Helenitta Melo da Silva Alves, Juliana Reis de Alcantara, Simonia Mara De Oliveira, Karen de Fátima Figueroa Bohórquez · 8 authors
Brazil's Unified Health System (Sistema Único de Saúde-SUS) represents one of the world's largest publicly funded universal healthcare systems, providing comprehensive healthcare services to more than 200 million citizens. Established through the 1988 Federal Constitution and regulated by subsequent legislation, the SUS is founded on the principles of universality, comprehensiveness, equity, decentralization, regionalization, and social participation. These principles have enabled substantial advances in health indicators, expanded access to essential services, and reduced historical inequalities in healthcare provision. Nevertheless, the system currently faces increasingly complex challenges associated with demographic transitions, epidemiological changes, chronic underfunding, regional disparities, technological innovation, workforce shortages, judicialization of healthcare, and the growing demand for high-cost medical technologies. This academic essay critically examines the constitutional principles underlying the SUS and analyzes the contemporary barriers that threaten the effective realization of universal access to healthcare in Brazil. By integrating theoretical discussions with institutional and policy perspectives, the essay explores how structural, political, economic, managerial, and demographic factors influence the sustainability of universal health coverage. The discussion also reflects upon future strategies capable of strengthening governance, financing, digital transformation, and public management while preserving the constitutional commitment to health as a fundamental social right.
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.
Background: Early childhood caries remains a major public health burden in Thailand, particularly among preschool children, despite the implementation of national oral health policies. With the decentralization of child development centers (CDCs) to local adminis-trative organizations (LAOs), understanding system-level determinants of oral health ser-vice effectiveness has become critical. This study aimed to identify key determinants in-fluencing the effectiveness of oral health care systems for preschool children within CDCs in northeastern Thailand. Methods: A cross-sectional analytical study was conducted among 270 stakeholders across urban, peri-urban, and rural CDCs in Ubon Ratchathani Province. Participants were selected using multi-stage random sampling. Data were col-lected between November 2023 and January 2024 using a structured questionnaire with established content validity (IOC > 0.50) and reliability (Cronbach’s alpha = 0.71–0.77). Variables were organized within an Input–Process–Output (IPO) framework. Descriptive statistics, Pearson’s correlation, and multiple linear regression analyses were performed to identify significant predictors of system effectiveness. Results: The oral health care system demonstrated strong performance in preventive service delivery, including universal oral health examinations and fluoride varnish application (100%), and high personnel readi-ness (99.63%). However, critical gaps were identified in monitoring and evaluation sys-tems (8.15%), budget adequacy (60.37%), and continuity of treatment follow-up (48.89%). The prevalence of dental caries among preschool children was 57.83%. Multiple regression analysis revealed that service delivery processes (β = 0.458, p < 0.001) and home visits by public health and dental personnel (β = 0.303, p = 0.008) were significant determinants of system effectiveness, jointly explaining 11.1% of the variance (R² = 0.111). Conclusions: The effectiveness of preschool oral health care systems in decentralized settings is driven pri-marily by the quality of service delivery processes and the integration of proactive commu-nity outreach through home visits. Strengthening monitoring and evaluation mechanisms, ensuring sustainable financing, and enhancing continuity of care between CDCs and households are essential for improving oral health outcomes. These findings provide ac-tionable evidence for policymakers and local health administrators seeking to optimize oral health systems under decentralized governance structures.
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.
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.
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.
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.
