Abstract Background Ethiopia has pursued Health Care Financing (HCF) reforms for over two decades as part of its commitment to achieving Universal Health Coverage (UHC). With a health policy anchored in Primary Health Care (PHC) and a decentralized planning framework, the country has introduced numerous interventions to strengthen domestic resource mobilization, enhance autonomy at service delivery points, and build local capacity. Methods This study analyzes PHC budget allocation and expenditure trends in 15 woredas across five regions from 2010 to 2016, using mixed methods. Results Financing of the HSS-PHC system yielded a performance score of 29%, indicating significant challenges in resource allocation and financial management. Two key indicators determined this: Funding and allocation of resources (14%) and purchasing and payment systems (39%). While nominal health budget allocations have increased over time, real-term values adjusted for the non-food consumer price index have declined. The average PHC spending represented 17.3% of general government expenditureâexceeding the Abuja Declaration targetâyet regional disparities were notable, ranging from 9% to 26.4%. Persistent challenges, especially in CBHI implementation, exempted service reimbursement, and provider-level autonomy, were particularly pronounced in pastoralist regions. Conclusions Inadequate budget allocation from the treasury, the expanding need of communities, shocks from different emergencies, and high inflation rates in recent years have led to widening gaps in health financing. Alternative financing mechanisms (CBHI) didnât catch up with the widening gap because of inadequate implementation, low potential as a financing strategy due to low premium rates, and lack of mechanisms to enforce reimbursement of health facilities. These findings underscore the need to reinforce public financial management and leadership capacity at district and facility levels to ensure more equitable, efficient, and transparent PHC financing.
ABSTRACT: Tobacco consumption remains a major public health concern globally due to its significant contribution to the burden of non-communicable diseases and associated economic costs. In decentralized governance systems, the effectiveness of tobacco control policies is influenced not only by regulatory frameworks but also by fiscal commitment and institutional capacity at subnational levels. This study aims to examine the relationship between tobacco-related fiscal transfers and the implementation of smoke-free policies across regional governments in Indonesia. A quantitative research design employing panel data analysis was used to evaluate fiscal allocation patterns and policy implementation dynamics during the period 2023â2025. Secondary data were obtained from national fiscal reports, regional budget documents, and administrative policy records. The findings indicate that although tobacco excise revenue transfers increased overall, regional commitment to allocating budgets for smoke-free policy implementation remained uneven. Econometric estimation demonstrates that tobacco revenue transfers and regional tobacco tax income significantly influence policy implementation commitment, while institutional capacity moderates the effectiveness of fiscal resource utilization. These results highlight the importance of strengthening fiscal health governance mechanisms, including performance-based intergovernmental transfers and integrated policy coordination, to ensure that tobacco tax revenues effectively support preventive health interventions and contribute to improved population health outcomes.
Dr Muâazu Omeiza Musa, Professor Olugbenga-Bello Adenike, MBBS, PhD, Adah Patrick Eneojo, Dr Onoja-Alexander Mary Ojonema, MBBS, PhD FWACP · 7 authors
Strengthening Primary Health Care (PHC) financing, governance, and operational readiness is fundamental to achieving resilient health systems and sustainable health security in low- and middle-income countries. Between 2022 and 2025, the Kogi State Government implemented a package of PHC reforms comprising Decentralized Facility Financing (DFF), the Minimum Service Package (MSP), and Continuous Quality Improvement (CQI) interventions to improve service delivery, strengthen facility readiness, stabilize commodity supply systems, and expand equitable access to vulnerable and hard-to-reach populations. We evaluated the Health Systems for Health Security success coefficients in Kogi State using a facility month DHIS2 panel of n=96 PHCs (January 2019âDecember 2025) and BHCPF Monthly Report Forms (2024â2025). The quasi experimental mixed methods design combined an augmented two way fixed effects Difference in Differences (DiD) estimator for average treatment effects, Interrupted Time Series (ITS) segmented regression to decompose immediate (level) and sustained (slope) impacts, multilevel mixed effects models for heterogeneity, and bootstrap causal mediation to quantify operational pathways. Models adjusted for seasonality, HRH density, environmental risk, and facility fixed effects; inference used cluster robust standard errors and bootstrap confidence intervals. Primary analysis used R (4.3.2) with lme4, fixest, brms/rstanarm, INLA, MatchIt/WeightIt, CausalImpact, sf, spdep; confirmatory DiD and event study checks used Stata/MP 18.0. All code was versioned in Git and analysis notebooks and key outputs were archived. DFF with