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.
Pneumonia, the leading infectious killer of children under five, has been called a “forgotten killer,” “a neglected tragedy,” and a “global cause without champions.”1, 2 Despite causing 800 000 child deaths, more than HIV/AIDS, tuberculosis and malaria combined, pneumonia has never attracted the levels of support commensurate with its burden.3 Less than 5% of international Development Assistance for Health and just 3% of all infectious disease research spending, are allocated to pneumonia.4 While the Global Action Plan for Diarrhoea and Pneumonia (GAPPD)5 launched by World Health Organization and UNICEF in 2013 did set a global target of three child pneumonia deaths per 1000 live births by 2025, no government had developed a national strategy to achieve this target by 2019.a The lack of funding and planning have contributed to slow progress meeting the target and just two countries—Bangladesh and Indonesia—of the 20 with more than 10 000 annual child pneumonia deaths are on track to achieve the GAPPD pneumonia target.6 At current rates of progress, an estimated 6.3 million children will die from pneumonia by 2030 and many low- and middle-income countries (LMICs) will fail to achieve the sustainable development goal for child survival. The solution is not another vertical program channeling billions of dollars to tackle a single disease. There would be little appetite from national governments or the global health and development community for such a mechanism, which might undermine efforts to expand the reach of integrated community case management (iCCM) and integrated management of childhood illness (IMCI) and strengthen primary health care services to deliver Universal Health Coverage (UHC). Experience suggests that further reductions in child mortality in LMICs will require approaches that are sensitive to the complex patterns of comorbidity between pneumonia, diarrhea, malaria and malnutrition, and cognizant of the rising challenges of rapid urbanization, vaccine hesitancy, air pollution, and the double burden of under and overnutrition. The case for harnessing existing mechanisms such as Gavi, the Global Fund, Unitaid, and the Global Financing Facility to better integrate vaccine delivery, nutrition, and community case management is increasingly compelling, and much more work is needed to align the efforts of international agencies engaged in child survival in the high-burden countries.7 The Every Breath Counts Coalition (EBCC; https://stoppneumonia.org/) was officially launched in November 2017 to provide a platform for governments and international health agencies to work together to achieve the GAPPD target. In an acknowledgment of the progress achieved by the Global Fund and Gavi, the 40 member EBCC is a public-private partnership with representation from UN agencies, nongovernmental organizations (NGOs), private foundations, pharmaceutical and medical technology companies, and universities. Each member has made a written commitment to support government efforts to accelerate reductions in child pneumonia deaths according to their capabilities along with the prevention, protection, diagnosis, and treatment continuum. EBCC works with governments to develop data-based pneumonia control strategies, delivered as part of national primary health care strengthening and UHC efforts. The EBCC has prioritized support to four large “transnational” clusters with large populations of children at heightened risk of death from pneumonia including, (a) Chad, Nigeria, Niger, and Mali, (b) Democratic Republic of Congo and Angola, (c) Ethiopia and Somalia, and (d) Pakistan and Afghanistan, the ambition of which is to support the development of bespoke pneumonia control strategies in each country. At the global level, three EBCC teams drive progress towards specific childhood pneumonia “global public goods” including: The development of routine indicators to measure access to pneumonia diagnosis and treatment; a set of agreed research priorities; and robust advocacy and communications activities. As Nigeria has the largest population of children at greatest risk of death from pneumonia, the EBCC supported the Nigerian Federal Ministry of Health (FMoH) to develop a pneumonia control strategy between January 2019 and 2020. Coalition members including USAID, the Nigerian offices of Dalberg, Save the Children, UNICEF, and the Clinton Health Access Initiative (CHAI) joined forces to support the process. To better understand the barriers preventing faster progress on reducing child pneumonia deaths in Nigeria, the Family Health Department within the FMoH invited 75 participants to a strategy workshop in Abuja in January 2019. Following this workshop, approximately 40 interviews with national and global stakeholders, supplemented by desk research and analysis of state-level policies and data on the burden of pneumonia deaths, were conducted by the strategy firm Dalberg on behalf of the FMoH. By early March 2019, the FMoH and the EBCC had developed a draft pneumonia control strategy, and the FMoH invited 30 partners to meet in Abuja in April 2019 to review the strategy and align the contents with the RMNCAH+N Strategy. EBCC and the FMoH then worked together to develop a more detailed implementation plan and an estimation of the financial resources needed to implement the strategy. Less than 7 months after the process began, a final workshop to validate the strategy took place in Abuja in July 2019. In October 2019, the Minister of Health officially approved the strategy and the strategy was officially launched in Nigeria on January 2020. This strategy development process generated several key lessons. The pneumonia control strategy development process elevated the status of childhood pneumonia as a key public health challenge in Nigeria. Bringing together a range of public (eg, Federal and State Ministries of Health and donor government missions), private (eg, manufacturers of vaccines, medical devices, and antibiotics), faith-based organizations, and civil society actors demonstrated an appetite for a greater focus on pneumonia and drew attention to the gaps and barriers in pneumonia control that were impeding progress to Nigeria's child survival target. Despite many competing priorities in health, stakeholders involved in the process became champions for pneumonia control. Two NGOs, Save the Children