Background: Mental health accounts for an estimated 14% of the global disease burden yet receives less than 2% of health budgets in most countries, with even lower investment in low- and middle-income settings. This study examines federal mental health financing trends from 2021-2025 to assess whether legislative reform translated into fiscal prioritization. Methods: A mixed-methods policy analysis was conducted, combining quantitative analysis of federal budget appropriation documents (2021-2025) with qualitative documentary review and comparative case studies. Mental health allocations were assessed by recurrent and capital expenditure, institutional distribution, and proportional share of total federal health spending. WHO reports, national policy documents from Ghana and Kenya, and peer-reviewed literature informed comparative analysis. Results: Federal mental health allocations increased from ₦23.33 billion in 2021 to ₦88.24 billion in 2025, a 278% nominal rise. However, the sector’s share of the total health budget declined from 3.67% to 3.12%, indicating relative marginalization. Over 90% of funding supported recurrent expenditures in ten federal neuropsychiatric hospitals, with minimal investment in community-based services or primary care integration. In contrast, Ghana and Kenya more effectively leveraged legislation, fiscal decentralization, and insurance mechanisms to expand access. Conclusion: Despite legislative reform, Nigeria’s mental health financing remains centralized, hospital-focused, and misaligned with population needs. Institutional inertia, weak coordination, and delayed implementation of the Act have constrained equitable scale-up. Activating the Mental Health Fund and integrating mental health into national financing mechanisms are urgently required to prevent deepening inequities.
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.
Ashar Prima, Dewi Gayatri, Yati Afiyanti, Christantie Effendy
Background: Indonesia faces a growing double burden of non-communicable diseases, particularly cancer. The latest data from the Global Cancer Observatory (Globocan) indicates over 408,661 new cases and 242,099 cancer-related deaths in 2022, with a projected 63% increase in the case burden between 2025 and 2040 without strategic intervention. Although a new legal framework through Health Law No. 17 of 2023 and the Minister of Health Decree (KMK) No. HK.01.07/MENKES/2180/2023 has mandated palliative care as an integral component of health services, its implementation still faces significant systemic barriers. Policy and Implications: This policy brief analyzes the disconnection between the policy mandate and on-the-ground reality, identifying critical gaps in accessibility, healthcare workforce capacity particularly among nursesand financing mechanisms through the National Health Insurance (JKN) program. The failure to effectively integrate palliative care not only causes unnecessary suffering for millions of patients but also burdens the health system with inefficient costs and suboptimal end-of-life care, reflected in the high "financial toxicity" experienced by patients. Recommendations: We recommend a four-pillar strategy: (1) Formalize and standardize palliative services within the JKN benefits package with a clear financing model to address regulatory ambiguity; (2) Develop a national competency-based palliative education and training strategy for all health workers, with a focus on empowering nurses in primary care; (3) Implement a decentralized and tiered palliative care delivery model centered on Community Health Centers (Puskesmas) to ensure equitable access; and (4) Launch a national public education campaign to destigmatize palliative care and increase awareness. Conclusion: The integration of palliative care is not merely an option but a strategic and ethical imperative for achieving Universal Health Coverage (UHC) in Indonesia. It is a cost-effective investment to improve patients' quality of life, support families, and ensure the sustainability of the national health system in facing future non-communicable disease challenges.
Open access
Healthcare Systems and Reforms
Palliative Care and End-of-Life Issues
Health Systems, Economic Evaluations, Quality of Life
Background: Decentralization in health systems enhances responsiveness and equity but is often accompanied by uneven implementation and resource disparities. Greece' health system has undergone successive phases of decentralization, culminating in a transformation in 2015 when regional health authorities (RHAs) assumed operational responsibility for public primary healthcare (PHC). This study presents the first comprehensive assessment of this transition, examining funding adequacy and resource allocation across RHAs. Methods: Financial and operational analyses were performed to assess disparities among RHAs and between RHAs and hospitals. Data were drawn from publicly available sources, including financial statements, reports from the Ministry of Health, and national statistics. The analysis examined patient visits, staffing levels, infrastructure, funding, labor productivity, and efficiency across health regions. Results: Between 2018 and 2023, patient visits declined at most RHAs. Staffing composition shifted toward nursing personnel, while medical staff numbers declined. Substantial intraregional and interregional disparities were observed in service utilization, staffing, infrastructure, funding, labor productivity, and efficiency. Hospitals continued to absorb a large share of PHC demand and funding, whereas RHA units held markedly fewer assets and received lower financial support. Funding imbalances among RHAs were evident, and the overall negative return on assets indicated systemic underfunding of public PHC. Conclusion: The ongoing decentralization of Greece's health system faces structural challenges, including overlapping territorial jurisdictions and uneven, occasionally insufficient, resource allocation. These challenges hinder progress toward health equity. Policy interventions should prioritize evidence-based resource allocation, standardized financing frameworks, and strengthened PHC integration to promote equitable and sustainable healthcare delivery under decentralized governance.
