Gloria Benny, Jaison Joseph, Hari Sankar, Devaki Nambiar
Abstract Background Palliative care needs are increasing in India, but access remains limited. Kerala is a notable exception, with a widely developed community-based, home-based palliative care approach. Its development coincided with governance reforms, particularly the People’s Planning Campaign (PPC) in 1996, which decentralisation by transferring planning responsibility, decision space, and financial authority to Local Self-Governments (LSGs), while expanding participation in priority-setting. Although Kerala’s palliative care outcomes are well documented, less is known about how decentralised institutions, political priorities, and local histories supported the model’s emergence and scale-up. This study examines how LSG-level decentralisation created conditions for initiatives, what mechanisms sustained them, and how they gained policy legitimacy, from those who witnessed and shaped these developments. Methods We used Witness Seminar (WS) methods, an oral-history approach bringing together people who witnessed or influenced a historical development to reconstruct events and create an archival record. Three WS were held in 2021 with 22 participants from the health department, LSGs, bureaucracy, civil society, and PPC policy spaces. Inductive thematic analysis was applied to English transcripts using ATLAS.ti 9, followed by realist analysis to develop Context–Mechanism–Outcome (CMO) explanations linking decentralisation processes with the evolution of palliative care in Kerala. Results CMO configurations showed how decentralisation created contexts and mechanisms through which palliative care emerged as a community movement and later gained system-level support. The PPC enabled local planning, participation, and ownership, while community-based, volunteer-led home-care programmes developed across several panchayats. LSGs implemented these programmes through government Primary Health Centres transferred under decentralisation. As the value of the model became evident, the state health department scaled up palliative care, with finance and HRH support from the National (Rural) Health Mission proving critical. Conclusion Palliative care came to be viewed by stakeholders as central to health service delivery in Kerala, contributing to the State Palliative Care Policy in 2008. Decentralisation and sustained community participation can generate legitimacy and political commitment to embed such programmes within services. However, durable implementation also requires system-level enablers such as financing, human resources, and administrative support, alongside local relational foundations including trust, leadership, and shared ownership.
Abdu A. Adamu, Kamal A. Ibrahim, Hyelhirra Adamu, Firdausi Umar-Sadiq
Abstract Under Nigeria’s 2014 National Health Act, the Basic Health Care Provision Fund (BHCPF) was created as a key health financing mechanism to bolster primary healthcare and promote progress towards Universal Health Coverage (UHC). The BHCPF, disbursed through four gateways, has catalyzed important health systems gains, including improved facility financing predictability and the nationwide creation of State Social Health Insurance Agencies. However, persistent bottlenecks, including weak oversight, lax fiduciary controls, poor accountability, and disparities in implementation quality, have constrained progress. These challenges precipitated a comprehensive set of reforms outlined in the 2025 BHCPF guidelines (BHCPF 2.0). These reforms introduce performance-linked disbursement, tiered direct facility financing, capitation-plus payment systems, and strengthened governance structures. Yet policy reform alone does not guarantee equitable and effective implementation, particularly in Nigeria’s complex, decentralized, and heterogeneous health system. This Commentary argues that institutionalizing implementation research in BHCPF’s governance framework offers a structured, evidence-driven pathway to bridge the gap between reform intent and real-world outcomes. Specifically, implementation research can: build theory-driven understanding of why and how reforms succeed or fail across diverse subnational contexts; monitor implementation fidelity and outcomes during rollout; distinguish necessary adaptations from fidelity drift; and test context-specific strategies to overcome barriers and promote facilitators. Ultimately, country-led, integrated implementation research is essential for fully realizing the transformative potential of BHCPF.
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 expenditure—exceeding the Abuja Declaration target—yet 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) didn’t 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.
Ezinne Victory Kanu, Charles Chibuisi Ehiemere, Ishaku Adamu Akyala, Eric Terkuma Chia · 5 authors
Despite global commitments under SDG-3, maternal mortality rates remain disproportionately high in Sub-Saharan Africa. This review examines how health policies have shaped outcomes between 2014 and 2024 in Nigeria, Rwanda, South Africa, and Gabon. A comparative narrative review was conducted using WHO, World Bank, UNFPA, DHS, and national policy documents. Guided by the Walt & Gilson Policy Triangle and the WHO Health System Building Blocks, policies were assessed for context, content, actors, process, and health system capacity. Data were synthesized thematically to compare implementation and outcomes. Rwanda achieved substantial declines through decentralized financing, performance-based funding, and community health worker integration. South Africa reduced deaths via integration of HIV and maternal services but still faces equity gaps. Gabon improved financial access but rural infrastructure and workforce limitations constrain outcomes. Nigeria’s fragmented governance and weak PHC financing explain stagnation despite multiple reforms. Implementation quality, not policy presence, drives progress. Strengthening governance, financing transparency, workforce readiness, and community engagement remains crucial for achieving SDG-3. This study highlights cross-country lessons transferable to similar contexts.
