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.
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.
HIV/AIDS continues to pose a significant public health challenge in Africa, with Sub-Saharan Africa accounting for the majority of global cases. While international donor funding has historically underpinned HIV/AIDS programs across the continent, the declining availability of external resources has emphasized the need for sustainable domestic financing. Local governments, situated at the intersection of national policies and community-level implementation, play a pivotal role in bridging this funding gap. This review examines the contributions of local governments to HIV/AIDS program funding in Africa through a comparative lens, focusing on successes, challenges, and opportunities for strengthening their role. Case studies from South Africa, Uganda, Nigeria, and Kenya highlight diverse approaches to resource mobilization, policy implementation, and community engagement. Persistent barriers, including limited fiscal capacity, donor dependency, weak governance structures, political instability, and competing priorities, are analyzed to inform strategic recommendations. The findings underscore the need for enhanced fiscal decentralization, capacity building, and innovative financing mechanisms to empower local governments in sustaining HIV/AIDS responses. By fostering greater local government participation, Africa can achieve more resilient and effective health systems, ensuring progress toward ending AIDS as a public health threat by 2030. Keywords: HIV/AIDS funding, Local government, Sustainable financing, Sub-Saharan Africa, Public health policy.
The concepts of the economic planning in Nepal starts form the Rana regime. Rana prime minister Juddha Samsher makes a concept to apply the program for development. From the initial stage of periodic plans health has given emphasis. The paper aims to overview the health priorities in periodic plans of Nepal. From the review of the literatures and documents it is found that from the First to Fourth Plans, Nepal focused on establishing essential healthcare infrastructure such as health posts and primary healthcare centers. Maternal and child health, alongside the control of communicable diseases, formed core priorities during this phase. The Fifth to Seventh Plans emphasized expanding healthcare services into rural areas through community-based approaches, aiming to improve healthcare access and outcomes across the population. From the Eighth to Tenth Plans, Nepal underwent health sector reforms, decentralizing healthcare services and focusing on universal health coverage. The transition into the Eleventh to Thirteenth Plans aligned with global health goals, emphasizing the reduction of maternal and child mortality, combating infectious diseases like HIV/AIDS, and addressing environmental health concerns such as air pollution. From Fourteenth to Sixteenth Plans, Nepal faces new challenges such as climate change impacts and COVID-19 pandemic and focus to strengthening health infrastructure, enhancing healthcare financing mechanisms, promoting health equity, and integrating mental health services into mainstream healthcare provisions. Every, periodic plans are influenced by the issues. So far, further plans should focus on non-communicable diseases (NCDs), actions to cope with climate change health impacts, health technologies and probable health emergencies.
Peter Binyaruka, John Maiba, Dastan Mshana, Agnes Gatome-Munyua · 5 authors
Primary care facilities' autonomy and the factors that influence it are understudied. Direct facility financing (DFF) is gaining popularity in low- and middle-income countries as a modality to finance primary care facilities. Tanzania has introduced DFF with the objectives of streamlining resource allocation, fostering fiscal decentralization, and granting autonomy to health facilities for enhanced service readiness and responsiveness. This study aims to contribute evidence on primary care facilities' autonomy to execute DFF funds and the factors influencing this autonomy.Qualitative interviews and group discussions were conducted with health workers, managers, and community representatives from two councils to understand their perceptions of the autonomy of primary care facilities under DFF and remaining bottlenecks to effective budget execution. Data were analyzed using thematic content analysis to explore factors that influence facility autonomy to execute DFF funds.Primary care facilities are well informed on financial management and have adequate autonomy to execute DFF funds. However, several factors constrain their autonomy, including delays in funds disbursement, complex procurement and approval processes, rigid spending caps, restrictions on reallocations, and weaknesses in financial management capacity.DFF is a promising modality for health financing that supports health system goals. However, various challenges continue to hinder the autonomy of frontline service providers to fully execute DFF funds. To improve DFF budget execution, policy makers in Tanzania and elsewhere should consider reforms to better align public financial management and health financing.
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.