Abstract Stronger health systems are better equipped to withstand shocks and continue providing quality services as response measures are implemented. We conducted a systematic review to synthesize the understanding of the concept of health system resilience from various stakeholders in Africa, focusing on definitions and attributes of a resilient health system. We conducted a search for peer-reviewed articles and grey literature, filtered for Africa, from 1980 to 2023, using the SPIDER framework. We searched four databases: PubMed, the Bielefeld Academic Search Engine, the Cumulative Index to Nursing and Allied Health Literature, and Scopus, and reviewed the websites of the World Health Organization, Africa CDC, and Ministries of Health of African countries. Articles were selected based on set inclusion and exclusion criteria. Qualitative articles were appraised using the Critical Appraisal Skills Programme, and mixed-methods articles using the Mixed Methods Appraisal Tool. We mapped the distribution of included articles by country studied; categorized the articles based on reported shock, health system building block described; and identified the definition of health system resilience, and its attributes in each article. The search yielded 4,306 relevant records, fifty-five of which were included in the study. Studies were found from 48 of the 54 African countries. Up to 75% of the articles focused on COVID-19; others were on Ebola Virus Disease, cholera, and meningitis. Service delivery and health workforce were the most frequently studied health system building blocks. In defining or describing health system resilience, the adaptive capacity (39, 65%) was most frequently mentioned, followed by absorptive capacity (17, 28%), preparedness (3, 5%), and recovery (1, 2%). Identified attributes of a resilient health system were: community engagement and involvement; leadership and governance; collaborations and partnerships; human resources for health; health education and promotion; health information systems; health service delivery; decentralization and local governance; health infrastructure and logistics; preparedness; learning and adaptation; and innovation and financing. Our review reports four core capacities that define a resilient health system: preparedness, absorptive capacity, adaptive capacity, and recovery. Essential attributes encompass community engagement, health education and promotion, leadership and governance, surveillance and laboratory capacity, innovation, service delivery, and adaptability.
Decentralization has emerged as a prominent strategy for health sector reform in low- and middle-income countries (LMICs), aiming to enhance service quality, efficiency, equity, and responsiveness. This study systematically reviews literature published between 2021 and 2025 to explore the role of decentralized health systems in shaping healthcare service quality across LMICs. Using PRISMA 2020 guidelines, 20 eligible studies were identified and analyzed from databases including PubMed, Scopus, Web of Science, and Google Scholar. Thematic synthesis of findings reveals mixed outcomes: while decentralization improves local responsiveness, enhances community engagement, and strengthens health system performance in some settings, it also exacerbates disparities in others due to uneven institutional capacity, limited fiscal resources, and fragmented coordination. Key performance areas identified include human resource deployment, financing, access to services, and equity in service delivery. The study emphasizes the significance of local capacity-building, efficient resource allocation, and integrated planning in attaining sustainable and equitable healthcare improvements within decentralized systems. This review provides practical insights for policymakers aiming to align decentralization strategies with health equity and service quality objectives.
Khanh Phuong Nguyen, The Due Ong, Xinyu Zhang, Tra My · 6 authors
Ensuring sufficient financial resources for improving effective and efficient procurement of vaccines was highlighted by the Immunization Agenda 2030, which is particularly challenging for middle-income countries (MICs) that are ineligible for support from Gavi, the Vaccine Alliance. In response to the broader decentralization of the governance system and decreased international development aid, the central government of Vietnam decentralized the responsibility of financing the Expanded Program on Immunization (EPI) to provincial governments in 2023 but rapidly reversed it considering its following negative consequences, for example, severe vaccine stockouts and the largest decline in childhood immunization coverage in over 20 years. This paper analyzed the consequences closely linked to decentralization in Vietnam, the underlying reasons, and lessons for other MICs. To avoid recurrence, MICs should ensure the primary role of the central government in EPI financing and management, improve the local management capacity, and allocate more resources toward less-developed areas to narrow the intra-country disparities.