and CHAI even decided to integrate parts of the pneumonia control strategy into their own newborn and child health programming. The pneumonia control strategy development process also showed that it is possible to focus on a specific cause of child death, while promoting integrated case management of childhood illnesses at community and facility levels (ie, iCCM and IMCI). By emphasizing that pneumonia should be accorded a level of attention commensurate with its disease burden, the FMoH and EBCC were able to reposition and prioritize pneumonia as a major killer, deserving of at least the same levels of investment as other leading but much better resourced killers (eg, malaria). The process to develop the pneumonia control strategy enhanced cross-sectoral and interministerial collaboration across all levels of government in Nigeria. Effective pneumonia control depends on the coordinated actions of different federal, state, and local government agencies to prevent, diagnose, and treat pneumonia at all levels of the health care system. The Nigerian FMoH had to work closely with the Agriculture, Energy, and Environment Ministries to prevent pneumonia by improving vaccination, nutrition, and clean air. In addition, the FMoH must find ways to influence State and Local Government health actors to improve the diagnosis and treatment of childhood pneumonia in primary health care and hospital services, as these are decentralized responsibilities. The FMoH and EBCC were able to bring these various government actors together for the first time to talk about pneumonia control and offer the support of private and nonprofit sector partners. Lastly, and critically, the experience in Nigeria highlights the importance of taking a data-driven approach that puts the most vulnerable populations of children first. While it is still challenging to map child pneumonia deaths at national and subnational levels, data are improving rapidly and governments have new tools to identify childhood pneumonia “hotspots” where deaths concentrate.8 In Nigeria, the subnational child pneumonia maps released by the Institute for Health Metrics and Evaluation in 2019 revealed “hotspots” in several northern states. Targeting pneumonia control efforts to these children represents the most cost-effective path to reduce pneumonia deaths and achieve the GAPPD target. The EBCC is committed to sharing these new tools with governments so that they can help direct scarce resources in ways that maximize the number of child pneumonia deaths prevented. These maps not only enable governments to prioritize the most vulnerable children but also to require their international health and development partners to do the same. Nigeria is pioneering a new approach to achieving the GAPPD target. Its pneumonia control strategy will need to be monitored and evaluated over the next 5 years to assess results, to ensure that partners are held accountable for delivering on their commitments and to capture learnings that can inform other governments. If successful, the Nigerian pneumonia control strategy could become a blueprint for other countries struggling with heavy burdens of child pneumonia deaths to achieve the GAPPD target and strengthen integrated newborn and child health policies and programs.
Haiti announced in 2018 its aim to achieve universal health coverage. In this paper, we discuss what this objective means for the country and what next steps should be taken. To contextualize the notion, we framed Haiti en route to the 2030 goal and analyzed qualitatively the status quo in terms of geographic, financial, and service access. For each dimension, we focused on the context, the government's policies and political agendas, their implementation progress, and key influential factors. Our analysis found little progress and numerous challenges. Geographic access was limited due principally to the insufficient number of facilities, difficulties in reaching health facilities, and local customs. Financial coverage was low because of the government's insufficient budgets, inefficient budget allocation, and ineffective management. Service access also had room for significant improvement for a lack of basic infrastructure and resources, gaps between the essential service package guidelines, health professionals' skills, and the needs, as well as deficiencies in people-centered care. These factors affected not only health service coverage but also its quality. We found that the root causes of these issues were composed of unstable financing mechanisms, opportunistic resource allocation, and ineffective management control systems. We suggest that to overcome these issues and achieve universal health coverage with decent service quality, Haiti's health system needs to be reformed by implementing strategic financing, decentralized management systems, and community engagement in primary health care.
ABSTRACT For the last three decades, healthcare systems have been under pressure to adapt to a neoliberal world and incorporate market principles. The introduction of market-based instruments, increasing competition among health care providers, introducing publicly -funded private sector provisioning of healthcare through health insurance financing systems to replace public provisioning of health care, promoting individual responsibility for health and finally, the introduction of market relations through privatization, deregulation and decentralization of health care have been some common elements seen globally. These reforms, undertaken under the guise of increasing efficiency and quality through competition and choice, have in fact harmed the physical, emotional and mental health of communities around the world and also contributed to a significant rise in inequities in health and healthcare access. They have weakened the public healthcare systems of countries and led to commercialization of healthcare. This article presents three case studies of resistance, to the commercialization of health care, by the People’s Health Movement (PHM) and associated networks. It aims to contribute to the understanding of the way neoliberal reforms, including those imposed under structural adjustment programmes and some promoted under the Universal Health Coverage (UHC) paradigm, have impacted country-level health systems and access of people to health care, and bring out lessons from the resistance against these reforms.