Abstract Health system is the backbone of delivering efficient preventive, promotive, curative and rehabilitative services. WHO has identified six building blocks of any health system. These include governance and leadership, infrastructure, workforce, financing, information management and access to essential medicines. Nepal has been striving to strengthen its health system despite several challenges in all WHO building blocks. Inadequate funds, geographical inequalities, insufficient health workforce, weak logistics, suboptimal health information system and inadequate health infrastructure have plagued Nepal health system for long. Natural calamities (e.g. earthquake of 2015) and COVID-19 pandemic overwhelmed the health system. In 2015, Nepal promulgated its new Constitution that devolved and decentralized several powers of generating revenue and exercising authority to sub-national governments viz the states/provinces and local civic bodies. Though functions of health system have been clearly defined at federal, state and local levels in the Constitution, transition of the erstwhile federal health system into new governance and implementation modalities continues to be challenging. There is a strong need to strengthen all building blocks of health system in Nepal at all levels of governance.
In this paper, it has been aimed to reveal the possible effects of Covid-19 Coronavirus epidemic on stock markets. In the analysis using daily data between 23 January 2020 and 13 March 2020, possible effects on stock markets has been investigated with Maki (2012) cointegration test using both Covid-19 daily total death and Covid-19 daily total case. According to the results obtained, all stock markets examined with total death act together in the long run. It has been understood that total cases have cointegration relationship of SSE, KOSPI and IBEX35 and do not have cointegration relationship with FTSE MIB, CAC40, DAX30. In this regard, it is considered as one of the optimal option for investors to avoid investments in stock markets, turn to investment in gold markets, which is the safe investment port of each crisis period in long run. Also, considering the possibility of turning all life into an internet environment, turning to cryptocurrencies is seen as another alternative option for investors. In this direction, it will be the preference of investors to turn to derivative markets and to the stock markets of countries where Covid-19 is relatively rare to avoid risk.
Nisha Bhat, Peter H. Kilmarx, Freeman Dube, Albert Manenji · 6 authors
BACKGROUND: We conducted a case study of the Zimbabwe National AIDS Trust Fund ('AIDS Levy') as an approach to domestic government financing of the response to HIV and AIDS. METHODS: Data came from three sources: a literature review, including a search for grey literature, review of government documents from the Zimbabwe National AIDS Council (NAC), and key informant interviews with representatives of the Zimbabwean government, civil society and international organizations. FINDINGS: The literature search yielded 139 sources, and 20 key informants were interviewed. Established by legislation in 1999, the AIDS Levy entails a 3% income tax for individuals and 3% tax on profits of employers and trusts (which excluded the mining industry until 2015). It is managed by the parastatal NAC through a decentralized structure of AIDS Action Committees. Revenues increased from inception to 2006 through 2008, a period of economic instability and hyperinflation. Following dollarization in 2009, annual revenues continued to increase, reaching US$38.6 million in 2014. By policy, at least 50% of funds are used for purchase of antiretroviral medications. Other spending includes administration and capital costs, HIV prevention, and monitoring and evaluation. Several financial controls and auditing systems are in place. Key informants perceived the AIDS Levy as a 'homegrown' solution that provided country ownership and reduced dependence on donor funding, but called for further increased transparency, accountability, and reduced administrative costs, as well as recommended changes to increase revenue. CONCLUSIONS: The Zimbabwe AIDS Levy has generated substantial resources, recently over US$35 million per year, and signals an important commitment by Zimbabweans, which may have helped attract other donor resources. Many key informants considered the Zimbabwe AIDS Levy to be a best practice for other countries to follow.