CQI produced statistically and programmatically meaningful gains across core BMPHS indicators: DPT3 +6.2 percentage points (95% CI 3.9â8.5); ANC1 +5.1 pp (95% CI 2.8â7.4); SBA +4.8 pp (95% CI 1.9â7.7); PNC +4.3 pp (95% CI 1.6â7.0). ITS decomposition for DPT3 showed an immediate level increase of +3.7 pp (95% CI 1.9â5.5) and a sustained slope of +0.12 pp/month (95% CI 0.06â0.18). Mediation analysis attributed large shares of the DPT3 gain to facility readiness, functional Ward Development Committees, tracer drug availability, and IPC compliance as the largest contributors. Predictable facility financing coupled with CQI and targeted investments in readiness, governance, and supply chain resilience yields rapid and sustained improvements in immunization and maternal health coverage. Policy priorities include protecting cold chain and tracer drug lines, institutionalizing WDC governance and IPC audits, and targeting surge HRH and outreach financing to high risk LGAs to close equity gaps. The findings demonstrate the predictability of decentralized financing combined with CQI, governance strengthening, outreach expansion, and operational readiness investments towards the improvement of PHC utilization, immunization coverage, maternal health services, and health system resilience. The study provided epidemiologic evidence to test integrated PHC financing reforms relevance in the strengthening of Health Systems for Health Security (HSFORSHS) in improving accessibility, equity, preparedness, surveillance functionality, and continuity of essential services in vulnerable populations.
Background: Mental health accounts for an estimated 14% of the global disease burden yet receives less than 2% of health budgets in most countries, with even lower investment in low- and middle-income settings. This study examines federal mental health financing trends from 2021-2025 to assess whether legislative reform translated into fiscal prioritization. Methods: A mixed-methods policy analysis was conducted, combining quantitative analysis of federal budget appropriation documents (2021-2025) with qualitative documentary review and comparative case studies. Mental health allocations were assessed by recurrent and capital expenditure, institutional distribution, and proportional share of total federal health spending. WHO reports, national policy documents from Ghana and Kenya, and peer-reviewed literature informed comparative analysis. Results: Federal mental health allocations increased from âŠ23.33 billion in 2021 to âŠ88.24 billion in 2025, a 278% nominal rise. However, the sectorâs share of the total health budget declined from 3.67% to 3.12%, indicating relative marginalization. Over 90% of funding supported recurrent expenditures in ten federal neuropsychiatric hospitals, with minimal investment in community-based services or primary care integration. In contrast, Ghana and Kenya more effectively leveraged legislation, fiscal decentralization, and insurance mechanisms to expand access. Conclusion: Despite legislative reform, Nigeriaâs mental health financing remains centralized, hospital-focused, and misaligned with population needs. Institutional inertia, weak coordination, and delayed implementation of the Act have constrained equitable scale-up. Activating the Mental Health Fund and integrating mental health into national financing mechanisms are urgently required to prevent deepening inequities.
James Kinjanzi Sirite, Prof. David Minja, Jane Njoroge
Purpose: This study examined the effect of revenue decentralization on healthcare service delivery in Turkana County, Kenya. Materials and Methods: Using a mixed-methods approach, the research collected data from 271 respondents, including county health and finance officials, hospital administrators, and community health representatives. Findings: The findings reveal that revenue decentralization significantly improves healthcare service delivery, with a one-unit increase in revenue decentralization leading to a 0.49-unit improvement in healthcare outcomes. However, delays in budget disbursement (averaging 5.11 months) and reliance on external revenue sources (36.9% tax autonomy) highlight challenges in financial sustainability and resource allocation. Qualitative responses underscore both the benefits of increased autonomy and access to funding, as well as the drawbacks of concentrated financing and disparities in rural healthcare access. The study concludes that optimizing tax autonomy mechanisms, strengthening intergovernmental grants, and improving financial management are critical to enhancing the positive effects of revenue decentralization. These findings contribute to the broader discourse on fiscal decentralization and its potential to address healthcare inequities in marginalized regions. Unique Contribution to Theory, Practice and Policy: To improve healthcare in Turkana County, enhance revenue decentralization by refining tax autonomy, increasing equitable intergovernmental grants, and addressing rural disparities. Implement 'nomadic health vouchers' using 15% of decentralized revenues and 'fiscal health compacts' to reduce budget delays. Ensure autonomy, accountability via blockchain, and drought-responsive budgets work together to boost accessibility and patient support, transforming fiscal policy into a tool for healthcare justice, especially for mothers and herders facing long waits and travel for care.