Health indicators have been gradually improving in India, but health for all is yet to be achieved. The life expectancy is 68.7 years, infant mortality rate is 33/1000 live births, maternal mortality ratio is 130/100,000 live births, and total fertility rate is 2.3 children/woman; however, large inequities by geography, gender, class, caste, religion, and region are seen.[1] Health of the Nation's States Report[2] indicates that despite rising income, poverty and hidden hunger still exist; environmental pollution has increased, more so, in urban areas; sanitation services and clean fuel use have not yet improved to the desired level, especially in the villages. In urban areas, slums have mushroomed, built area has increased, and open spaces have shrunk. Moreover, dietary patterns have changed in favor of more sugar, salt, fat, and alcohol, whereas consumption of vegetables and fruits has declined. Mechanization, especially motorized transport, has encouraged sedentary life styles and a rise in road traffic injuries is noticed. The gap between aspirations and real-life situations has pushed many into addictions and mental health problems. To address these issues, multisectoral public health actions are needed, in addition to the reorientation of health sector. In the last decade, the implementation of the National Health Mission (NHM) did bring back some focus on social determinants of health and encouraged development of a health system based on primary health care.[3] Investments in health system led to improvement in health services. It had an impact on health indicators, but the full potential of NHM is yet to be realized.[4] The recently announced Ayushman Bharat Mission (ABM) has started insurance coverage for selected package of medical and surgical procedures for hospitalized patients belonging to socioeconomically vulnerable families on the lines of Rashtriya Swasthya Bima Yojna though the insurance amount is larger.[5] The development of subcenters into health and wellness centers continues to be under the NHM. These two missions, i.e., NHM and ABM, deal with primary and secondary care, respectively. In the absence of a linkage between these two missions, it may not be possible to maintain a balance. Therefore, the funds earmarked for ABM should flow through the primary health-care system on per capita basis. The primary health-care providers should be empowered to decide which patient to refer, to which hospital (public or private), and at what cost to pay, so that ultimately health services are cashless for the patient. Coordinated actions are required not only within the health and family welfare ministry, but across multiple sectors. Hence, to operationalize multisectoral public health action in a decentralized manner, every village or urban ward should have Arogya Kendra (health center) financed by the state through a village or ward fund, but managed by local volunteers under the guidance of the community it serves, and it should have a decentralized Integrated Health Information System for Universal Health Care supported by Information Communication Technology (ICT), if possible. Devolution of funds to district health societies and decentralization of planning, implementation, and monitoring would build a sustainable system rooted in local sociocultural contexts, which will be able to harness the locally available resources. However, broad policy framework, guidelines, and oversight can remain at the central and state level. Primary health-care teams should be incentivized to invest in prevention and health promotion, so that health literacy improves and spending on illness care can be reduced. Therefore, NHM and ABM should advocate for a comprehensive public health-oriented “whole-of-government” intersectoral health promotion initiative keeping in view “inclusive growth” and “health development” as a social goal of the society. Health impact assessment of all public policies should be mandated by legislation. “Prevention of diseases” is a more cost-effective strategy than the popular approach of “Treatment.” Therefore, several countries have reengineered their health systems in a variety of ways to protect and improve peoples' health. For example, in England, the Health and Social Care Act 2012 reorganized the health services to create National Health Service England and Public Health England,[6] and in Thailand, the National Health Security Act 2002 granted everyone the right to a standard and efficient health service and established National Health Security Office to improve universal health coverage.[7] The World Health Organization has also recently planned a call to countries to set up leadership at all levels to protect the people from public health emergencies, to improve universal health coverage, and to ensure that people enjoy better health and well-being.[8] Indian should also reorganize its health system. Parliament should promulgate Indian Public Health Act with a mandate to protect and promote health of people as a fundamental right to health and health care. An autonomous “Public Health Commission” should be established to implement the provisions of the Act. It should have a public health commissioner with three deputy commissioners to head (a) epidemiology, (b) public policy, and (c) health promotion and education divisions. At state level, an additional public health commissioner should chair the State Public Health Commission which should have three deputy commissioners representing the above-mentioned three divisions, and at district level, a public health officer should head the District Public Health Commission who should be assisted by three additional public health officers. Each municipality should have a deputy public health officer and three public health supervisors. The Panchayat Raj Institutions, at district and community development block level, should have a deputy public health officer and an assistant public health officer. At Panchayat level, a public health supervisor should be appointed. Public Health Commission should have sufficient infrastructure (secretarial support staff, technical staff, equipment, office space, and budget) so that, in coordination with all sectors, a Public Health Action Plan can be prepared, funded, implemented, and monitored periodically. In summary, to achieve the universal health coverage, major challenge in India is promotion of health, prevention of diseases, and provision of health care in a balanced manner, which will require innovative public policies, strategies, and programs in many sectors. Development and implementation of a multisectoral approach to achieve sustainable development goals is the need of the hour. Establishment of a Public Health Commission will go a long way in achieving coordination of various initiatives not only in the Ministry of Health and Family Welfare but also in many other relevant ministries/sectors. At least 5% of the gross domestic product should be earmarked for public health and a responsive governance mechanism as outlined above should be set up, to achieve universal health coverage by 2030 as envisaged in the United Nations sustainable development goals which are also endorsed by the Government of India.[9]