Background: In this era of decentralization , access and provision of drugs for people in the local area is the responsi- bility of local governments. Because the limitations of the local budget, the central government is obliged to guarantee the availability of drugs in the area. Financing sources of drugs from central and local government have not reached the stan- dard of WHO i.e. 2 dollars per capita. To cover demand of financing drug, a Specific Allocation Fund (DAK) proposed state budget that funds given to certain areas to fund special activities that are regional affairs and in accordance with na- tional priorities. General criteria to consider certain areas (re- gional fiscal capacity), specific criteria (regional characteris- tics) and technical criteria (policy formulation from Ministry of Health). Since drug financing is allocated in DAK in 2010, there is a need to evaluate the drug financing at the local level. The purpose : to evaluate the amount of DAK for Pharma- ceutical services in 2011 and 2012. Methods : The study used secondary data from 2010 and 2011 consist of 6 (six) factors: fiscal capacity, character of the area, population number, proportion of poverty , local bud- get for drugs and prediction for the remaining stock of the drug. The analysis statistics uses chi-square and multiple regression. Qualitative interviews is conducted with manag- ers of pharmacy in 2 districts with high financial capability. Results : Result from multiple regression test of the 6 factors used in the allocation of SAF 2011 and 2012 shows only 3 factors that really affects the allocation which are the number of population, the poor and the prediction of the remaining stock of the drug . However, the highest factor is the popula- tion. Result for qualitative with 2 respondents shows that since they got DAK they reduced local budget for drugs, because the drug financing is sufficient from DAK. Conclusion : local sense of ownership towards the health budget in the area is low resulting in reliance on the central health budget. The effeciency of the central budget causes reduction of health budget both in central and local level. Latar belakang : Dalam era desentralisasi ini, akses dan penyediaan obat bagi masyarakat di daerah menjadi tanggung jawab pemerintah daerah. Namun keterbatasan anggaran daerah maka pemerintah pusat berkewajiban menjamin ketersediaan obat di daerah. Sumber pembiayaan obat di daerah melalui APBN dan APBD belum mencapai standar WHO, 2 dol- lar per kapita. Untuk menutupi kekurangan pembiayaan obat, diusulkan DAK yaitu dana APBN yang diberikan kepada daerah tertentu untuk mendanai kegiatan khusus yang merupakan urusan daerah dan sesuai dengan prioritas nasional. Daerah tertentu mempertimbangkan kriteria umum (kemampuan fiskal daerah), kriteria khusus (karakteristik daerah) dan kriteria teknis (rumusan kebijakan Kementerian Kesehatan). Sejak kebijakan obat melalui DAK pada tahun 2010, perlu dilakukan evaluasi besaran DAK Bidang Kesehatan untuk Kefarmasian tahun 2011 dan 2012. Tujuan : tujuan penelitian ini adalah melakukan evaluasi besaran DAK Bidang Kesehatan untuk Kefarmasian 2011 dan 2012. Metode : Penelitian menggunakan data sekunder 2010 dan 2011 yang terdiri 6 faktor yaitu; kemampuan fiskal, karakter wilayah, jumlah penduduk, penduduk miskin, anggaran obat dalam APBD dan prediksi sisa stok obat untuk pengalokasian DAK 2011 dan 2012. Uji analisis menggunakan chi square dan multipel regresi. Kualitatif dengan wawancara pengelola farmasi di 2 kabupaten dengan kemampuan keuangan tinggi. Hasil: Dari uji multiple regresi terhadap 6 faktor yang digunakan dalam pengalokasian DAK 2011 dan 2012 hanya 3 yang mempengaruhi alokasi yaitu jumlah penduduk, penduduk miskin dan prediksi sisa stok obat. Namun yang paling tinggi adalah jumah penduduk. Untuk kualitatif pada 2 responden, sejak mendapat DAK terjadi pengurangan anggaran obat di APBD, karena pembiayaan obat cukup dengan DAK. Kesimpulan: daerah belum memahami ownership anggaran kesehatan di daerah sehingga masih mengandalkan anggaran dari pusat, dimana ketidakstabilan anggaran pusat dengan ef isiensi menyebabkan pemotongan merata anggaran kesehatan di pusat dan daerah.
INTRODUCTION: This article reports the results and the lessons learned from implementing the decentralized approach to tuberculosis (TB) detection and treatment, embedded with Human Immunodeficiency Virus (HIV) co-infection in health district. The objective was to increase the TB screening indicators in the district using the common ways for offering care to patients in health district. METHODS: Conducted from August 2006 to July 2007, this large-scale intervention using Non-experimental study Designs has implemented a decentralized approach for fighting against TB in Orodara Health District (OHD), Burkina Faso. Pretest-posttest design has been used for quantitative part using indicators in one hand, and postests-only design for the qualitative part in other hand. In the pretest-posttest design, the TB indicators from years before 2006 (from 2002 to 2005) were used as earlier measurement observations allowing examining changes over time. The decentralized approach was incorporated into the annual planning of the OHD. For the quantitative study design, indicators used were those from National TB Program in Burkina Faso: TB detection rate, incidence density of TB per 100,000 inhabitants per year, and HIV prevalence in incident TB cases with positive smears. Data entry and analysis employed Microsoft Access and Excel software. For the qualitative, in-depth interview was used in which a total of 16 persons have been interviewed. Discussions were tape-recorded and transcribed verbatim for analysis using the computer-based qualitative software program named QSR NVIVO. RESULTS: There were a total of 99,259 outpatient visits during the study period: the7,345 patients (7.43%) presented with cough. Of the 7,345 patient having cough, 503 cases (6.8%) were declared chronic coughing. These 503 patients were screened for TB, including 35.59% whose coughing had lasted 10 to 15 days. We observed an increase in a measured variable was observed. The TB detection rate and incidence-density rate based on positive smears were 16.11% (11.00% in 2005) and 10.42 per 100,000 inhabitants per year (6.88 per 100,000 inhabitants in 2005), respectively. There were 29 patients positive for TB: 41.37% of these had cough lasting 10 to 15 days, 10.34% were also positive for HIV, and 68.97% were from rural areas. Health workers and patients reported satisfaction with the intervention. It was found that implementing a decentralized approach to TB prevention in rural areas is plausible and effective under some conditions: considering that health district system is functional; carefully designing the intervention for TB case management; setting up and implementing of decentralized approach including strong monitoring; and taking into account the all financing, community and volunteer involvement, evaluation of the cost savings from integrating specific donor funding, and being supported by regional and central levels including National TB program. CONCLUSION: The study has shown that TB detection rate can be increased by implementing a decentralized approach to primary care. When carefully implemented, a decentralized approach is a suitable approach to TB and HIV prevention in rural and inaccessible settings.