Reading the letter âTransforming Health Insurance in Bangladesh: A Future-Ready Approachâ that was submitted in response to âThe Urgent Need for Developing a Common Health Insurance Policy in Bangladesh: A Perspectiveâ [1] inspired me to write this response, and I am grateful to the author(s) for their work. The author(s) makes a valid and necessary point about the need for a paradigm shift away from traditional state-led models and towards decentralized, technology-driven, behaviorally informed strategies. But while we're looking at the present situation, we must also recognize the government's current efforts and see how they could support or even lay the groundwork for a universal health insurance program that would benefit all citizens. The Health Ministry of Bangladesh has announced that the government has initiated a program to offer free medical treatment and medications to the population. The ministry has announced plans to implement 24-h health services at 500 centers and to distribute a healthcare card to each household under the âShyastha Surokkha Karmasuchiâ (SSK) package. This card enhances patient identification at hospital admission and optimizes the payment process by monitoring diagnostic information and service usage; however, it has not been fully implemented yet [2]. The government's efforts to improve healthcare access and quality are commendable, but they also bring attention to a basic problem. People with lower and medium incomes, as well as those working in the informal economy, are disproportionately impacted by the unequal distribution of resources caused by the tax-based approach that forms the basis of many of these programs. Several economic studies have pointed out that, in Bangladesh, many families continue to struggle financially since out-of-pocket costs make up around 68.5% of overall healthcare spending [3]. Despite the importance of programs like SSK that offer free services, this circumstance shows that these efforts do not solve the underlying problems with the healthcare funding system, which include structural disparities and financial instability. A shift toward a universal, all-encompassing health insurance system seems essential and advantageous in this light. A strong health insurance system might have two benefits: first, it would help those who can't pay for medical treatment get coverage, and second, it would provide a system for reliable, long-term financing. Germany, France, and Japan are only a few examples of the nations that have demonstrated that social-insurance models may achieve both universal coverage and fair allocation of resources through income-based premiums and required participation [4]. The difficulty for Bangladesh comes from trying to apply these models to our own social and economic situation. The large informal sector of the Bangladeshi economy, which has long been exempt from traditional tax and insurance systems, is a major obstacle to the widespread adoption of health insurance. We propose a multi-pronged strategy to address this. To begin, one way to guarantee affordability is through progressive premium systems, in which contributions change according to income levels. Premium payments from informal workers might be made easier with the use of innovative collecting techniques, such as community-based networks and mobile payment systems like âbKashâ and âNagad,â which would reduce administrative responsibilities [5]. Second, providing low-income groups with government subsidies is essential. The state may make sure that no one is left out because they don't have enough money by paying part of the premiums for those who are vulnerable. It is really essential for everyone to take part; to eliminate coverage gaps and deal with fluctuating participation rates, it is recommended to use a default opt-in method. This means that all citizens would be automatically registered in the health insurance program, and opting out would only be permitted under certain circumstances. Behavioral economics principles have been used successfully in other contexts to significantly boost enrollment using this method. The insurance system's risk pool and financial foundation may be further expanded if measures were to be considered that would promote the formalization of workers in the informal sector [5]. Integrating technology stands alongside these funding improvements as another pillar of a health insurance system prepared for the future. Claims processing using blockchain technology, for instance, has the potential to streamline administrative operations, make them more transparent, and cut down on fraud and settlement delays [6]. Furthermore, predictive underwriting algorithms have allowed for more precise and inexpensive premium changes in East African pilot programs using AI-driven adaptive pricing techniques [7]. Bangladesh can create a system that can handle large-scale operations while catering to people of varying income levels by adopting this state-of-the-art technology. Without the larger healthcare system, no health insurance system can possibly operate. While it is great that SSK and other government programs are working to make services more accessible, such as free prescription programs and 24/7 care centers, these efforts should be supplemented by steps to make sure healthcare resources are distributed fairly. When contrasted with metropolitan regions, rural communities still lack enough infrastructure and medical specialists. We can encourage fair allocation of resources with a single health insurance system