Zambia has been using output-based approaches for over two decades to finance whole or part of the public health system. Between 1996 and 2006, performance-based contracting (PBC) was implemented countrywide with the Central Board of Health (CBoH) as the provider of health services. This study reviews the association between PBC and equity of access to maternal health services in Zambia between 1996 and 2006. A comprehensive document review was undertaken to evaluate the implementation process, followed by a trend analysis of health expenditure at district level, and a segmented regression analysis of data on antenatal care (ANC) and deliveries at health facilities that was obtained from five demographic and health survey datasets (1992, 1996, 2002, 2007 and 2014). The results show that PBC was anchored by high-level political support, an overarching policy and legal framework, and collective planning and implementation with all key stakeholders. Decentralization of health service provision was also an enabling factor. ANC coverage increased in both the lower and upper wealth quintiles during the PBC era, followed by a declining trend after the PBC era in both quintiles. Further, the percentage of women delivering at health facilities increased during the PBC era, particularly in rural areas and among the poor. The positive trend continued after the PBC era with similar patterns in both lower and upper wealth quintiles. Despite these gains, per capita health expenditure at district level declined during the PBC era, with the situation worsening after the PBC era. The study concludes that a nationwide PBC approach can contribute to improved equity of access to maternal health services and that PBC is a cost-efficient and sustainable policy reform. The study calls for policymakers to comprehensively evaluate the impact of health system reforms before terminating them.
<ns4:p> <ns4:bold>Background:</ns4:bold> Health sector decentralization, defined as the transfer of decision making over health sector resources from a central to a peripheral entity; has been and continues to be a widely adopted health system reforms in many low and middle-income countries (LMICs). However, its reported effects have been varied. Nevertheless, decentralization reforms aimed at providing public hospital management autonomy are increasing in prevalence in many LMICs. The range and form of this autonomy because of these reforms has often produced mixed effects. We set out to understand the range of financial management autonomy that has been granted to public hospitals in decentralized health systems in LMICs, and what forms of accountability arrangements have been used to facilitate this autonomy. </ns4:p> <ns4:p> <ns4:bold>Methods:</ns4:bold> We systematically searched PubMed, Google Scholar, Web of Science and CINAHL databases for published articles on this subject. We only included articles that reported empirical findings on hospital level financing and financial management in the context of decentralization in LMICs and/or those that included findings on hospital level finance management accountability arrangements. After a systematic search we found four articles that met our inclusion criteria. We undertook a thematic synthesis of the data and narrative reporting of our findings. </ns4:p> <ns4:p> <ns4:bold>Results:</ns4:bold> From the review – we find that decentralization reforms did not result in improved funding flows, finance management autonomy or accountability mechanisms and for public hospitals. These outcomes were irrespective of the mode and form of decentralization reform adopted. </ns4:p> <ns4:p> <ns4:bold>Conclusion:</ns4:bold> From our review, it is evident that though health sector decentralization reforms have been widely promoted and adopted in the past few decades across LMICs, there is minimal evidence that these reforms have improved funding flows to public hospitals, improved financial management autonomy or accountability mechanisms; so as to enhance the performance of these hospitals at sub-national level. </ns4:p>
Trisya Rakmawati, Reece Hinchcliff, Jerico Franciscus Pardosi
The local-level impacts of decentralizing national health systems are significant yet infrequently examined. This review aims to assess whether localized health services delivery in Indonesia, which commenced a health system decentralization process in 2001, achieved its objectives or could be enhanced. A systematic review was undertaken to collate published evidence regarding this topic and synthesize key findings holistically using the six building blocks framework of the World Health Organization (WHO) to categorize health system performance. Four research databases were searched in 2016 for relevant evidence published between 2001 and 2015. The inclusion criteria were relevance to the topic of decentralization impacts at the district level, original research, and published in English. Included articles were appraised for quality using a standardized tool, with key findings synthesized using the WHO building blocks. Twenty-nine articles met the inclusion criteria and categorized under the WHO building blocks categories. The findings highlight problematic impacts of decentralization related to three building blocks: service delivery, health financing, and workforce. In the 15 years of post-decentralization in Indonesia, the service delivery, health workforce, and health financing blocks should be prioritized for further research and policy evaluation to improve the overall health system performance at the district level.