Brittany Hagedorn, Jeremy Cooper, Oluwole Odutolu, Ojukwu Mark Ojukwu · 5 authors
Abstract Background The availability of essential medicines and supplies remains a serious impediment to effective primary health care (PHC) in many lower and lower middle-income countries. Most of these countries rely on centralized procurement, centralized stores, and a “push” distribution system. We describe here the impacts of a large-scale randomized trial in Nigeria, which provided modest funding directly to facilities to spend, on supply availability. Methods Districts in three states were randomly allocated to either direct facility financing (DFF) or performance-based financing (PBF) and matched to a control group. Both DFF and PBF transferred funds to facility bank accounts and allowed the facility management committee to spend on operational costs, including essential drugs. Facilities could procure medicines on the government’s essential drug list from pre-approved suppliers if they were certified by the national drug regulator. We conducted a difference-in-difference (DiD) analysis using facility survey data to assess the impact on availability of essential drugs and supplies. Results Drug availability was initially similar for the three arms of the trial (9 of 29 essential medicines). After three years, DFF and PBF facilities had significantly higher product availability than control (p<0.05). This amounted to an increase of 28/ 34 percentage points in DFF/PBF facilities (an additional 8/10 products, respectively), and only 10% in control (3 additional products). We did note that there was little difference between control and intervention arms in the availability of medicines for donor-supported vertical programs like immunization, family planning, and malaria. However, there were very large improvements for products like antibiotics, obstetrical drugs, diagnostics, and TB medications. Conclusion Providing funds directly to health facilities improved drug availability. It was superior to the typical centralized procurement and “push” distribution system that is widespread in lower-income settings. This approach is already spreading and should be adopted more widely.
Abstract Background: Kenya’s public health sector is facing a crisis of poor quality of healthcare, as evidenced by an acute shortage of healthcare workers, frequent industrial unrest, broken-down healthcare facilities, and erratic supply of essential commodities. In a bid to enhance the quality of healthcare through the availability of modern medical equipment and technologies, the government, since 2015, rolled out asset leasing financing for national referral healthcare facilities. Methods: We conducted a study with the objective of exploring stakeholders’ perspectives on the effectiveness of asset lease financing in enhancing the quality of tertiary healthcare in Kenya. The study used qualitative data, utilizing a case study design and an interpretivism approach. A total of 32 stakeholders participated. These include 7 Ministry of Health policymakers, 7 National Treasury policymakers, 10 tertiary hospitals managers, and 8 social health investors’ financial experts. We used semi-structured interviews to collect qualitative data, which was transcribed and analyzed using a thematic approach. Results: The results showed that though Asset Leasing Financing mechanism has addressed structural inequities by redistributing high-end medical infrastructure across tertiary hospitals geographies and contributed to improved timeliness and reach of care, stakeholders felt that it has not fully achieved its transformative potential in Kenya’s healthcare due to a convergence of governance weaknesses, implementation inefficiencies, and institutional misalignments. Conclusions: We recommend the need for a contextualized, accountable, policy-backed but possibly an asset leasing model decentralized to the tertiary hospitals governance. This could enhance the entire delivery of the financing model to improve tertiary healthcare quality. We also demonstrated the theoretical contribution and local policy implication of the study.
