systems, analyzing the External System (health system, stakeholders, financing) and Internal System (goals, management, workforce, infrastructure, processes, technology and culture). The "objective" component of the PPS system was identified as the central element. The lack of a unified objective and of a central coordination and unmanaged pharmaceutical services prevented integrated internal planning and planning with other sectors. Stakeholders and documents referred only to technical elements of the system: Infrastructure, technical process, and technology. The social components of the workforce and culture were not mentioned. The organizational culture established was the culture of isolation: "Each one does his own". The pharmacists working in the municipal health system did not know each other. There was no integration strategy between pharmacists and their work processes. Consequently, the municipal PPS had limited scope as a public policy. It had constrained the characteristics of PPS as a complex and open system. Understanding the municipal PPS as a sociotechnical system can push the development of a new level of policy and practice to ensure the population's right to the access to and rational use of medicines.
Open access
Public Health in Brazil
Health Systems, Economic Evaluations, Quality of Life
The coronavirus disease 2019 (COVID-19) pandemic, with its overlapping public health and economic emergencies, is a global reminder of the importance of addressing social and environmental determinants of health and inequality, and investing in health systems oriented towards primary care, all of which are components of a primary health care (PHC) approach. PHC – the importance of which was famously articulated in the Declaration of Alma-Ata in 1978 and reaffirmed at the 2018 Astana Conference – is recognized as one of the best ways of promoting population health and well-being.[1,2,3] PHC is “a whole-of-society approach to health that aims to ensure the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and preferences (as individuals, families, and communities) as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment”.[4] It promotes a focus on health systems oriented towards primary care, which have been shown to strengthen appropriateness, access, quality and efficiency of care, through their defining focus on people and the delivery of integrated preventive, curative and public health services.[5] However, the efficacy and impact of such primary care is understood to be intrinsically linked to, and embedded within, a broader context that is inclusive of participatory and responsive financing and governance structures, and policies and actions in non-health sectors.[6] In 2020, with the aim of supporting countries to operationalize PHC, the World Health Organization (WHO) launched its Operational framework for primary health care: transforming vision into action.[7] Showcasing evidence-based strategic and operational levers, the framework highlights the need for a whole-of-society approach. Of note, the framework’s emphasis – on more and better multisectoral action, empowerment of people and communities, and the urgency of strengthening primary care as the “service front”[6] and programmatic engine of universal health coverage[2] – overlaps considerably with issues highlighted by the COVID-19 pandemic. In the WHO South-East Asia Region, Member States have articulated a high-level commitment to the vision of PHC as one means by which to improve health and well- being. Even before the COVID-19 pandemic, an estimated 60 million people annually in the region experienced poverty because of out-of-pocket spending on health care. Regionally, various initiatives are seeking to both build primary care capacity and implement policies and strategies that reflect a multisectoral approach. As observed in the WHO Regional Director’s message accompanying this special issue, since 2014, achieving universal health coverage has been one of the flagship priorities across the South-East Asia Region, with service coverage improving from an average of 47% a decade ago to more than 61% in 2020. However, many challenges remain; the COVID-19 pandemic has provided opportunities for innovation and adaptation but has also presented new problems or compounded problems in relation to Member States’ efforts to operationalize PHC. In this supplement, South-East Asia Region authors and others reflect on the challenges and lessons learned regarding PHC during the first 12 months of the COVID-19 pandemic, highlighting among other things examples of the rapid review and extension of health workforce capability; the expedited introduction of technological solutions to maintain and strengthen health care access; and newly decentralized governance arrangements designed to enable the integration of public health functions into front-line services.[8,9] Addressing the critical issue of access to essential services, for example, Reddy et al.[10] present findings from the analysis of routine facility data in India’s Telangana state, which show a positive association between a highly decentralized model of hypertension care that brings follow-up services and medicines closer to communities and indicators of service uptake and hypertension outcomes. Although identifying some decreases in service access during the pandemic-induced lockdown, the same study suggests a potentially protective effect on access to and use of hypertension follow-up services in populations covered by decentralized services compared with those covered by non-decentralized services. Zangmo et al.[11] similarly describe various adaptations to traditional models of antenatal care employed to ensure continuity of this vital service in country settings experiencing widespread social and economic lockdowns. Bezbaruah et al.