BACKGROUND: Universal health coverage (UHC) assures all types of health service and protects all citizens financially in any conditions due to illness. Globally, the UN sustainable development goal (SDG) provides high priority for UHC as a health related goal. The National health system of Nepal has prioritized in similar way. The aim of this study is to explore the challenges and opportunities on the road to UHC in Nepal. METHOD: We used varieties of search terminologies with popular search engines like PubMed, Google, Google Scholar, etc. to identify studies regarding Nepal's progress towards UHC. Reports of original studies, policies, guidelines and government manuals were taken from the web pages of Ministry of Health and its department/division. Searches were designed to identify the status of service coverage on UHC, financial protection on health particularly, health insurance coverage with its legal status. Other associated factors related to UHC were also explored and presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. RESULTS: We found 14 studies that were related to legal assurance, risk pulling and financing of health service, 11 studies associated to UHC service coverage status and, 7 articles linked to government stewardship, health system and governance on health care. Constitutional provision, global support, progress on the health insurance act, decentralization of health service to the grass root level, positive trends of increasing service coverage are seen as opportunities. However, existing volunteer types of health insurance, misleading role of trade unions and high proportion of population outside the country are main challenges. The political commitment under the changing political context, a sense of national priority and international support were identified as the facilitating factors towards UHC. CONCLUSION: To achieve UHC, service and population coverage of health services has to be expanded along with financial protection for marginalized communities. Government stewardship, support of stakeholders and fair contribution and distribution of resources by appropriate health financing modality can speed up the path of UHC in Nepal.
The 2012 national health policy is the \n overarching health policy framework in Zambia. The policy \n takes a human rights approach to health care provision, \n where all citizens are entitled to basic health care \n (Ministry of Health 2012). The policy is actualized through \n successive five-year national health strategic plans. \n Operationally, Zambia’s health system is centralized, with \n delegated responsibilities from the center to lower levels \n of the health care delivery system. The Ministry of Health \n plays a dual role of policy formulation and strategic \n planning and delivery of health services, with provincial \n and district health offices being upwardly accountable to \n the Ministry of Health headquarters. Going forward, Zambia \n is in the process of launching two major reforms which will \n further affect the organization of the health sector. These \n are (a) implementation of the National Decentralization \n Policy, and (b) introduction of a National Health Insurance \n (NHI) scheme. The PHC function (including transfer of PHC \n staff to local government authorities) is among the front \n runner for decentralization. If national decentralization is \n fully implemented, it will affect the way health services \n are organized, delivered, and financed in the country. Thus, \n adequate preparations in the health sector are required to \n minimize challenges. Secondly, Zambia enacted the NHI Act in \n April 2018 which provides the legal mandate to establish the \n NHI management authority, and the NHI scheme. At the time of \n this study, it was envisaged that implementation of the NHI \n scheme will be done in a phased manner with a view of \n covering the entire population in the medium to long term. \n However, depending on the final design and implementation \n process, the NHI will have a substantial effect on the \n financing and delivery of health programs and services in \n Zambia. One of the immediate challenges will be providing \n insurance cover to the informal sector and indigent people \n in rural areas.
Financing is a major challenge and concern for the future of family planning (FP) programs. As countries commit to increasing access to and quality of FP services and to universal health care (UHC), it is crucial that UHC schemes include FP and other reproductive health services. This brief aims to: 1) document trends in UHC and health financing, drawing out implications for policymakers and programmers; and 2) identify opportunities for the FP community of practice to advocate for the inclusion of quality FP services within UHC and health financing discussions. With this brief, we aim to highlight experiences in Kenya, given that there is a body of experience with health financing reforms and UHC schemes and a relatively strong national FP program. The Kenya case study is instructive for other countries with decentralized and mixed health systems as they seek to integrate FP within their own UHC initiatives and health financing reforms.