James Kinjanzi Sirite, Prof. David Minja, Jane Njoroge
Purpose: This study examined the effect of revenue decentralization on healthcare service delivery in Turkana County, Kenya. Materials and Methods: Using a mixed-methods approach, the research collected data from 271 respondents, including county health and finance officials, hospital administrators, and community health representatives. Findings: The findings reveal that revenue decentralization significantly improves healthcare service delivery, with a one-unit increase in revenue decentralization leading to a 0.49-unit improvement in healthcare outcomes. However, delays in budget disbursement (averaging 5.11 months) and reliance on external revenue sources (36.9% tax autonomy) highlight challenges in financial sustainability and resource allocation. Qualitative responses underscore both the benefits of increased autonomy and access to funding, as well as the drawbacks of concentrated financing and disparities in rural healthcare access. The study concludes that optimizing tax autonomy mechanisms, strengthening intergovernmental grants, and improving financial management are critical to enhancing the positive effects of revenue decentralization. These findings contribute to the broader discourse on fiscal decentralization and its potential to address healthcare inequities in marginalized regions. Unique Contribution to Theory, Practice and Policy: To improve healthcare in Turkana County, enhance revenue decentralization by refining tax autonomy, increasing equitable intergovernmental grants, and addressing rural disparities. Implement 'nomadic health vouchers' using 15% of decentralized revenues and 'fiscal health compacts' to reduce budget delays. Ensure autonomy, accountability via blockchain, and drought-responsive budgets work together to boost accessibility and patient support, transforming fiscal policy into a tool for healthcare justice, especially for mothers and herders facing long waits and travel for care.
Reading the letter “Transforming Health Insurance in Bangladesh: A Future-Ready Approach” that was submitted in response to “The Urgent Need for Developing a Common Health Insurance Policy in Bangladesh: A Perspective” [1] inspired me to write this response, and I am grateful to the author(s) for their work. The author(s) makes a valid and necessary point about the need for a paradigm shift away from traditional state-led models and towards decentralized, technology-driven, behaviorally informed strategies. But while we're looking at the present situation, we must also recognize the government's current efforts and see how they could support or even lay the groundwork for a universal health insurance program that would benefit all citizens. The Health Ministry of Bangladesh has announced that the government has initiated a program to offer free medical treatment and medications to the population. The ministry has announced plans to implement 24-h health services at 500 centers and to distribute a healthcare card to each household under the “Shyastha Surokkha Karmasuchi” (SSK) package. This card enhances patient identification at hospital admission and optimizes the payment process by monitoring diagnostic information and service usage; however, it has not been fully implemented yet [2]. The government's efforts to improve healthcare access and quality are commendable, but they also bring attention to a basic problem. People with lower and medium incomes, as well as those working in the informal economy, are disproportionately impacted by the unequal distribution of resources caused by the tax-based approach that forms the basis of many of these programs. Several economic studies have pointed out that, in Bangladesh, many families continue to struggle financially since out-of-pocket costs make up around 68.5% of overall healthcare spending [3]. Despite the importance of programs like SSK that offer free services, this circumstance shows that these efforts do not solve the underlying problems with the healthcare funding system, which include structural disparities and financial instability. A shift toward a universal, all-encompassing health insurance system seems essential and advantageous in this light. A strong health insurance system might have two benefits: first, it would help those who can't pay for medical treatment get coverage, and second, it would provide a system for reliable, long-term financing. Germany, France, and Japan are only a few examples of the nations that have demonstrated that social-insurance models may achieve both universal coverage and fair allocation of resources through income-based premiums and required participation [4]. The difficulty for Bangladesh comes from trying to apply these models to our own social and economic situation. The large informal sector of the Bangladeshi economy, which has long been exempt from traditional tax and insurance systems, is a major obstacle to the widespread adoption of health insurance. We propose a multi-pronged strategy to address this. To begin, one way to guarantee affordability is through progressive premium systems, in which contributions change according to income levels. Premium payments from informal workers might be made easier with the use of innovative collecting techniques, such as community-based networks and mobile payment systems like “bKash” and “Nagad,” which would reduce administrative responsibilities [5]. Second, providing low-income groups with government subsidies is essential. The state may make sure that no one is left out because they don't have enough money by paying part of the premiums for those who are vulnerable. It is really essential for everyone to take part; to eliminate coverage gaps and deal with fluctuating participation rates, it is recommended to use a default opt-in method. This means that all citizens would be automatically registered in the health insurance program, and opting out would only be permitted under certain circumstances. Behavioral economics principles have been used successfully in other contexts to significantly boost enrollment using this method. The insurance system's risk pool and financial foundation may be further expanded if measures were to be considered that would promote the formalization of workers in the informal sector [5]. Integrating technology stands alongside these funding improvements as another pillar of a health insurance system prepared for the future. Claims processing using blockchain technology, for instance, has the potential to streamline administrative operations, make them more transparent, and cut down on fraud and settlement delays [6]. Furthermore, predictive underwriting algorithms have allowed