Background: Accessibility to essential drugs is a public right, therefore it's the government responsibility to make them available.Previously before the era of regional autonomy, public drug management in all districts/cities was performed by the so-called District Pharmaceutical Warehouses (GFK).However, nowadays the situation has changed because of the difference in vision and perception of each regional government on the former warehouses.Some public drug management units in certain districts/cities are not functioning optimally.Inefficient drug procurement regarding the number and kind of drugs as well as timeliness results in gap between drug need and procurement.Furthermore, loosening in drug supply procedure makes essential drugs more unavailable to public.On the other hand, decentralization policy in drug management also undeniably brings advantages to the districts, for example capacity building in drug procurement, increasing capability in budget management and negotiation with district decision makers as well as enhancing regional economic activity.In revitalizing district pharmaceutical warehouses so as to attain minimal health care standards in districts/cities, baseline data in drug management and financing in several districts/cities should make a valuable contribution.Methods: A cross sectional descriptive study had been carried out during July-December 2006 in 26 districts/cities out of 11 provinces.Samples were 26 district health offices (Dinas Kesehatan Kabupaten/Kota) and 26 District Pharmaceutical Warehouses (GFK) where as respondents were head of drug section and head of warehousing respectively.Data were collected by means of structured questionnaires and in-depth interviews as well as the collection of secondary data of drug logistics.Qualitative and quantitative analysis was performed. Results:The study shows that: 1) although health budget in general had risen, the average percentage of drug budget allocation from 21 district health authorities was only 12.06%, reflecting the low drug priority in district health policy because drug expenditures may amount up to 40% of the total health budget.2) Public drug management was mostly performed by the so-called regional technical provider unit (UPTD) with some limitations concerning human resources and material in achieving an effective and efficient drug management, and 3) there was still lack of pharmacist assistants to manage drugs in primary health care (Puskesmas) up to 20% and even more piteously the lack of pharmacist in district drug management unit (GF/UPOP Kabupaten/Kota, 12,5%).Conclusions: Apart from the achievement of predetermined indicators stated in minimal health care standards in districts/ cities, especially regarding essential and generic drugs, drug management in general has been well performed concerning planning and drug availability.More support and commitment from the district government is a must considering that regional development can not be separated from the health development of the subject themselves.
OBJECTIVE: Scaling up antiretroviral treatment (ART) through decentralization of HIV care is increasingly recommended as a strategy toward ensuring equitable access to treatment. However, there have been hitherto few attempts to empirically examine the performance of this policy, and particularly its role in protecting against the risk of catastrophic health expenditures (CHE). This article therefore seeks to assess whether HIV care decentralization has a protective effect against the risk of CHE associated with HIV infection. DATA SOURCE AND STUDY DESIGN: We use primary data from the cross-sectional EVAL-ANRS 12-116 survey, conducted in 2006-2007 among a random sample of 3,151 HIV-infected outpatients followed up in 27 hospitals in Cameroon. DATA COLLECTION AND METHODS: Data collected contain sociodemographic, economic, and clinical information on patients as well as health care supply-related characteristics. We assess the determinants of CHE among the ART-treated patients using a hierarchical logistic model (n = 2,412), designed to adequately investigate the separate effects of patients and supply-related characteristics. PRINCIPAL FINDINGS: Expenditures for HIV care exceed 17 percent of household income for 50 percent of the study population. After adjusting for individual characteristics and technological level, decentralization of HIV services emerges as the main health system factor explaining interclass variance, with a protective effect on the risk of CHE. CONCLUSION: The findings suggest that HIV care decentralization is likely to enhance equity in access to ART. Decentralization appears, however, to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced.