BACKGROUND: Climate shocks increasingly threaten Africa’s economic and institutional stability, yet their indirect effects through social sectors such as health remain insufficiently understood. Guided by political economy and welfare theory, this study examines how climate-induced disruptions affect access to healthcare, public or institutional trust, and the broader risk of social unrest and attitude towards coups d’état support across African countries. METHODS: The analysis uses cross-sectional data from 53,176 households across Africa and applies an ordered probit model with country fixed effects to account for country size and population structure. RESULTS: Climate shocks notably drought and flood events, significantly reduce access to healthcare services and erode public trust in health governance systems. Diminished health access and declining institutional confidence further increase the likelihood of social unrest and coup events, serving as key mediating channels through which environmental stress contributes to political instability. CONCLUSION: Strengthening climate-resilient health infrastructure, decentralizing public health financing, and investing in highly exposed regions are essential policy responses. Enhancing social protection and institutional credibility can help break the destabilizing feedback loop between environmental shocks, welfare declines, and political unrest.
BACKGROUND: Noncommunicable diseases (NCDs), including hypertension and diabetes, account for approximately 27% of all deaths in Kenya, with 26% of adults having elevated blood pressure. Despite devolution of health services to county governments in 2013, financing for NCD management at the primary health care (PHC) level remains weak. This study examines financial determinants shaping hypertension and diabetes care in PHC facilities within a devolved county health system in rural Kisumu County, Kenya. METHODS: We conducted a convergent parallel mixed-methods cross-sectional study in seven public PHC facilities in Seme Sub-County, providing new facility-level evidence on how the interaction between devolution’s financing architecture, facility-level financial autonomy constraints, and resource allocation mechanisms shapes chronic disease care effectiveness in rural Kenya. Quantitative data were collected via structured questionnaires and retrospective document review of financial records (January–August 2024). Qualitative data were gathered through key informant interviews (n = 7) with facility in-charges exploring planning, budgeting, and resource allocation. Descriptive statistics were produced in STATA v16; qualitative data were analyzed thematically in R. RESULTS: All seven facilities prepared annual workplans and budgets, but none achieved comprehensive NCD-specific planning (workplan + budget + dedicated NCD budget line). Funding sources were narrow: 71.4% (n = 5) of the facilities depended on NHIF reimbursements and donor support, while only 28.6% (n = 2) received direct county funding; 57.1% (n = 4) of the facilities relied on only two funding streams. Although all facilities held bank accounts, none had formal financial autonomy and expenditures required county-level approval, typically taking 3–4 weeks (57.1%, n = 4) to over two months (28.6%, n = 2). Combined with unreliable central supplies, this lack of autonomy meant facilities could not procure locally when stockouts occurred; consequently 85.7% (n = 6) of the facilities reported frequent medication stockouts. Facility in-charges attributed these failures to inadequate, unpredictable funding and centralized approval processes that prevented timely local procurement. CONCLUSIONS: Rural PHC facilities operate under structural governance failures in Kenya’s devolved health financing system that systematically undermine effective NCD care. The centralization of financial authority at county level, absence of ring-fenced NCD budgets, and misalignment between planning processes and resource allocation represent system-level policy contradictions rather than facility-level operational deficiencies. Addressing these governance failures requires not only increased funding but constitutional fiscal decision-space for facilities, mandatory NCD budget protection, and reformed disbursement mechanisms essential for equitable chronic care under Kenya’s UHC agenda. The sustainability of chronic care depends fundamentally on facility decision space, not only on funding volume. These findings are transferable to other Kenyan counties under the same devolved framework and to decentralized health systems in sub-Saharan Africa facing similar tensions between fiscal accountability and operational autonomy for chronic disease management.
BACKGROUND India’s health systems reform journey has been marked by institutional innovations that have reshaped service delivery, governance, financing, and beyond. Among these, a foundational yet often overlooked innovation is the creation of a structured ecosystem for health policy guidance: a network of State Health Systems Resource Centres (SHSRCs), supported by the National Health Systems Resource Centre (NHSRC). These institutions were not intended as parallel implementation units. Rather, they were envisioned as embedded policy advisory bodies that are intended to synthesize evidence, support strategic planning, and enable system-wide reforms. While NHSRC continues to serve as the apex technical institution supporting the Ministry of Health and Family Welfare (MoHFW), the SHSRCs were designed to play a decentralized and synergistic role within states. However, they remain variably recognized and underutilized. Unlocking their full potential could substantially enhance the capacity for state-level, evidence-informed decision-making and strategic design. AN INSTITUTIONAL DESIGN WITH PURPOSE Established in 2007, NHSRC functions as the principal technical support agency for MoHFW, with a mandate that includes policy and strategy development, technical assistance to states, and capacity building under the National Health Mission (NHM). Over time, it has played a pivotal role in institutionalizing quality improvement processes, advancing health financing reforms, guiding human resource strategies, strengthening secondary care and governance, innovations in community processes, and improved primary health care. Its enhanced role over the past 5 years, particularly through expanded expertise in evidence generation, implementation research, and the information technology realm, has been well appreciated and acknowledged. The SHSRCs, supported under the NHM and guided by NHSRC, were first envisioned under the National Rural Health Mission as in-house technical institutions to support health systems strengthening and policy development, particularly in the Empowered Action Group states.