[12] and Zakoji and Sundararaman[13] observe the critical importance of integrating emergency response capabilities and functions with routine community engagement and health workforce functions in support of effective and sustained emergency response measures that can be led by local stakeholders and are trusted by local populations. Bahl[14] et al. describe how, despite the reduction in immunization services and surveillance for vaccine-preventable diseases across the South-East Asia Region early in the pandemic, rapid adaptation of guidelines and action plans meant that, in most countries, immunization coverage recovered during July–September 2020 to levels seen during the corresponding months in 2019. In fact, this was observed in Bangladesh, as reported by Wangmo et al.,[15] where the rate of fully immunized children fell by 46% between January and April 2020 but recovered to 100% by June 2020. The benefits of long-term community engagement (a key pillar of comprehensive PHC), including through investment in community health workers, is evident in several contributions (Bezbaruah et al.,[12] Zakoji and Sundararaman,[13] Reddy et al.[10]). These contributions provide further evidence of the critical role of primary care services not only in ensuring access to essential health care during public health emergencies but also in providing a platform for long-term and sustained efforts to strengthen national and subnational health systems through community engagement.[3] Even with examples of innovation and adaptation, multiple challenges to progressing PHC in the South-East Asia Region remain, particularly in the new context of the COVID-19 crisis. Zapata et al.[16] and Tangcharoensathien[17] note that, despite several decades of investment by Member States in human resources for health, huge health workforce challenges remain, with only two countries currently meeting the revised WHO threshold of 44.5 health workers per 10 000 population. The pandemic has highlighted the need to prioritize locally appropriate actions in the delivery of primary care, yet health budgets are overstretched and, as Kwon[18] points out, health governance and financing systems are too often unresponsive in the face of shifting health needs. Tandon et al.[19] observe that, in many South-East Asia Region countries, low levels of public spending on health and tied donor funding inhibit investment in primary care or the types of multisectoral action needed to realize PHC. Alongside the political economy of pharmaceutical research, development and sales, such budget constraints can influence the availability of medicines, which, despite the remarkable efforts behind the COVAX initiative, will affect the ability of different countries to access and roll out COVID-19 vaccines. Reflecting on a long-standing challenge, Khan et al.[20] observe how, despite mixed health systems being the norm in the region, attention to, and investment in, effective regulatory mechanisms to ensure the quality and affordability of nongovernment (private for-profit and not-for-profit) services remain weak. Reflecting on issues of health governance, Tangcharoensathien[17] and Guisset et al.[21] observe how, often, decisions about health service type and availability are driven by siloed governance and financing systems that are distant, if not disconnected, from the realities of both patients and frontline providers. Looking at the intersection of such governance and regulatory issues, Rajbhandary et al.[22] describe the need for urgent investment to strengthen health information systems in the South-East Asia Region, noting the growing capacity for the collection and collation of health information within regional Member States but also the still underdeveloped capacity for analysing and utilizing these data at subnational and particularly facility levels, where it is arguably most needed. Walcott and Akinola[23] reflect on the power of digital technologies, including data capture from rapidly expanding telemedicine applications, to inform on better targeted interventions and advance the universal health care agenda. Wangmo et al. present data illustrating the positive role that health information systems, and especially the collection and use of routine data, have played in Bangladesh, to help identify and inform the government response, down to the health facility level, on early reductions in coverage of essential services during the first months of the COVID-19 pandemic. Providing an important synthesis of many of these issues, Peiris et al.[24] review the literature to highlight how, even when accounting for some welcome pandemic-related health service adaptations, country-level attention to strategic functions that would strengthen underlying health systems in support of PHC remains generally weak. Challenges include many of the strategic areas identified in WHO’s operational framework, such as leadership, governance and policy, funding and allocation of resources, and engagement of communities and other stakeholders.[7] Around the globe, the COVID-19 pandemic has laid bare the devastating impact of both structural inequities and suboptimally designed health systems. The pandemic has highlighted the pressing need to move away from brittle, uncoordinated and disease-specific responses and to reorient health systems towards a PHC approach. “Building back better” in the South-East Asia Region and beyond means taking stock of current weaknesses in often fragmented health systems and service functions and making changes to improve responsiveness, resilience and the capability to deliver better and more equitable health outcomes. This collection speaks to emerging insights and opportunities created by the willingness to adapt in the context of the COVID-19 pandemic but also to an urgent need to pay more attention to and invest more in PHC, before the health and economic impacts of the pandemic slow or reverse the progress made in recent decades. We hope that this collection serves to reinforce the need for enacted commitment to the vision of health for all, through investment in well-aligned governance, financing and structural reforms.