Options for health financing reform are often portrayed as a choice between general taxation (known as the Beveridge model) and social health insurance (known as the Bismarck model). Ten years of health financing reform in Kyrgyzstan, since the introduction of its compulsory health insurance fund in 1997, provide an excellent example of why it is wrong to reduce health financing policy to a choice between the Beveridge and Bismarck models. Rather than fragment the system according to the insurance status of the population, as many other low- and middle-income countries have done, the Kyrgyz reforms were guided by the objective of having a single system for the entire population. Key features include the role and gradual development of the compulsory health insurance fund as the single purchaser of health-care services for the entire population using output-based payment methods, the complete restructuring of pooling arrangements from the former decentralized budgetary structure to a single national pool, and the establishment of an explicit benefit package. Central to the process was the transformation of the role of general budget revenues - the main source of public funding for health - from directly subsidizing the supply of services to subsidizing the purchase of services on behalf of the entire population by redirecting them into the health insurance fund. Through their approach to health financing policy, and pooling in particular, the Kyrgyz health reformers demonstrated that different sources of funds can be used in an explicitly complementary manner to enable the creation of a unified, universal system.
Rifat Atun, Martin McKee, Francis Drobniewski, Richard Coker
OBJECTIVE: To develop a methodology and an instrument that allow the simultaneous rapid and systematic examination of the broad public health context, the health care systems, and the features of disease-specific programmes. METHODS: Drawing on methodologies used for rapid situational assessments of vertical programmes for tackling communicable disease, we analysed programmes for the control human of immunodeficiency virus (HIV) and their health systems context in three regions in the Russian Federation. The analysis was conducted in three phases: first, analysis of published literature, documents and routine data from the regions; second, interviews with key informants, and third, further data collection and analysis. Synthesis of findings through exploration of emergent themes, with iteration, resulted in the identification of the key systems issues that influenced programme delivery. FINDINGS: We observed a complex political economy within which efforts to control HIV sit, an intricate legal environment, and a high degree of decentralization of financing and operational responsibility. Although each region displays some commonalities arising from the Soviet traditions of public health control, there are considerable variations in the epidemiological trajectories, cultural responses, the political environment, financing, organization and service delivery, and the extent of multisectoral work in response to HIV epidemics. CONCLUSION: Within a centralized, post-Soviet health system, centrally directed measures to enhance HIV control may have varying degrees of impact at the regional level. Although the central tenets of effective vertical HIV programmes may be present, local imperatives substantially influence their interpretation, operationalization and effectiveness. Systematic analysis of the context within which vertical programmes are embedded is necessary to enhance understanding of how the relevant policies are prioritized and translated to action.
Background: Health account is one method to acquire information about financial situation in the district or the state. Based on the information, the analysis on the policy can be made, such as priority setting and equity. The information is also used for policy decision and financial planning. Complete health finance data can be acquired in condition when there is a district health account.\nObjective: To describe health financial before and after the decentralization was implemented (1998 to 2002) in Sinjai District.\nMethod: This research is a quasi experiment research with before and after design. Method of health account development, is adopted from National Health Account.\nResult: This research showed that there was an increase of health funding since 1998 to 2002 in Sinjai District obtained from the government. Before decentralization central government role in health finance was high (11,6% to 60%), but after decentralization, the role of central government decreased and district government role increased (24% to 83%). From finance intermediary site the role of hospital as finance intermediary increased since 1999 to 2002 (11% to 40%). District Health Official still! took prominent finance intermediary point in Sinjai District. From health provider site, health expenditure allocation at community health center showed a trend to decrease. Health care administration and investment function showed escalation trend. Public health action constantly decreased since 1998 to 20002.\nConclusions: Sinjai District Health Finance increased since 1998 to 2002. Due to the increase of hospital health financial allodation, hospital finance intermediary also increased. On the other hand, the financial allocation in public health programs decreased. This pattern of health finance should be reserved for a pro-poor resource allocation.\n\nKeywords: health finance, District Health Account
Innocent Semali, Don de Savigny, M Tanner, C. Akim
Following successful establishment of Expanded Program on Immunization (EPI) in the 1970's as vertical program, the burden of disease for many of the vaccine preventable diseases was pushed to low levels. The current round of health reforms in Tanzania calls for decentralization and integration of vertical programs. This has the potential to assist or erode generally good performance of EPI. Reforms on the programme have been undertaken in Tanzania since 1996, and have included 1) integration of the procurement, storage, and distribution of vaccine and related equipment into the operations of a quasi-autonomous drug procurement agency. 2) government financing of procurement of the oral polio vaccine, cold chain kerosene, and 3) the integration of kerosene and vaccine distribution, supervision and monitoring to district health system. Our analysis shows that the integration of the procurement and distribution of vaccines into the operations of the drug procurement agency, and privatization of the distribution of the cold chain kerosene initially stalled EPI reforms for several reasons and had an adverse effect on EPI decentralization and coverage. The major cause of the problems was opposition from the EPI providers at district level who had to accept decreased income consequent to the reforms. We conclude that greater involvement of all stakeholders in the planning of the programme, would have presented an opportunity for forecasting the opposition and developing mitigating strategies.