[1] However, their formation varies widely. Maharashtra and Madhya Pradesh, for instance, have established autonomous SHSRCs with independent governance and operational flexibility. Others, like Kerala, have adopted a fully embedded model within the state health department, with no legal autonomy but strong proximity to decision-making. Gujarat has adopted a hybrid approach, combining knowledge management cells, technical support functions, and programmatic units aligned with NHM priorities. In Chhattisgarh, the model transitioned from a registered society to an outsourced public–private partnership structure. Newer entrants like Meghalaya illustrate growing development partner involvement in SHSRC functions through philanthropic support. In the absence of a unified design, this diversity has led to fragmentation in roles, mandates, and institutional identity. To address this, the MoHFW released a national SHSRC Framework in 2024, formalizing key principles of governance, technical leadership, and accountability.[2] The framework aims to guide states in repositioning SHSRCs as embedded policy support institutions that are context-specific yet aligned with national health priorities. AN UNEVEN LANDSCAPE OF UTILIZATION Despite the clarity of this institutional design, the operational landscape of SHSRCs across India remains uneven. While some centers have emerged as credible partners to their state governments, others face challenges ranging from intermittent staffing and fragmented mandates to unclear positioning within state bureaucracies. In several instances, donor-funded Technical Support Units (TSUs) have taken on overlapping roles. These arrangements may address immediate programmatic needs but often lack the institutional continuity, embedded authority, and public accountability required for long-term reform.[3] Overreliance on donor-funded TSUs risks fragmenting institutional ownership and accountability, weakening the state’s own capacity to generate and use evidence for policy guidance. Recognizing these risks, NHSRC has begun working with state governments to revitalize SHSRCs and help align them with national and state-level priorities, while safeguarding their role as government-owned and state-anchored policy advisory bodies. EARLY EVIDENCE OF WHAT WORKS Where SHSRCs have been clearly institutionalized, their contributions to health policy and systems strengthening are evident. In Chhattisgarh, SHSRC was central to the design and implementation of the Mitanin program, which later became the foundation for the national ASHA model. Its positioning as a public, in-house technical agency enabled long-term continuity, responsiveness to state-specific challenges, and innovation uptake.[4] In Odisha, the SHSRC has supported district health planning, capacity building, and institutional development initiatives across program areas. In Tamil Nadu, it has supported quality assurance mechanisms and monitoring systems within the health department. These cases suggest that, when adequately structured and supported, SHSRCs can serve as trusted intermediaries that connect evidence, program strategy, and systemic reform. STRENGTHENING SHSRCS FOR HEALTH POLICY GUIDANCE For SHSRCs to fulfil their intended role as policy advisory institutions, four strategic actions are necessary. First, states must clearly define the mandate and governance of SHSRCs based on the MoHFW’s framework. This includes formalizing their distinct identity from TSUs, clarifying reporting structures, and embedding them within state health departments with a long-term vision. Second, sustainable financing should be assured through NHM provisions to reduce dependence on external actors. While TSUs may continue to serve specialized programmatic functions, they should not be equated as substitutes for in-house capacity. Third, investment in technical leadership and multidisciplinary staffing is essential. SHSRCs must attract professionals across epidemiology, public finance, implementation research, health systems, and data analytics. These are all disciplines critical to robust policy guidance. Establishing leadership structures that ensure continuity and accountability will further enhance operational coherence and effectiveness. Fourth, SHSRCs should continually expand their engagement with emerging health system interventions and institutionalize mechanisms. This includes supporting research, evaluation, and evidence-based decision-making. Their potential as platforms for resource optimization and collaboration with academic and public health institutions remains significantly underleveraged. NHSRC, through its existing mandate, can continue to play a catalytic role in this transformation by facilitating peer learning, technical handholding, and capacity strengthening. A STRATEGIC ASSET FOR THE NEXT PHASE OF REFORM As India deepens its health system reforms through initiatives such as Ayushman Bharat, and ongoing programme interventions under NHM, the need for decentralized, embedded policy guidance becomes more urgent. SHSRCs are already positioned to fulfil this role, not as supplementary structures but as enduring public institutions grounded in local systems and aligned with national goals. The imperative now is not to create new structures but to recognize and invest in the institutional capacities already in place. Authors’ contributions Maj. Gen. (Prof) Dr Atul Kotwal: Conceptualization; Writing – Original Draft, Writing – Review and Editing; Supervision. Dr Tarannum Ahmed: Conceptualization; Writing – Original Draft, Writing – Review and Editing. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest to declare.
Results-Based Financing (RBF) has been promoted as an innovative health financing mechanism to improve service delivery and health outcomes in low-resource settings. However, evidence on its impact within devolved health systems remains limited. This study examines how RBF influences key performance indicators (KPIs) in Zambia's devolved district health services. An embedded multiple-case study was conducted across 12 districts in Northern Province, Zambia. Mixed methods were employed, combining qualitative interviews with 44 stakeholders and quantitative analysis of health facility data. The study focused on maternal and child health indicators, service utilization patterns, and health worker motivation following RBF implementation. RBF implementation was associated with improvements in several KPIs: maternal health outcomes (100% of facilities reported improvements), medicine availability (91%), and the quality of primary healthcare services (67%). Health worker motivation increased, with 42% agreeing and 24% strongly agreeing that RBF positively affected service delivery. Community-based volunteers responded positively to incentive structures. However, challenges included delayed fund disbursement (91.7% reported), inadequate funding (83.3%), and monitoring gaps (50%). RBF can enhance key health indicators in devolved systems when properly designed and implemented. Success depends on timely incentive disbursement, robust monitoring systems, and integration with existing community health structures. The study provides evidence for policymakers considering RBF scale-up in decentralized health systems.