that is built with targeted incentives and a tiered reimbursement mechanism. For instance, healthcare providers may be more motivated to offer high-quality services to rural communities if they were to get higher payment rates for institutions in underserved locations and participate in public-private partnerships. In conclusion, free healthcare programs are a huge step forward, but they also show how flawed a system that relies just on taxes to pay for healthcare may be. The solution to long-term, fair healthcare in Bangladesh lies in a universal health insurance system that is prepared for the future and can flexibly integrate public programs with creative private sector solutions. The healthcare system in Bangladesh may be revolutionized by adopting a hybrid model that incorporates digital technology, progressive premium collections, behavioral defaults, and mandated insurance. A more equitable and effective distribution of resources would be fostered by such a system, which would shield its inhabitants from ruinous medical bills. It is anticipated that these reflections will contribute to the ongoing conversation regarding the enhancement of healthcare financing in Bangladesh. An approach that is collaborative and integrates the benefits of state-driven initiatives with decentralized, technology-enabled, and socially equitable models is likely to facilitate long-term reform. S.M.R.D. conceptualized, supervised, and wrote the draft. The author has nothing to report. The author declares no conflicts of interest. The lead author SMRD affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
The article explores the transformation of public administration mechanisms in the healthcare system under conditions of decentralization. The study aims to analyze the impact of decentralization on the transformation of public administration in the healthcare sector of Ukraine and to identify the challenges and directions for improving its management processes. The research examines current healthcare reforms being implemented in Ukraine, particularly the introduction of the National Health Service, the electronic healthcare system, new financing mechanisms through the Medical Guarantee Program, and the decentralization of powers to the local level. The dynamics of healthcare funding in Ukraine for 2023â2024 are analyzed, indicating the continued prioritization of the sector amidst public administration reforms. A positive trend has been observed in the increased budget allocations for specialized care, centralized procurement of medicines, emergency response, and other key areas. The analysis of international experience shows that the effectiveness of decentralization depends on the fiscal autonomy of communities, managerial capacity, transparency in decision-making, and precise coordination between levels of government. The study substantiates that decentralization opens new opportunities to improve the efficiency and accessibility of healthcare services but is accompanied by several challenges: staff shortages, lack of unified medical service standards, and inequality in access to healthcare. To address these challenges, the paper justifies directions for transforming public administration mechanisms through enhancing professional capacity, standardization, digital transformation of management processes, and developing a culture of accountability. The proposed directions for transformation will help ensure equal access to medical services, strengthen the managerial capacity of local self-government bodies, reduce administrative risks, increase transparency and public trust, and promote the innovative development of the healthcare sector through digitalization. Keywords: public administration mechanisms, decentralization, healthcare, public administration, budgetary fundings.
Roberto Fantozzi, Stefania Gabriele, Alberto Zanardi
âą A reform in 2023 introduced new criteria for allocating healthcare funding in Italy. âą Socio-economic variables were included among the criteria for allocating funding across Regions. âą We simulate the new scheme and compare it with an alternative in which age and socio-economic indicators are jointly considered in estimating health needs. âą It turns out that more resources would be allocated to the Regions with greater deprivation. This paper discusses a reform recently implemented in the Italian National Health Service, aimed at adding some socio-economic indicators to the criteria adopted for allocating healthcare funding to Regions. The reform is based on international experience in healthcare financing in decentralized settings and provides a case study of special interest since Italy is a country with significant territorial disparities and severe budget constraints. The paper first discusses the long-standing debate between Italian Regions which led to the reform. Second, it reviews the main features of the reform which provides for the inclusion of socio-economic indicators via a simplified formula. Moreover, a possible revision of the reform is proposed, fully exploiting the information on the heterogeneity of health needs according to age and socio-economic indicators. By integrating the information on deprivation inside the risk adjustment mechanism, the weight of the different drivers is determined by the distribution of needs and not on a discretionary basis. Simulating the proposed revision suggests that more resources could be allocated to the Regions with higher levels of deprivation compared to a scenario that closely replicates the reform.