Nathaniel Mason, Charles O. Oyaya, Julia Boulenouar
Abstract Motivation Across the Global South, unclear institutional frameworks undermine progress in improving services. Often, ongoing decentralization reforms reduce clarity further. Policy professionals working on institutional reform lack comparative models. Purpose To identify key challenges for the institutional arrangements for urban sanitation in decentralizing contexts, in Kenya and elsewhere, and to propose possible responses. Approach and methods We use key informant interviews and literature review in a problem‐driven analysis, drawing from three comparative case studies: South Africa, Indonesia and Tamil Nadu State. The analysis builds upon research on institutional effectiveness—co‐operation, collaboration and co‐ordination—rooted in game theory and elaborated in the 2017 World Development Report. Findings Three key problems in Kenya are identified: overlaps and competition around sector leadership at national and devolved levels; weak incentives for county governments to commit policy attention and finance, despite devolution; and limited regulatory oversight. Policy implications We identify a range of options for urban sanitation policy‐makers: (a) to engage non‐sectoral authorities in co‐ordinating multi‐sectoral issues across all levels of government; (b) to encourage political commitment to pro‐poor sanitation services at decentralized levels; and (c) to use incentive‐based and risk‐based approaches to regulate decentralized entities and strengthen local capacity for monitoring and enforcement.
BACKGROUND: Decentralization is promoted as a strategy to improve health system performance by bringing decision-making closer to service delivery. Some studies have investigated if decentralization actually improves the health system. However, few have explored the conditions that enable it to be effective. To determine these conditions, we have analyzed the perspectives of decision-makers in the Philippines where devolution, one form of decentralization, was introduced 25 years ago. METHODS: Drawing from the "decision space" approach, we interviewed 27 decision-makers with an average of 23.6 years of working across different levels of the Philippine government health sector and representing various local settings. Qualitative analysis followed the "Framework Method." Conditions that either enable or hinder the effectiveness of decentralization were identified by exploring decision-making in five health sector functions. RESULTS: These conditions include: for planning, having a multi-stakeholder approach and monitoring implementation; for financing and budget allocation, capacities to raise revenues at local levels and pooling of funds at central level; for resource management, having a central level capable of augmenting resource needs at local levels and a good working relationship between the local health officer and the elected local official; for program implementation and service delivery, promoting innovation at local levels while maintaining fidelity to national objectives; and for monitoring and data management, a central level capable of ensuring that data collection from local levels is performed in a timely and accurate manner. CONCLUSIONS: The Philippine experience suggests that decentralization is a long and complex journey and not an automatic solution for enhancing service delivery. The role of the central decision-maker (e.g. Ministry of Health) remains important to assist local levels unable to perform their functions well. It is policy-relevant to analyze the conditions that make decentralization work and the optimal combination of decentralized and centralized functions that enhance the health system.
Moritz Piatti-Fünfkirchen, Magnus Lindelöw, Katelyn Jison Yoo
Progress toward universal health care (UHC) in Africa will require sustained increases in public spending on health and reduced reliance on out-of-pocket financing. This article reviews trends and patterns of government spending in the East and Southern Africa regions and points out methodological challenges with interpreting data from the World Health Organization's (WHO) Global Health Expenditure Database (GHED) and other sources. Government expenditure for health has increased for most countries, albeit at a slower rate than gross domestic product (GDP). In most countries there has been a prioritization away from health in government budgets, putting the onus on the private sector and donors to fill the gap. Donor support is important in the region but reliance on external spending is not consistent with countries' stated ambitions of universal health coverage. A number of methodological challenges with estimating health expenditures are identified. Capturing health expenditures adequately across agencies and levels of decentralization can be challenging, and off-budget funds and arrears are evasive. Measurement error can be significant because actual expenditure information can be hard to come by and is often dated and unreliable. Furthermore, how external financing is captured will affect government health expenditure estimates. These factors have contributed to differences in expenditure estimates between the WHO GHED and country-specific public expenditure reviews and complicate interpretation. The article concludes that it is critical to strengthen national data capacity and international efforts to promote quality and consistency of data. The GHED is an invaluable resource for monitoring and benchmarking health expenditures. It is best used in combination with deep dive country expenditure assessments.