Open access
Global Maternal and Child Health
Health Systems, Economic Evaluations, Quality of Life
Zambia has implemented significant health-sector decentralization since 1992, culminating in the devolution of district health services to local authorities under the 2016 Constitutional Amendment. Results-Based Financing (RBF) has been piloted as a performance incentive mechanism, but its institutionalization within devolved structures remains largely unexplored. This study explores the opportunities and challenges of embedding RBF within Zambia's devolved health system, with a focus on Northern Province. A qualitative case study design was used, involving forty-four participants from twelve districts. Purposive sampling selected health workers from provincial and district health offices, local authority representatives, and national stakeholders. Data collection included semi-structured interviews, document reviews, and observations, with thematic analysis conducted using NVivo 9. Most respondents (82%) reported involvement in RBF implementation, and fifty-three% believed that increased Constituency Development Fund (CDF) allocations improved district health services. Key benefits cited were increased accountability (81.8%) and greater community participation (77.3%). Challenges included insufficient funding (83.3%), delays in disbursing funds (91.7%), and limited understanding among local authority implementers. Infrastructure development and procurement of medical equipment were identified as primary areas for CDF improvements (56%). Respondents also agreed (53%) that the Ministry of Health and the Ministry of Local Government would support the institutionalization of RBF. Effective integration of RBF into devolved systems requires harmonizing policies between health and local government ministries, building capacity within local authorities, and aligning RBF with other domestic financing mechanisms, such as CDFs. A phased approach to integration, with clearly defined governance structures, is recommended to ensure sustainable scaling.
Open access
Global Maternal and Child Health
Primary Care and Health Outcomes
Health Systems, Economic Evaluations, Quality of Life
Lukman Ademola Adepoju, Oyetunji Oyewale, Odekunle Bola Odegbemi, Ifeoluwa Abraham Adeagbo · 5 authors
Over 40 years after the identification of human immunodeficiency virus (HIV), Nigeria remain one of the highest burdens of HIV infections in the world, accounting for almost 10% of new infections in sub-Saharan Africa. Despite significant investments and technical supports from different foreign donors including the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund, and bilateral partners. The persistent structural, financial, and programmatic gaps continue to hamper the country’s HIV response. This assessment of HIV-related interventions in Nigeria examines what has been achieved, what still need to be done, and how to establish a sustainable and domestically owned HIV care. The review summarizes evidence from peer-reviewed literature (2018–2025) and major institutional reports (UNAIDS, NACA, WHO, PEPFAR) to assess five key domains: coverage and access, funding and sustainability, health system strengthening, monitoring and evaluation, and sociocultural barriers. Evidence shows that while substantial progress has been achieved in testing, antiretroviral therapy (ART) coverage, and community-based care, the HIV response remains heavily donor-dependent, urban-centered, and fragmented across vertical program streams. The review concludes that to achieve long-term epidemic control (EC) and universal health coverage (UHC) in Nigeria’s HIV care and programming with there is a need for domestic financing, health system integration, decentralized service delivery, and data-driven accountability frameworks.
The 2025 Annual Meeting of National Neglected Tropical Disease (NTD) Programme Managers (2025 PMM) in the WHO African Region convened stakeholders in Lomé, Togo, under the theme "Innovating for Acceleration: Pathway to NTD Elimination." A key focus was the changing funding environment and the necessity for enhanced integration of NTD services within health systems to guarantee sustainable advancement toward the 2030 elimination goals. The conference was convened in the context of substantial disruptions stemming from the USAID funding pause, which interrupted essential mass drug administration (MDA) programmes and epidemiological monitoring activities across multiple nations. Country experiences highlighted the fragility of external funding dependence and underscored the importance of domestic resource mobilization, decentralized implementation, and programmatic integration. Strategic discussions highlighted opportunities to incorporate NTD services into national health financing mechanisms, and routine health campaigns, alongside leveraging digital tools and partnerships. Participants emphasized the urgency of political commitment, sustained investments, and integrated service delivery models to build resilience and close equity gaps. The meeting further underscored the need for bold, country-led responses and multisectoral collaboration to advance NTD elimination efforts in a rapidly evolving global health financing environment.
Dr Mu’azu 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 2019–December 2025) and BHCPF Monthly Report Forms (2024–2025). 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 3.9–8.5); ANC1 +5.1 pp (95% CI 2.8–7.4); SBA +4.8 pp (95% CI 1.9–7.7); PNC +4.3 pp (95% CI 1.6–7.0). ITS decomposition for DPT3 showed an immediate level increase of +3.7 pp (95% CI 1.9–5.5) and a sustained slope of +0.12 pp/month (95% CI 0.06–0.18). 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.