Open access
Global Health Care Issues
Employment and Welfare Studies
Health Systems, Economic Evaluations, Quality of Life
Through the commercial determinants of health framework, gambling has been identified as a powerful threat to health. This research critically examines cryptocurrency, which is promoted and sold as a highly gamblified product. Using the commercial determinants of health framework, the multifaceted ways in which cryptocurrency firm operations may impact health outcomes are highlighted. Political influence is exerted through substantial donations, with high-profile cases illustrating the sector's attempts to sway policy, whilst cryptocurrencies often operate in unregulated markets. Marketing strategies mirror those of traditional harmful industries, deploying immense advertising budgets and celebrity endorsements to promote highly speculative and risky financial products. Cryptocurrency mining, demanding considerable energy consumption, causes significant environmental damage. Financial practices include hundreds of outright frauds targeting low- and middle-income countries. Cryptocurrency investment, with 24/7 access and promises of huge wealth, mirrors gambling and is likely to result in public health harms through the same mechanisms as other forms of gambling. Despite the supposed potential of blockchain technology for improving payment and contract systems, the lack of realization of these benefits contrasts sharply with the immediate and growing costs associated with cryptocurrency speculation. Cryptoassets are a case study for the need for health promotion professionals to critically evaluate new technologies and advocate for regulatory measures to protect public health in the face of novel, high-risk products that overlap gambling and finance.
Mohsin Raza Khan, Muhammad Arsalan Nazir, Sabeen Afzal
PURPOSE: This study aims to analyze the challenges in financing the healthcare system of Pakistan and develop a comprehensive health financing strategy aimed at achieving universal health coverage (UHC). DESIGN/METHODOLOGY/APPROACH: The paper utilizes World Health Organization (WHO) framework on health financing to build the argument. It uses qualitative research design involving focus group discussions and in-depth interviews with key stakeholders, including Federal Board of Revenue, Ministry of Finance, Planning Commission, development partners, academia and health ministries at federal and provincial levels, as well as social health insurance entities. FINDINGS: The research findings highlight several critical issues within Pakistan's healthcare system: Firstly, health spending is inadequate to provide financial protection to 24 million people. Secondly, the available health funding is allocated in clusters and caters primarily to specific groups, which exacerbates inequities in healthcare provision. Thirdly, the existence of multiple purchasing agents who operate concurrently to buy health services results in duplication and wastage of resources. Fourthly, the public financial management system, intended to support the swift distribution of public funds to health facilities, is not aligned with the requirements of the health system. Lastly, the devolved health setup has led to governance issues in managing the health sector. ORIGINALITY/VALUE: This study fills a significant gap in the literature on health financing within Pakistan and proposes a unique empirical approach using WHO's framework in a decentralized healthcare context. It also provides actionable recommendations for policymakers to develop strategies that improve the effectiveness of public financial management and health service delivery.
Background: Health financing is one of the focuses in the National Health System Reform major project in the 2022 Government Work Plan. However, obstacles have been found in health financing in Indonesia, including a lack of promote and preventive financing; less non-governmental involvement; and weak development of national health insurance (JKN) services. Purpose: To understand the principles of health financing for the realization of universal health coverage. This principle uses the concept of Kutzin et al (2017) and Atim et al (2021), namely revenue raising; pooling revenues; purchasing services; benefit design and rationing mechanism; and governance and institutional arrangements, including decentralization. Method: Focuses on the principles of health financing by utilizing secondary data sources through qualitative methods. The data sources were obtained from scientific journals, official government reports, related web pages, and others. Results: The effectiveness of increasing income for health financing cannot yet be measured. Revenue collection was found to overlap with health financing sources. There was a deficit for the JKN budget, and the community was not disciplined in paying contributions in purchasing services and distribution mechanisms. For the principle of decentralization, regional governments still depend on the central government in planning and budgeting health financing. Conclusion: The principles of health financing in Indonesia are not yet optimal in practice. This article contributes to looking at the gaps in information regarding the government's commitment to universal health coverage.
Constant Fouopi Djiogap, Justin Romuald Amougou Manga, Simon Pierre Onana, Fabrice Ewolo Bitoto
Abstract We study the effects of fiscal decentralization on people's access to health and education services in Cameroon. It is generally believed that fiscal decentralization is an essential way to improve people's access to social services such as education and health. After reviewing the literature, we employed the Driscoll and Kraay estimate in a sample of 45 rural and urban municipalities for the period 2010â2020 to find our results. The results show that fiscal decentralization has a positive effect on the number of classrooms per pupil and the number of desks per pupil. At the same time, it negatively affects public hospitals per capita and the state of public hospitals. To improve people's access to education and health services in Cameroon, it is necessary to encourage the transfer of powers to municipalities. There is a need to control the actions of local officials to avoid mismanagement of resources that will not benefit the population. Also, the responsibility for selecting communal projects financed via the public investment budget within the framework of decentralization should be exclusively that of municipal executives, and not that of the central government.