The current need and enthusiasm for health reforms open an important arena for deeper analysis of the policy process with a view to understanding the political determinants of reforms and strengthening implementation. The studies described in this thesis analyse positions of different actors in the reform process, their actions in support or opposition of the process, and their impact on the health sector reform process. Globally and especially in developing countries health sector reforms have been implemented over long periods. Although there have been improvements in health, the remaining burden of disease in many countries is still very high. Reasons for the high burden of disease have been classified into lack of resources and poor organizational and managerial capacity. Good stewardship was needed to facilitate improvement in the performance of health systems. Stakeholders’ alignment and support was one of the most important components of good stewardship. However, stakeholder analysis had not been a common undertaking in developing countries despite the reforms that were being implemented in most of them. It was the aim of this study to answer the question: What has been the role and importance of stakeholders in supporting or opposing the health sector reform process? The study was conducted in Tanzania as one of the poorest countries in Africa, using the decentralization of the Expanded Programme on Immunization (EPI) as a case reference. The study units were the Ministry of Health Headquarters, Medical Stores Department, Expanded Programme on Immunization, national archives, regions and districts. At district level the study units were District Council, Council Health Management Team, EPI managers at regional and district levels, ward and village authorities, health facility, facility providers and households. Qualitative and quantitative methods were used to collect data from January 2000 to June 2002. Relevant data collection instruments were prepared and pre-tested. The qualitative data collection methods included document review, \nin-depth interviews, key informants interviews and observations. Quantitative \nmethods involved retrieval of secondary data, health facility survey and \nhousehold surveys. Regular discussions with key informants and data \ncollectors were held to verify the findings. Qualitative data was analysed \nmanually. Quantitative data was captured and analysed using Epi Info version \n6.1 and STATA version 6.0. The study involved answering five main questions. The first question was: Do \nreforms learn from history? Analysis of the waves of health reforms prior to \nthe current reforms from 1926 was done to answer the question. The main \nstakeholders in the reforms were the political party in power, the government \nand donors who supported the reforms each time. Each wave of health sector \nreforms provided information on health provision, financing and resource \ngeneration. Due to the political contexts, information on failures of health \nfinancing did not provide lessons for succeeding reforms of the health sector. \nStakeholders’ political interests opposed lessons that did not match the \npolitical ideology at the time i.e. free public services versus privatization and \npaying for social services. Lessons from previous health reforms were \nselective, and did not consider health-financing needs among others. The \nongoing health reforms needed to use information from all functional aspects \nof the health system to provide lessons for improving the health system. The second question was: Who were the stakeholders in the current health \nreforms and what were their interests and reactions? The main stakeholders \nwere donors, and the government. The two had a very high support for the \nreforms evidenced by their participation in problem identification, justification, \nreform design, planning and implementation. The health sector reforms thus \nhad high political support at central level. In the implementation process, \nissues that triggered stakeholders’ reaction included sectoral versus local \ngovernment decentralization. Another issue was the donor modality in \nfinancing the health sector and need for adopting new financial management \nsystems. Among the donors there was hesitancy to join the common financing \nmodalities that included a Sector Wide Approach (SWAp) and Basket \n Funding. As a result, there was delay in the process in order to reach better \nconsensus. \nThe third question was: What was the impact of stakeholders in the process of \nreforming a vertical programme like EPI? Health Sector Reforms in EPI \nincluded integration of generic functions, for example, vaccine procurement to \nmedical stores department. Qualitative and quantitative data was collected \nand analysed from the Ministry of Health, EPI management unit. This again \nrevealed that EPI reforms were well supported by the government and donors \ncentrally. EPI managers at both district and regional levels