Nigeria continues to face one of the highest maternal mortality burdens globally, a situation that is closely linked to the low utilization of essential maternal and child health services. To address this challenge, the Nigeria State Health Investment Project (NSHIP) introduced two innovative financing mechanisms Performance-Based Financing (PBF) and Decentralized Facility Financing (DFF) aimed at improving the performance of primary healthcare facilities. This study compared the effectiveness of these financing approaches in enhancing service utilization while accounting for the selection bias commonly associated with non-experimental research designs. The study adopted a retrospective quantitative approach and analyzed data from 216 Primary Health Care (PHC) facilities located in Adamawa, Nasarawa, and Ondo States between 2022 and 2025. Propensity Score Matching (PSM) was used to create comparable groups of facilities based on important characteristics such as staffing levels and bed capacity. Thereafter, Analysis of Covariance (ANCOVA) and Welch’s ANOVA were employed to examine differences in service utilization across key maternal and child health indicators, including Outpatient Department (OPD) attendance, Antenatal Care (ANC) visits, Skilled Deliveries, Family Planning (FP) uptake, and Complete Vaccination Coverage (CVC). The results revealed that facilities operating under the PBF model consistently recorded higher utilization rates than those supported through DFF in several critical service areas. Specifically, PBF facilities achieved significantly better outcomes in OPD attendance (Mean Difference = 3,276; p < .01; Partial Eta Squared = 0.19), Skilled Deliveries (Mean Difference = 322; p < .001; Partial Eta Squared = 0.34), and Family Planning uptake (Mean Difference = 1,180; p < .001; Partial Eta Squared = 0.36). These findings indicate that PBF had a substantial positive influence on services that require active provider engagement and community mobilization. In contrast, no statistically significant difference was found between PBF and DFF in Complete Vaccination Coverage (p = .70), suggesting that both financing approaches were equally effective in supporting routine immunization services. The study concludes that PBF offers a clear advantage for demand-driven maternal and reproductive health services, whereas DFF provides comparable results for supply-driven programmes such as routine immunization. These findings highlight the importance of adopting a differentiated financing strategy within Nigeria’s primary healthcare system. Rather than relying on a single financing model, policymakers should consider a hybrid approach that combines the strengths of both PBF and DFF to maximize health outcomes while ensuring efficient use of available resources. However, as this study focused solely on service volumes, future research is recommended to evaluate the impact of these financing models on clinical quality of care, maternal mortality outcomes, and cost-effectiveness across broader geographic settings.
Hermann Ngouakam, Goumeni Kouemaha Yannick, Ngouyombo Ange, Antaon Jesse Saint Saba · 5 authors
Résumé Un district sanitaire (DS) est une zone sanitaire décentralisée, relativement autonome sur le plan opérationnel et programmatique, et couvrant l’essentiel des besoins de santé d’une population entre 50 000 à 300 000 habitants résidant dans ses limites géographiques. L’atteinte des cibles de l’ODD 3 passe par la viabilisation des DS, conformément aux résolutions arrêtées à Alma-Ata. L’évaluation constitue la clé́ de voute du succès de tout système de santé car elle permet de révéler les lacunes des plans de santé pendant leur mise en œuvre. Objectif : évaluer le niveau de viabilité des districts de santé de la région de l’Extrême-Nord du Cameroun en 2022. Méthodologie : il s’agissait d’une étude semi-qualitative à collecte des données rétrospective et prospective dans onze districts de santé de la région de l’Extrême-Nord du Cameroun, à travers un échantillonnage en grappe. Les services de santé de 11 FOSA offrant le paquet complémentaire d’activité représenté par l’hôpital régional ou un hôpital de district et 22 FOSA offrant le paquet minimum d’activité (PMA), représentés par un centre de santé intégré ou un centre médical d’arrondissement ont été enquêtés. Résultats : le niveau de mise en place était bon pour 8/11 districts de santé, le niveau de mise en œuvre était moyen pour 8/11 districts de santé, le niveau de rapportage des données était bon pour 8/11 districts de santé. Nous avons plus de 90% des bénéficiaires étaient satisfaits de l’accueil, des attentes et des services reçus. La perception des prestataires de soin était bonne pour 53,62% concernant les infrastructures et matériels, pour 47,82% concernant la motivation et pour 60,87% concernant la charge de travail. Conclusion : après cotation, nous avons retrouvé que 8/11 districts de santé évalués étaient en cours de viabilisation. Il y’a nécessité d’accélérer le processus si nous voulons parvenir à l’atteinte des cibles de l’objectif de développement durable 3 Mots clés : Viabilité – Districts de santé – Région – Extrême-Nord du Cameroun. Abstract According to the World Health Organization (WHO), a health district (DS) is a decentralized health zone, relatively autonomous operationally and programmatically, and covering most of the health needs of a population between 50,000 and 300,000 inhabitants residing within its geographical limits. Achieving the targets of SDG 3 requires the servicing of the HDs, in fact, the district health system offers the best chance of implementing the PHC in accordance with the resolutions adopted in Alma-Ata. Evaluation is the key to the success of any health system because it reveals the shortcomings of health plans during their implementation. Since the adoption of the SDGs in 2015 by the country, no assessment of the sustainability of SDs at the country level has been carried out. Objective : To assess the viability of health districts in the Far North region of Cameroon in 2022. Methodology : This is a semi-qualitative study with retrospective and prospective data collection in the Far North region of Cameroon. Eleven health districts were selected through cluster sampling. Results : The level of implementation was good for 8/11 health districts, the level of implementation was average for 8/11 health districts, and the level of data reporting was good for 8/11 health districts. More than 90% of beneficiaries were satisfied with the reception, expectations, and services received. The perception of care providers was good for 53.62% concerning infrastructure and materials, 47.82% concerning motivation, and 60.87% concerning workload. Conclusion: After scoring, we found that 8/11 health districts assessed were in the process of being serviced. There is a need to accelerate the process if we are to achieve the targets of Sustainable Development Goal 3. Keywords : Viability – Health Districts – Region – Far North of Cameroon.