BACKGROUND & OBJECTIVES: Numerous studies have highlighted the regressive and immiserating impact of out-of-pocket (OOP) health spending in India. However, most of these studies have explored this issue at the national or up to the State level, with an associated risk of overlooking intra-State diversities in the health system and health-seeking behaviour and their implication on the financial burden of healthcare. This study was aimed to address this issue by analyzing district level diversities in inequity, financial burden and impoverishing impact of OOP health spending. METHODS: A household survey of 62,335 individuals from 12,134 households, covering eight districts across three States, namely Gujarat, Haryana and Rajasthan was conducted during 2014-2015. Other than general household characteristics, the survey collected information on household OOP [sum total of expenditure on doctor consultation, drugs, diagnostic tests etc. on inpatient depatment (IPD), outpatient depatment (OPD) or chronic ailments] and household monthly consumption expenditure [sum total of monthly expenditure on food, clothing, education, healthcare (OOP) and others]. Gini index of consumption expenditure, concentration index and Kakwani index (KI) of progressivity of OOP, catastrophic burden (at 20% threshold) and poverty impact (using district-level poverty thresholds) were computed, for these eight districts using the survey data. The concentration curve (of OOP expenditure) and Lorenz curve (of consumption expenditure) for the eight districts were also drawn. RESULTS: The distribution of OOP was found to be regressive in all the districts, with significant inter-district variations in equity parameters within a State (KI ranges from -0.062 to -0.353). Chhota Udepur, the only tribal district within the sample was found to have the most regressive distribution (KI of -0.353) of OOP. Furthermore, the economic burden of OOP was more pronounced among the rural sample (CB of 19.2% and IM of 8.9%) compared to the urban sample (CB of 9.4% and IM of 3.7%). INTERPRETATION & CONCLUSIONS: The results indicate that greater decentralized planning taking into account district-level health financing patterns could be an effective way to tackle inequity and financial vulnerability emerging out of OOP expenses on healthcare.
Adelyne Maria Mendes Pereira, Luciana Dias de Lima, Cristiani Vieira Machado
This article discusses the processes of de centralization and regionalization of health policy in Brazil and Spain between 1980 and 2015. The study was developed with contributions of the historical institutionalism and of the historical com parative method, by means of three dimensions of analysis: State context; trajectory and institution ality of the decentralization and regionalization of health; and constraints. The study showed that,in both countries, the more general context of re-democratization and decentralization of the State conditioned the reforms of health systems and their political-administrative organization. In addition, historical, institutional and political factors have had a specific impact in each case, influencing the regional organization of services, the balance of power and the division of responsibilities between the governmental spheres in the management, financing and coordination of health policy. The study suggests that the way these factors interrelated over time is important for understanding the decentralization and regionalization of health systems in different contexts.
Background: Governments engage in setting health sector priorities among competing interests to maximize health system goals within the available resources. This is important as misalignment between health priorities and budget allocations can lead to low budget allocations and underspending in the health sector.\nGoal: The goals of the study are twofold. First, measure the extent of alignment between a stated government priority and actual government expenditure. Second, if there is misalignment, explain the underlying bottlenecks including institutions, structures, and capacities.\nMethod: The study focuses on one stated health sector priority shared between Kenya and Mozambique, which is improving geographical equity of governmental resources for health. An explanatory mixed methods design is used, in which quantitative analysis is followed by a qualitative assessment. In quantitative analysis, Gini index is used to summarize the differences in per capita health expenditures across regions. In addition, health expenditure is decomposed as a product of total budget, health budget priority, and health budget execution to identify whether resource allocation or resource utilization lead to geographical inequity. The qualitative assessment consisted of 23 semi-structured key informant interviews, 10 for Kenya, 11 for Mozambique, to explain the quantitative results.\nResults: In both Kenya and Mozambique there is geographical inequity in government health spending, which is inconsistent with the stated government priority (Gini greater than zero). The decomposition of health expenditure suggests that, in Kenya, the misalignment is driven by both resource allocation and utilization processes; in Mozambique, it is driven largely by the resource allocation process. \nThe qualitative analysis reveals several bottlenecks that are common between the two countries. At the institutional level, there is institutional separation between planning and budgeting, decision-making is ad hoc, and difficult decisions on hard choices and tradeoffs are left to the end of the budget process. At the structural level, rapid and unplanned decentralization in Kenya and the deconcentration model in Mozambique have led to inadequate structures to align planning and budgeting. At the capacity level, there are too many administrative demands on planning and budgeting staff, who also lack technical expertise and adequate data to make evidence-based decisions.