for more precise and inexpensive premium changes in East African pilot programs using AI-driven adaptive pricing techniques [7]. Bangladesh can create a system that can handle large-scale operations while catering to people of varying income levels by adopting this state-of-the-art technology. Without the larger healthcare system, no health insurance system can possibly operate. While it is great that SSK and other government programs are working to make services more accessible, such as free prescription programs and 24/7 care centers, these efforts should be supplemented by steps to make sure healthcare resources are distributed fairly. When contrasted with metropolitan regions, rural communities still lack enough infrastructure and medical specialists. We can encourage fair allocation of resources with a single health insurance system that is built with targeted incentives and a tiered reimbursement mechanism. For instance, healthcare providers may be more motivated to offer high-quality services to rural communities if they were to get higher payment rates for institutions in underserved locations and participate in public-private partnerships. In conclusion, free healthcare programs are a huge step forward, but they also show how flawed a system that relies just on taxes to pay for healthcare may be. The solution to long-term, fair healthcare in Bangladesh lies in a universal health insurance system that is prepared for the future and can flexibly integrate public programs with creative private sector solutions. The healthcare system in Bangladesh may be revolutionized by adopting a hybrid model that incorporates digital technology, progressive premium collections, behavioral defaults, and mandated insurance. A more equitable and effective distribution of resources would be fostered by such a system, which would shield its inhabitants from ruinous medical bills. It is anticipated that these reflections will contribute to the ongoing conversation regarding the enhancement of healthcare financing in Bangladesh. An approach that is collaborative and integrates the benefits of state-driven initiatives with decentralized, technology-enabled, and socially equitable models is likely to facilitate long-term reform. S.M.R.D. conceptualized, supervised, and wrote the draft. The author has nothing to report. The author declares no conflicts of interest. The lead author SMRD affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
I am writing in response to “The Urgent Need for Developing a Common Health Insurance Policy in Bangladesh: A Perspective” [1]. The article effectively highlights the pressing need for a universal health insurance system in Bangladesh. However, it largely advocates for conventional solutions that have faced challenges in implementation across low- and middle-income countries. A paradigm shift is necessary—one that moves beyond traditional state-led models to explore decentralized, technology-driven, and behaviorally informed strategies tailored to Bangladesh's economic and social realities. Habib and Molla reports that out-of-pocket healthcare spending amounts to 68.5% of total healthcare costs in Bangladesh which causes financial difficulties for numerous citizens [2]. They suggest raising government funding while improving coverage through existing health programs. Using only state-funded initiatives fails to address the constraints that stem from both fiscal capacity and administrative efficiency issues. A better solution combines mandatory insurance with voluntary options through digital financial access while employing behavioral economics to boost participation rates. The scarcity of health insurance payments stems from people's distrust of financial institutions and their inability to see immediate advantages from coverage. Behavioral economics provides solutions through default enrollment models which require people to actively decline insurance coverage. Mobile banking platforms bKash and Nagad should integrate health insurance services through automatic micro-premium withdrawals which maintain user involvement while avoiding yearly payment requirements. Insurance communication becomes more effective through behavioral alignment when risk protection messages replace long-term health investment messaging. A new approach would be the implementation of health insurance models supported by diaspora communities. The annual remittance amount of over $22 billion in Bangladesh lacks an organized system to direct this money toward healthcare funding. Insurance plans that allow expatriates to pay insurance premiums for family members and support community-based risk funds would enhance healthcare coverage among vulnerable populations. The Philippines and Mexico together with other countries have established successful diaspora-backed healthcare insurance systems which reduced healthcare expenses paid directly by patients to millions of people [3, 4]. Technological integration is also crucial. The article correctly identifies healthcare financing problems yet fails to investigate blockchain-based claims automation and AI-based adaptive pricing solutions. Blockchain technology brings transparency to operations while reducing fraud and streamlines claim settlements through automation to establish system-wide trust [5]. AI-driven underwriting systems allow for risk-based premium adjustments which enables insurance affordability for different income groups according to Rix [6]. Proof-of-concept deployments in Rwanda and Kenya show that these innovations can scale up for emerging markets [7, 8]. Bangladesh needs to prevent implementing models from high-income countries because their economic and institutional structures differ too much from its own. The country needs to prioritize a combined method that includes public-private collaborations with technological enhancements and behavioral economic practices. The implementation of mobile-based microinsurance and remittance-backed financing and blockchain claims processing requires initial testing through pilot programs for framework scalability purposes. The absence of forward-thinking strategies makes universal health coverage efforts stay theoretical instead of becoming practical initiatives. MD. Faisal Ahmed: writing – review and editing, writing – original draft, conceptualization, methodology, investigation, validation, resources, data curation. The author declares no conflicts of interest. Data sharing not applicable to this article as no data sets were generated or analyzed during the current study. No new data were generated or analyzed in this study. All supporting information and references are publicly available as cited in the article.