Adah Patrick Eneojo, Olorunmaiye Theophilus, Dr Emmanuel Bola Jonah K, Adah William Arome · 7 authors
Uptake of the Basic Minimum Package of Health Services (BMPHS) in Kogi State has been limited by supply‑side constraints, demand‑side barriers, and place‑based vulnerabilities concentrated in riverine and rural LGAs. The IMPACT rollout (2022–2025) combined Decentralized Facility Financing (DFF) with bundled Continuous Quality Improvement (CQI) supports to strengthen facility responsiveness, stabilize commodities, and expand outreach. We used a quasi‑experimental, mixed‑methods design on a facility‑month DHIS2 panel (2019–2025; n = 96 PHCs). Quantitative inference triangulated three counterfactual generators: augmented two‑way fixed‑effects Difference‑in‑Differences (DiD) for average effects, Interrupted Time Series (ITS) segmented regression to decompose immediate (level) and sustained (slope) impacts, and facility‑level counterfactuals via synthetic control and matrix completion for robustness. Multilevel mixed‑effects models estimated heterogeneity; causal mediation (bootstrap, 5,000 sims) quantified pathways (cold‑chain uptime, outreach frequency, commodity availability). Qualitative interviews and supervision records explained fidelity and contextual moderators. Costing used activity‑based methods with probabilistic sensitivity analysis. DFF plus CQI produced both rapid operational gains and durable system strengthening. Primary policy‑relevant estimates: DiD DPT3 +6.2 percentage points, ITS immediate level change α₂ = +3.7pp, and ITS slope α₃ = +0.12 pp/month. Mediation attributed ~41% of the DPT3 gain to improved cold‑chain uptime; outreach and commodity availability explained large shares of ANC1 and IPTp3 gains. Results are robust across lagged‑outcome DiD, matrix completion, generalized synthetic control, event‑study checks, and autocorrelation corrections. Cost‑effectiveness benchmarks show program‑level ICERs consistent with high probability of value for money for composite BMPHS gains. To maximize equitable BMPHS gains, prioritize cold‑chain resilience, predictable and timely disbursements, and earmarked outreach financing for high‑environmental‑risk LGAs. Embed both the ITS level (α₂) and slope (α₃) as complementary KPIs in routine dashboards: α₂ signals rapid operational fixes; α₃ signals durable system strengthening. Scale‑up should pair DFF with CQI, protected commodity lines, and context‑sensitive outreach modalities to sustain and equitably distribute gains.
The research focuses on the mechanisms, challenges, and consequences that UHC reform in Kenya has, conceptualizing UHC as a long-term government policy project that cuts across the governance, financing, and state capacity nexus. Based on theoretical frameworks of policy learning, incrementalism, and institutional capacity, the article evaluates the effects of Kenya's devolved system of health and strategic purchasing mechanism on UHC implementation and equity outcomes. Using qualitative policy analysis of government reports and academic publications, the research unveils structural constraints of the social health insurance program over time, the presence of inequalities in the delivery of services, and constraints of governance that mitigate the effects of reforms. These results bring into focus the necessity to strengthen the institutional capacity, strategic purchasing, and intergovernmental mobilization to achieve equitable and sustainable UHC. The article is a policy theory contribution to intricate social reforms through the way in which iterative policy learning and governance structure frame reform paths in a lower- and middle-income setting.
Introduction: The decentralization of Subdistrict Health Promoting Hospitals (SHPHs) to Provincial Administrative Organizations (PAOs) in Thailand represents a significant structural reform with direct implications for nurses working in primary healthcare settings. This study aimed to develop a competency model for nurses employed in SHPHs under PAO jurisdiction, ensuring alignment with decentralization policies and local health system needs. Methods: A mixed-methods design was used in 2 phases. Phase 1 employed qualitative methods to explore current nursing roles through in-depth interviews and thematic analysis. Phase 2 involved developing the competency model using quantitative data and the Delphi technique with expert consensus. Results: Findings from phase one indicated that nurses continue to play a vital role in community-based health promotion and care for vulnerable populations. Following decentralization, nurses have adapted to new responsibilities involving local workforce coordination, budgeting, and health information systems, necessitating expanded competencies. The competency model delineates stratified expectations by facility size: small SHPHs require generalist proficiency for autonomous service delivery; medium SHPHs necessitate specialized and collaborative competencies for programmatic functions; and large SHPHs demand advanced skills in systems management, strategic planning, and specialized care to align with institutional complexity. Conclusion: Although nurses’ core responsibilities in primary care remain central, decentralization has introduced new demands requiring advanced clinical, technological, data management, and interprofessional collaboration competencies. These expanded roles have strengthened nurses’ contributions to local health governance under the PAO system.