For countries looking to implement multisectoral nutrition plans, it is critical to understand what works and how programs should be delivered and scaled-up in each context. Programs can learn from each other on how to adapt to new information, evidence and events related to scaling-up and district stakeholders can play important roles in implementation of this multisectoral plan. As part of "Pathways-to-Better Nutrition" (PBN) case study conducted by USAID/SPRING Project, this research set out to explore district leaders' perceptions of the nutrition situation, programs and opportunities for integration. Qualitative data were collected through key-informant interviews and focus group discussions. Thirty-five district and local leaders belonging to district and sub-county multisectoral nutrition committees in Kisoro and Lira were interviewed. Grounded Theory Approach was used to identify themes for coding and key domains included: learning, adoption and evidence of scale-up; adoption of innovations/interventions to local context, financing of nutrition-sensitive activities and long-term planning. Additionally, quantitative data collected by Feed the Future Innovation Lab for Nutrition were analyzed in each of the districts to provide nutrition snapshots. Malnutrition in the study districts was worse than the national average for stunting, anemia and women's underweight. The majority (91%) of respondents were not familiar with these nutrition statistics. Both study areas have formed nutrition multisectoral working groups (District Nutrition Coordinating Committees) and have developed management structures to implement interventions. Government stakeholders from every nutrition-sensitive sector referred to the lack of clear government programs that support nutrition directly in local policy environment. Key agricultural-related programs are focusing on wealth creation, value-addition or increasing agricultural productivity without nutrition lens (not "nutrition sensitive"). Nutrition is not on the 'list' of key priorities of district health departments unlike HIV/AIDS, malaria or sexual reproductive health. About 69% respondents believe they lack operational capacities and soft-power skills to design, implement and manage nutrition interventions such as leveraging of resources and being able to convey evidence. The understanding of "Scaling-up Nutrition" also differed by respondent, and this has resulted in different goals and measurements. Challenges related to nutrition financing were also noted, including fiscal decentralization, use of Output-Based Financing mechanisms, limited flexibility to re-allocate funds for nutrition, and lack of standard reporting procedures or implementation strategy. Efforts to address malnutrition need to be multisectoral, coupled with increased coordination of different sectors and ministries for sustained impact on nutrition outcomes.
Marcelo Battesini, Carla Lourenço Tavares de Andrade, Marismary Horsth De Seta
Health Surveillance carries out a set of actions to prevent health risks related to the consumption of products and the provision of services under the Unified Health System (SUS). The implementation of Health Surveillance actions relies heavily on the federal funding policy, which induces its decentralization. This text aims to analyze the federal funding of Health Surveillance to States and Municipalities from the scheduled onlendings in the period 2005-2012. Among the main results are the increase of per capita values, steady at around the mean value of R$ 1.25/inhabitant/year; the increased number of municipalities that agreed to carry out strategic actions; and a stable trend in the proportions of each federated entity at around 50% to Municipalities, 25% to state federated entities and 20% to the Central Public Health Laboratories (LACENs). Results show that the adoption of unified nationwide per capita values caused distortions that indicate inequity among state territories, pointing to the need to clarify the concept of equity in financing under the National Health Surveillance System and to broaden the discussion on the currently used allocation criteria.
Edwine Barasa, Anthony Muchai Manyara, Sassy Molyneux, Benjamin Tsofa
BACKGROUND: In 2013, Kenya transitioned into a devolved system of government with a central government and 47 semi-autonomous county governments. In this paper, we report early experiences of devolution in the Kenyan health sector, with a focus on public county hospitals. Specifically, we examine changes in hospital autonomy as a result of devolution, and how these have affected hospital functioning. METHODS: We used a qualitative case study approach to examine the level of autonomy that hospitals had over key management functions and how this had affected hospital functioning in three county hospitals in coastal Kenya. We collected data by in-depth interviews of county health managers and hospital managers in the case study hospitals (n = 21). We adopted the framework proposed by Chawla et al (1995) to examine the autonomy that hospitals had over five management domains (strategic management, finance, procurement, human resource, and administration), and how these influenced hospital functioning. FINDINGS: Devolution had resulted in a substantial reduction in the autonomy of county hospitals over the five key functions examined. This resulted in weakened hospital management and leadership, reduced community participation in hospital affairs, compromised quality of services, reduced motivation among hospital staff, non-alignment of county and hospital priorities, staff insubordination, and compromised quality of care. CONCLUSION: Increasing the autonomy of county hospitals in Kenya will improve their functioning. County governments should develop legislation that give hospitals greater control over resources and key management functions.
Rwanda is a good example of how a country can overcome challenges and obstacles to improve the socioeconomic well-being of citizens. With no reliable healthcare system in 1994, after the genocide against the Tutsi, the country has come a long way in building a decent healthcare system for its people. The purpose of this research is to analyze the changing PPP mixed in health care sector in Rwanda. The study was carried out to reflect/reveal or bring to light the perennial problems of the healthcare mixes within a period of six months. This work looked at the public-private sector mixes in healthcare system using Rwanda as a case study. In Rwanda, the ministry of health began health sector reforms in accordance with the Lusaka declaration in 1995. These reforms included decentralization of the health system, development of the primary healthcare system, and community participation in managing health service financing. Rwanda is one of the few African countries with 90% coverage in all Districts for immunization and access to critical health services including TB treatment and access to ARVs for HIV patients. Within a very short period of 23 years, Rwanda has built a working health system in which even the poor and disadvantaged have access to quality medical care through the Community Based Health Insurance.