In Spain, the public National Health Service provides care to Spaniards and other residents and is tailored for a decentralized state of autonomies. Each Autonomous Community has legislative capacity in its organization and management. We study the case of the collaboration between private hospitals and the public health service in La Rioja, an Autonomous Community of Spain located in the North of the Iberian Peninsula, due to the importance that this relationship has in health systems, in general. We applied the case study method as a methodological tool in a long-term local study. The interpretation was carried out within a national context, which allows us to understand its meaning and the historical keys to hospital development in this region. Primary sources have been reviewed (mainly reports, catalogs, and censuses of hospitals from the Ministry of Health and the Government of La Rioja) and other secondary sources, located in archives, libraries, Institute of Rioja Studies, and Department of Health. The hospital system in La Rioja was characterized by a predominance of public beds compared with private ones, although there has been a growing trend in the number of private beds from 2013 onwards due to the incorporation of health and social care convalescent hospitals (two). La Rioja has been promoting public-private collaboration (seen as a strategic alliance) and focusing on agreements in the socio-health space, particularly using the management service agreement and the concession of work formulas. The development of the public health service in La Rioja, from 1986 to 2019, has been determined by a progressive lower dependence on specialized hospitals from other health services of neighboring Autonomous Communities and by a mixed public-private hospital system.
The Covid-19 vaccine market concentration and hoarding that left many Global South countries unable to access vaccines in a timely manner have led to calls to expand and decentralize manufacturing capacity as a critical element towards more equitable access to vaccines globally Multiple initiatives are underway to build manufacturing infrastructure in low-and middle income countries (LMICs). However, without proper attention to who owns and controls the production and underlying technologies, there is a risk that well-meaning donor investments reinforce market dynamics that favour a handful of major international producers over truly local efforts This is particularly relevant for the African Vaccine Manufacturing Accelerator (AVMA), the new US$ 1Bn financing instrument approved by the Board of Gavi, the Vaccine Alliance, in December 2023
Open access
Global Health Care Issues
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
The healthcare corruption has aroused heated discussions in China recently.From the beginning of 2023 to the present, at least 155 hospital directors have been investigated that the number is more than twice that of last year.The healthcare corruption was not only a matter of physician morality but also reflected the defects of China's medical system. 1 Since the establishment of China's Urban Employee Basic Medical Insurance (UEBMI) in 1998, China has formed a fragmented health insurance system in urban areas.Fragmentation hindered the mutual aid function of health insurance.Therefore, from 2009 to 2020, China carried out the health financing reform of UEBMI which adjusted the pooling level from the county to the municipal level.However, the increasing financialization of the healthcare system would result in physicians weakening accountability to the public. 2Horizontal integration and vertical management of fiscal power enabled the municipal governments to concentrate and allocate health funding, but the administrative decentralization led to laxity of spending supervision by county governments.This flawed system was a tough test for physicians.Without supervision, physicians might induce patients to increase healthcare services for the purpose of maximizing income. 3Figure 1 was the framework of Unified Pool arrangement in China.The paper aimed to discuss whether the unified pool reform would trigger healthcare corruption.Treating the pooling level adjustment reform of UEBMI as a quasi-experiment, the study tried to interpret the empirical results based on Chinese health insurance regulations, and explored the reasons for the high incidence of healthcare corruption in China.Instead of focusing solely on patients' utilization of healthcare services, the paper considered the behaviors of healthcare provider (eg, hospitals, physicians) and healthcare policy executor (eg, county governments, medical insurance bureau) by a quasi-experiment.The effects of the unified pool reform on outpatient expenditure were examined by using the staggered DID model, and the moderating effects of physician density were examined by using DDD model.The micro data in the study were from the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, 2015, and 2018 The macro data were from China City Statistical Yearbook.The documents were from on the official websites of the municipal-level governments, the Medical Insurance Bureau, and the Human Resources and Social Security Bureau.After excluding the samples with missing information and the samples of municipalities directly under the central government, this paper finally obtained panel data for 4 periods, 573 respondents who were continuously tracked, and a total of 2292 observations.Table 1 showed that the treatment effects on outpatient reimbursement expenditure were significant at a 5% significance level, no matter whether control variables were added.The implementation of unified pool reform would lead to a significant increase in outpatient reimbursement expenditure, rather than copayment expenditure.The treatment effects on outpatient expenses were also mainly caused by the increase in outpatient reimbursement expenditure.We utilized the parallel trend test