Decentralization is widely promoted as a governance reform to improve efficiency, accountability, and responsiveness in public service delivery, particularly in the health sector. In Pakistan, the 18th Constitutional Amendment of 2010 marked a significant shift in governance by devolving health sector responsibilities from the federal government to provincial governments. This reform substantially transformed Public Financial Management (PFM) arrangements in the health sector, affecting budgeting, expenditure control, and accountability mechanisms. This paper examines the impact of decentralization on health sector PFM in Pakistan by situating the reform within broader theoretical and empirical literature. It analyzes changes in health financing, governance, and service delivery outcomes while identifying persistent institutional and fiscal challenges. The study argues that although decentralization has enhanced provincial autonomy and policy responsiveness, weaknesses in public financial management capacity, coordination, and equity continue to limit its effectiveness. Strengthening PFM systems is therefore essential for translating decentralized governance into improved health outcomes in Pakistan.
The decentralization of Emergency Medical Services (EMS) to local administrative organizations is a critical policy initiative in Thailand aimed at enhancing service responsiveness and community participation. This study applied a prospective Health Impact Assessment (HIA) to identify positive and negative health impacts of EMS decentralization in Chonburi Province and develop evidence-based policy recommendations to guide the transition from the Ministry of Public Health to local governance. A mixed-methods approach was designed based on the six-step HIA framework. The study involved 562 participants, including EMS providers, recipients, and policymakers. Qualitative participants were selected through purposive sampling for interviews and focus groups, and quantitative participants through stratified random sampling for surveys. Qualitative data were thematically analyzed, and quantitative data were analyzed descriptively. Findings revealed both positive and negative impacts across four pre-hospital care activity domains (dispatch, incident response, referral, and administrative management) and four dimensions of well-being (physical, mental, social, and spiritual). Positive impacts included improved responsiveness, collaboration, and staff motivation, while negative impacts involved personnel shortages, communication gaps, and limited budgets. The derived policy recommendations emphasize structured workforce planning, upgraded communication systems, sustainable financing, and participatory monitoring to strengthen decentralized EMS. The use of HIA provided a systematic and participatory process that translated empirical evidence into actionable policy guidance for health service decentralization in Thailand and similar contexts.
The withdrawal of the USA from the World Health Organization and the freeze on USAID are among the major events in the realm of U.S. foreign policy under the U.S. president. Within his broader “America First” policy, aimed at reducing the U.S.‘s international commitments and rethinking its role in global organizations and foreign aid, this review attempts to make a case for Africa by examining the implications of recent reductions in U.S. funding. We conducted a comparative case study of Nigeria, Ghana, Zambia, and Rwanda, selected for their aid volume, exposure to disruption events, and availability of outcome data. Using process tracing and critical narrative synthesis, we analyzed policy documents, expenditure reports and peer-reviewed studies to assess how each country responded to aid disruptions and what structural factors shaped their resilience or fragility. Three dominant patterns emerged: acute service interruptions (Nigeria, Zambia), structural fragmentation (Ghana), and resilient adaptation (Rwanda). Key drivers of vulnerability included overreliance on tied aid, SAP-era health system legacies, and underdeveloped domestic financing mechanisms. Rwanda’s ability to maintain high ART coverage and reduce malaria deaths by 88% during funding cuts reflects a deliberate break from aid dependency through community-based insurance, decentralized governance, and regional procurement strategies. Donor transitions are not neutral events; they expose and exacerbate pre-existing structural weaknesses. Current models that frame aid withdrawal as empowerment risk, replicating past harm unless coupled with institutional reform and reciprocal accountability. This study suggests assessing transition readiness and reorienting global health partnerships toward equitable, resilient, and sovereign systems.
Health system resilience (HSR) is essential to sustaining equitable essential functions under acute and chronic stressors in decentralized systems. We developed and validated a Brazil-tailored HSR framework that distinguishes steady-state performance from resilience-specific capacities and assigns responsibilities across federal, state, regional, and municipal levels. Using a three-phase qualitative deductive-inductive approach with 48 international and national experts, we identified nine dimensions, 18 subdimensions, and 65 indicators that prioritise governance coherence, surge workforce strategies, emergency regulation, real-time monitoring, and access to critical technologies. The framework clarifies boundaries between general health system performance and adaptive, absorptive, and transformative functions, and specifies how managers can apply it in practice through structured scoping, mapping, scoring, prioritisation, planning, and monitoring steps. Although designed for Brazil's Unified Health System (SUS), the development logic generalises to other decentralised contexts with appropriate re-allocation of responsibilities and calibration to national financing rules. This policy-facing tool supports actionable resilience strengthening in complex, multi-level systems.