The article deals with the impact of the COVID-19 pandemic on the financing of the health care system, and the main challenges to the stability of the financial mechanisms of post-pandemic health care development have been identified. The author substantiates the peculiarities of the crisis of health care financing in the conditions of the current pandemic, further economic recession and decreased fiscal sustainability. The global practice of fiscal response to the manifestations of the COVID-19 pandemic has been systematized and the volumes of the corresponding financing in the countries with insurance and budgetary systems of health care financing have been estimated. The article identifies mechanisms for the transformation and expansion of the fiscal space in the context of expanded financing of the growing need for medical care in the face of new epidemic risks in different countries. Most often, the expansion of a country's fiscal space is carried out by: redistributing the existing amount of government expenditure for health care and redirecting funding flows from financing certain types of medical care to financing programs to overcome and combat COVID-19; changes in the priority of government health expenditure to combat COVID-19 compared to other budget expenditures on the social sphere and economic development; and using national reserve funds and emergency funds. It has been found that in the field of health care, the vast majority of countries have reduced the economic and territorial deprivation of all population groups in access to the diagnosis and treatment of COVID-19. The author emphasizes the weaknesses of insurance based and decentralized health financing mechanisms to respond to the growing need for health care and financial stability during the pandemic. Substantiated the necessity to expand the fiscal space needed to cover the fiscal gap in Ukraine caused by the requirement to increase health care financing in response
Étienne V Langlois, Andrew McKenzie, Helen Schneider, Jeffrey W. Mecaskey
Primary health care offers a cost-effective route to achieving universal health coverage (UHC). However, primary health-care systems are weak in many low- and middle-income countries and often fail to provide comprehensive, people-centred, integrated care. We analysed the primary health-care systems in 20 low- and middle-income countries using a semi-grounded approach. Options for strengthening primary health-care systems were identified by thematic content analysis. We found that: (i) despite the growing burden of noncommunicable disease, many low- and middle-income countries lacked funds for preventive services; (ii) community health workers were often under-resourced, poorly supported and lacked training; (iii) out-of-pocket expenditure exceeded 40% of total health expenditure in half the countries studied, which affected equity; and (iv) health insurance schemes were hampered by the fragmentation of public and private systems, underfunding, corruption and poor engagement of informal workers. In 14 countries, the private sector was largely unregulated. Moreover, community engagement in primary health care was weak in countries where services were largely privatized. In some countries, decentralization led to the fragmentation of primary health care. Performance improved when financial incentives were linked to regulation and quality improvement, and community involvement was strong. Policy-making should be supported by adequate resources for primary health-care implementation and government spending on primary health care should be increased by at least 1% of gross domestic product. Devising equity-enhancing financing schemes and improving the accountability of primary health-care management is also needed. Support from primary health-care systems is critical for progress towards UHC in the decade to 2030.
In the implementation of decentralization, the Special Allocation Fund (DAK) for health is given to certain areas of Indonesia to support health financing. The performance of this financing, along with national health development priorities’ achievements, is illustrated through the indicators of coverage of deliveries in health care facilities (PF) and coverage of first neonatal visits (KN1). Yearly increases in the health DAK budget have not been accompanied by increases in these coverages, and there are still significant disparities between regions. Using secondary data at the district/city level for 2014–2017, this study aims to investigate the impact of health DAK on coverage of PF and KN1. The analytical method deployed is linear regression of panel data using a fixed-effects model. The results show that in the short term, health DAK has a positive but insignificant effect on PF and KN1 coverage. However, health DAK has a positive and significant impact on PF coverage in the second year. Impact on KN1 coverage is unfeasible, even over a period of two years. These results indicate that the processes of planning, budgeting, and administering of health DAK require improvement so that benefits can be felt in the short term through better innovations in health programs. Nevertheless, given that our findings are based on a short period of study, the results from such analyses should consequently be treated with the utmost caution Therefore, future research should target a longer period of data collection to detect more trusty lagged effects and structural breaks of a policy intervention.
The Nigeria State Health Investment Project (NSHIP) was implemented in three Nigerian states between 2013 and 2018. Under the NSHIP, some local government areas were randomly assigned to Performance-Based Financing (PBF) intervention while others received decentralized facility financing (DFF) for comparison. This article evaluates the effect of PBF compared with DFF on health service delivery indicators in Adamawa state, under this quasi-experimental design, using the difference-in-differences technique. The analysis used health facility monthly data collected by the Health Management Information System through the District Health Information Software 2 (DHIS2). The PBF intervention group significantly increased the quantity of most of its service delivery indicators, such as antenatal care visits and deliveries by skilled personnel compared with the comparison group (DFF) after the introduction of NSHIP, although the baseline level of service delivery between PBF and DFF health facilities was statistically identical prior to the introduction of the intervention. We also conducted robustness check analysis to confirm the effect of PBF. Overall, we found a significant positive effect of PBF on most service delivery outcomes, except full vaccinations and post-natal care. One important policy implication is that we should carefully use PBF for targeted indicators.
BACKGROUND: The Philippines decentralized government health services through devolution to local governments in 1992. Over the years, opinions varied on the impact of devolved governance to decision-making for local health services. The objective of this study was to analyze decision-makers' perspectives on who should be making decisions for local health services and on their preferred structure of health service governance should they be able to change the situation. METHODS: We employed a mixed methods approach that included an online survey in one region and in-depth interviews with purposively-selected decision-makers in the Philippine health system. Study participants were asked about their perspectives on decision-making in the functions of planning, health financing, resource management, human resources for health, health service delivery, and data management and monitoring. Analysis of survey results through visualization of data on charts was complemented by the themes that emerged from the qualitative analysis of in-depth interviews based on the Framework Method. RESULTS: We received 24 online survey responses and interviewed 27 other decision-makers. Survey respondents expressed a preference to shift decision-making away from the local politician in favor of the local health officer in five functions. Most survey participants also preferred re-centralization. Analysis of the interviews suggested that the preferences expressed were likely driven by an expectation that re-centralization would provide a solution to the perceived politicization in decision-making and the reliance of local governments on central support. CONCLUSIONS: Rather than re-centralize the health system, one policy option for consideration for the Philippines would be to maintain devolution but with a revitalized role for the central level to maintain oversight over local governments and regulate their decision-making for the functions. Decentralization, whether in the Philippines or elsewhere, must not only transfer decision-making responsibility to local levels but also ensure that those granted with the decision space could perform decision-making with adequate capacities and could grasp the importance of health services.