Giovanni Guarducci, Gabriele Messina, Simona Carbone, Nicola Nante
BACKGROUND: In a Beveridgean decentralized healthcare system, like the Italian one, where regions are responsible for their own health planning and financing, the analysis of patients' mobility appears very interesting as it has economic and social implications. The study aims to analyze both patients' mobility for hospital rehabilitation and if the beds endowment is a driver for these flows; Methods: From 2011 to 2019, admissions data were collected from the Hospital Discharge Cards database of the Italian Ministry of Health, population data from the Italian National Institute of Statistics and data on beds endowment from the Italian Ministry of Health website. To evaluate patients' mobility, we used Gandy's Nomogram, while to assess if beds endowments are mobility drivers, we created two matrices, one with attraction indexes (AI) and one with escape indexes (EI). The beds endowment, for each Italian region, was correlated with AI and EI. Spearman's test was carried out through STATA software; Results: Gandy's Nomogram showed that only some northern regions had good hospital planning for rehabilitation. A statistically significant correlation between beds endowment and AI was found for four regions and with EI for eight regions; Conclusions: Only some northern regions appear able to satisfy the care needs of their residents, with a positive attractions minus escapes epidemiological balance. The beds endowment seems to be a driver of patients' mobility, mainly for escapes. Certainly, the search for mobility drivers needs further investigation given the situation in Molise and Basilicata.
Background: Health outcomes differ between countries, even in a relatively homogenous area such as the European Union. Research has been inconclusive about the explanation of this heterogeneity in health outcomes. Our study contributes to the literature by analyzing the impact of health financing and economic, behavioral and country-specific characteristics on health outcomes in EU member states. Methods: This study is based on macro-level EU panel data covering the period from 2000 to 2018. The association between health outcomes and explanatory variables is analyzed by random-effects and fixed-country effects regression models. To address the endogeneity problem of health expenditure, instrumental variables are applied. Life expectancy and infant mortality are used as outputs, and a vector of independent variables is used as inputs. Results: The explanatory variables included in this study are more associated with infant mortality rather than with life expectancy. The impact of the explanatory variables on life expectancy appears to be only marginal. Public health expenditure, the number of physicians, consumption of fruit and vegetables, the decentralization of the health system, and fixed-country effects are the main determinants of both life expectancy and infant mortality. Conclusions: Health status differences Results from complex and often intertwined processes. Increasing public health expenditure is not sufficient to achieve better health outcomes. Such increases must be complemented by giving more importance to the promotion of healthy lifestyles, improved education and additional human resources to sustain health services.
The adoption of decentralization by devolution in Tanzania has enabled the implementation of a Direct Health Facility Financing (DHFF) program in the facilities. While copious gains have been reported under DHFF, there are also notable failures to improve health service provision. This study aims to explore the experience of implementing the DHFF program in the rural areas of the Kigoma District Council. An exploratory qualitative study was conducted in Primary Health Care (PHC) facilities of the Kigoma District Council. A purposive sampling technique was used to draw 21 key informants including leaders of health facilities and members of the Health Facility Governing Committees (HFGC). Key Informant Interviews (KII) were used to solicit information from the study participants. Content analysis technique was used to analyze data collected from study participants. Our findings present enablers and barriers in the implementation of DHFF. Successful implementation of DHFF was enabled by the availability of formal training and supportive supervision, adherence to DHFF guidelines, availability of planning guidelines at the health facility, functionality of the HFGC, and adherence to the procurement process. A low sense of ownership of the program, delays and insufficient fund disbursement, shortage of health workers, and inadequate knowledge of DHFF program implementation emerged as the barriers that impeded successful program implementation. Evaluating the implementation experience of the DHFF program requires policymakers at the national level to devise a mechanism for the timely disbursement of funds, reinforcing capacity building to increase the autonomy of health facilities in their daily operations. Furthermore, structural and operational barriers warrant further operational and implementation research.
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 regionâs 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.