opposed some of \nthe EPI reforms. They argued that coverage was falling due to the reforms. \nHowever, there was no concrete evidence relating reforms in the EPI \nprogramme and falling coverage. The primary aim of certain actors was to \nmake sure that they continued receiving extra income from EPI functions. One \nof the effects of stakeholders’ reaction was reversal of reforms (recentralization) \nand return to the status quo. The fourth question was: What was the immediate reaction of stakeholders to \ndecentralization at district level and how might it have affected performance of \nEPI functions and the challenges? The immediate reaction of stakeholders \nwas reduced cooperation between the Council Health Management Team \n(CHMT) and the District Council who were politically supreme in the district. \nWithin the Council Health Management Team there was inadequate \ncommunication, which led to poor teamwork. The result of this was reduced \nsupervisory visits to peripheral health facilities. The EPI coverage in the study \ndistrict was 52.8 per cent, which was well below the previous national average \n(80 per cent). A logistic regression model for EPI service quality variables on \nchildren between 12 months and 23 months who had completed vaccination \nwas applied. Certain EPI quality of service variables predicted significant \nchanges in the odds ratio for completing vaccination. It was then suggested \nthat strategies were needed to improve management skills among the CHMT \nand District Council members. Also there was a need of hastening the \nprocess of increasing remuneration and motivation of peripheral health \nworkers. The fifth and final question was: What was the interest of the stakeholders \nand prospects of increasing EPI coverage at district level? Decentralization \nand integration of EPI functions were among the reforms at district level. The \nanalysis revealed that active stakeholders at district level were the Ministry of \nHealth, CHMT, EPI managers at district and regional levels and facility \nproviders. The Ministry of Health opposed integration of EPI at district level by \nissuing the directive that DCCOs and MCHCOs (EPI manager at district level) \nshould resume their tasks. However, the CHMT had no option but to comply. \nThis action reversed some of the health reforms at district level. Analysis of \nthe importance the community attached to EPI, using willingness to pay for \nEPI cold chain kerosene, was done. The support was low (48.7 per cent). EPI \nservice quality variables were significantly negatively associated with odds \nratio for willingness to pay for EPI input. Simulation with Policy Maker \ncomputer software predicted that an increased number of stakeholders \nthrough community participation would significantly improve the current low \nlevel of EPI coverage. It was then proposed to do a similar analysis in other \nvertical programmes and implement on a trial basis the results of the \nsimulation. \nIn conclusion, stakeholders were found to be active and influential in the \nhealth sectors of developing countries like Tanzania but poorly considered in \nimplementation of reforms. Stakeholders are important since some strongly \nsupport while others oppose the reforms. The reaction of stakeholders is \nevident through deployment or non-deployment of information depending on \ninterest and context. This would result in poor management leading to \ninefficiency in resource use, which would then be followed by poor quality of \nservices, poor support by communities and consequently poor utilization of \nhealth services. It is suggested that stakeholder analysis be conducted in \nother vertical programmes in the process of integration. Promotion of \nstakeholder analysis and also Policy Maker as a tool to manage stakeholders \nwill facilitate the management of reforms in the health sector.
This paper addresses the decentralization of health services financed by the Unified Health System (SUS) in the city of Natal initiated in the mid 90s. This decentralization primarily involved the transference of health services financed by SUS, which had previously been developed by the state of Rio Grande do Norte, to the city government of Natal. Based on the data gathered mainly from SUS¿ Ambulatory Information System (SIS/SUS), the authors attempted to verify to what extent this decentralization of health services provided by SUS in the city of Natal had improved public access to health services or, on the contrary, had resulted in a privatization process, implying more difficult access to those services.
Abengourou, with a population of 444,000 \n inhabitants, is one of the ten regions in Cote \n d'Ivoire. In this region, the fight against HIV/AIDS is \n enforced by a Regional Coordination Committee. What is \n special compared to other regional initiatives in the fight \n against HIV/AIDS is the organizational and community \n approach as well as the system established for financing activities.