BACKGROUND: Nepal has been undergoing demographic and epidemiological transitions, marked by an increasing burden of non-communicable diseases (NCDs) and injuries. These transitions have led to financial implications, including rising out-of-pocket (OOP) expenses. This study reviews and synthesizes evidence on the status, issues and challenges in health financing system, policies, and programs to achieve universal health coverage (UHC) in Nepal. METHODS: We conducted a scoping review of literature on Nepal's health financing system, policies, and programs. A search strategy was developed using keywords related to two core concepts: health financing and universal health coverage. Grey literature was identified from the web pages of relevant ministries and organizations. A total of 148 studies/policy documents published in Nepali and English up to 31 December 2024 were included. Policies and content related to the health financing system were reviewed to understand the status, issues and challenges of health financing functions, and UHC . A framework-guided deductive content analysis approach was employed, and findings were interpreted using the three UHC components: service coverage, population coverage, and financial coverage. RESULTS: Nepal's health policy documents prioritize financial protection for low-income people and target groups through social health protection programs/schemes. However, multiple social health protection schemes coexist with fragmented risk pooling and low efficiency in health financing. OOP expenditure is high at 54.2%, with 10% of the population facing catastrophic health expenditures. Injuries and chronic morbidities contribute significantly to this burden, with 70% of injury-related and 62% of NCD-related expenses borne through OOP payments. Despite efforts to improve financial risk protection, the National Health Insurance Program (NHIP) suffers from low population coverage (28%), low renewal rate (54%), and financial sustainability issues (as provider payments exceed revenue collection). The UHC service coverage index, though improving, was only 54 out of 100 in 2021 reflecting limited health system capacity and insufficient readiness to address health challenges, including those posed by shifting demographics and the growing burden of NCDs. Nepal's total health expenditure remains around 2% of GDP, with persistent inefficiencies in resource allocation, fiscal decentralization, and budget absorption. CONCLUSIONS: Nepal's health financing policies align with UHC goals, yet critical gaps remain in multiple dimensions . Issues such as inefficiencies, underfunding, and fragmented social health protection schemes limit equitable access to quality health care. Therefore, comprehensive structural reforms-spanning legal, institutional, and policy frameworks-are urgently needed. Key reforms include: (1) merging or harmonizing existing social health protection schemes for efficient pooling and purchasing; (2) enhancing domestic health financing through increased health funding (≥5% of GDP) via payroll contributions, progressive taxation, and earmarked sin taxes; (3) reforming NHIP to mandatory enrollment starting from formal sector, subsidizing premium for informal sector and free coverage for disadvantaged groups, alongside strengthening policy implementation including accrediting of health facilities, ensuring service quality, prioritising and expanding coverage packages with strategic purchasing from all public and private health facilities; and (4) equitable public financing to ensure needs-based allocation across government levels that respond to demographic and epidemiological patterns. Further research is needed to assess hybrid tax and premium based insurance models, strategic purchasing optimization, and digital health innovations for financial sustainability.