Nepal’s health policy landscape has shifted from a centralized, curative model to a more preventive, equitable, and decentralized system. Since the first National Health Policy in 1991, subsequent reforms in 1997, 2014, and 2019 have aimed to expand access, strengthen institutional capacity, and align the health sector with global commitments such as the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC). The National Health Policy 2019 (NHP 2019) represents the most recent and comprehensive effort to advance Primary Health Care (PHC) within a federal governance structure and further reinforce these national and global priorities. This review critically examines NHP 2019 through document analysis of government policies, implementation reports, and peer-reviewed literature; comparative policy review against earlier national policies and regional standards; and evaluation using the WHO health system building blocks framework. NHP 2019 strengthens PHC by expanding health insurance, integrating federal-provincial-local roles, and promoting digital health and essential public health services. Implementation evidence shows progress in decentralization and community-level service delivery. However, major gaps persist, including inequitable financing, rural workforce shortages, weak health information systems, inadequate coordination across government tiers, and limited inclusion of marginalized groups and traditional health practices. NHP 2019 is conceptually strong but faces operational challenges. Its success depends on sustained financing, evidence-driven governance, improved intergovernmental coordination, and equitable workforce and resource allocation. Strengthening monitoring systems and integrating community and traditional health practices are critical for achieving the policy’s vision of healthier and more informed citizens and for guiding decision-makers in advancing PHC-oriented reforms.
Samuel Wesonga Usolo, Annette Okoth, David Angwenyi
Youth unemployment remains a major concern, particularly in African countries with the youngest population globally. In Kenya, youth unemployment rate has shown fluctuations despite several government efforts such as the Youth Enterprise Development Fund (YEDF), Kenya Youth Empowerment Project (KYEP) and the Youth Employment Scheme Abroad (YESA). The impact of devolution on youth unemployment in Kenya has had little investigation on, which is the reason for this study. The study aims to assess the effect of devolution on youth unemployment rates in Kenya, utilizing Autoregressive Integrated Moving Average-Intervention model. This research was informed by the Keynesian and Decentralization theories of employment, which collectively illustrate how government efforts, like introduction of devolution, are anticipated to influence labor market results. This study used the yearly secondary data on youth unemployment rates from the World Bank covering the period from 1991 to 2022. Computational analysis was done using Python programming. An ARIMA (0, 0, 0)(0,0,1)[4] was selected as the most suitable model for the youth unemployment rates prior to devolution (noise model) due to its lowest Akaike Information Criterion (AIC) value of 234.746 in comparison to other identified candidate models. By including devolution as an intervention in the selected noise model, its statistical significance was established at the 0.05 level of significance. Comparative analysis findings revealed that the average youth unemployment rate increased from 6.67% prior to devolution to 10.19% during the devolution period. The projected counterfactual rate during devolution was approximated to be 8.583%, which confirmed the observed increase as statistically significant. In conclusion, the effect of devolution was found to be statistically significant, implying that youth unemployment rates increased during devolution, as confirmed by the fitted ARIMA - Intervention model. Based on the upward trend in youth unemployment rates, the study recommended that policymakers prioritize other context specific and targeted interventions to address structural barriers in the youth labour markets. These should include expanding access to skills training and vocational education, fostering youth entrepreneurship through financing and mentorship programs, and aligning education curriculum with labour market needs.
Introduction Lassa fever remains endemic in Nigeria, yet diagnostics, treatment, and hospitalization are excluded from the National Health Insurance Scheme (NHIS), leaving most patients to cover costs out-of-pocket. With NHIS coverage below 10%, both epidemic preparedness and financial protection are compromised. The 2022 National Health Insurance Authority Act offers a policy window to integrate Lassa fever services into NHIS and advance Universal Health Coverage (UHC). Methods A systematic desk review of national health policy, epidemic preparedness, and financing documents published between 2010 and 2024 was conducted using the PRISMA framework. Key sources included the NHIS Operational Guidelines (2012), National Health Policy (2016), NHIA Act (2022), Nigeria’s UHC Roadmap (2020–2030), and NCDC Lassa fever Incident Action Plans (2023–2024). Screening identified 62 unique records, 31 full texts were assessed, and 17 documents met inclusion criteria. Thematic analysis explored gaps in benefit design, financing barriers, and the roles of the Basic Health Care Provision Fund and the COVID-19 Preparedness and Response Project funds. Results The review revealed that NHIS benefit packages omit Lassa fever services and that primary health centers in endemic states lack accreditation. Analysis of the 2023 Incident Action Plan showed that only 6 of 38 (16%) priority activities were fully implemented, 7 of 38 (18%) were partially implemented, and 25 of 38 (66%) were largely not conducted. In 2024, flexible, decentralized financing markedly improved Emergency Operations Centre activation and case reporting. Conclusion Achieving resilient and equitable outbreak response in Nigeria requires more than emergency activation—it demands structural reform. Integrating Lassa fever services into NHIS benefit packages is not just a policy option; it is a public health imperative. Strategic actions such as expanding NHIS accreditation to endemic PHCs, institutionalizing flexible subnational financing, and operationalizing joint NHIA–NCDC accountability frameworks can transform underfunded response plans into sustainable national capacity. These reforms will not only improve the execution of IAPs but also serve as a model for embedding epidemic preparedness within UHC systems across West Africa.