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.
Many countries in the Asia Pacific rely on community health workers (CHWs) to care for various health needs. In the Greater Mekong Subregion (GMS), malaria CHWs have been an essential component of malaria elimination. Yet as the malaria burden declines, the role of malaria CHWs in local health systems and communities is changing. There is a need to expand malaria CHW roles to take on the provision of health services beyond malaria. This study sought to understand the process and experience of this role expansion including implementation, financing, policy, and sustainability within the Asia Pacific region. We documented malaria CHW programs that included health services in addition to malaria. We conducted 21 key-stakeholder interviews from thirteen programs in eight countries throughout the Asia Pacific region virtually in English and findings were analyzed using rapid-matrix analysis. Participants were recruited by an online landscaping survey, with an inclusion criterion of five + years' work experience and English speaking. Governments ran five of the thirteen programs; six were international non-governmental organizations (INGOs), and two were academic. Senior staff from programs that have expanded roles of malaria CHWs or integrated CHW programs explained expansion processes, challenges, and opportunities. We found that integration can occur in multiple program domains and does not necessarily occur in all domains simultaneously. We identified entry points for role expansion: integrated policy and financing, planning, assessments, and research. Operational entry points included the selection, training, motivation, management, supervision, and monitoring of CHWs. Enabling factors included decentralized management structures, health system linkages, commodity provision and referral procedures, and community engagement. While there is not a linear or unique path towards integration, we provide considerations for the policy level, practical implementation steps, and enabling factors for countries in the GMS to consider as they move towards sustainable, integrated malaria CHWs.
Costase Ndayishimiye, Richard Nduwayezu, Christoph Sowada, Katarzyna Dubas‐Jakóbczyk
Results-based healthcare financing policies have been adopted in countries worldwide, including those with limited resources. We conducted a retrospective, semistructured interview study to evaluate healthcare providers' experiences with Rwanda's performance-based financing (PBF) policy and the factors influencing its implementation. Guided by the health policy evaluation model-context, content, process, and actors-as a deductive framework supplemented by inductive coding, we analysed data from 21 participants (doctors, n = 13; nurses, n = 5; midwives, n = 3). Providers described PBF as a key motivator, supplementing incomes, increasing accountability, and fostering teamwork to meet performance targets. PBF was credited with improving patient outcomes, particularly in incentivized services; however, concerns arose regarding disparities in service prioritization. Key facilitators of and barriers to the implementation of PBF were identified, providing insights into its operational dynamics. Strong political commitment and integration into national strategies, such as Imihigo, along with decentralization through district steering committees, were key contextual enablers, enhancing the program's flexibility and alignment with local priorities. The content factors centred on a two-tiered contracting system, combining national accreditation processes with individual performance incentives. Process factors supporting PBF were characterized by decentralized evaluations, audits, and multilevel communication, which collectively bolstered accountability mechanisms. The engagement and capacity of stakeholders were highlighted as crucial to the success of PBF. Nonetheless, significant barriers, such as payment delays, manual documentation, untimely evaluations, insufficient training, limited provider participation in decision-making, and the exclusion of patients as stakeholders, were identified. These findings offer practical recommendations for policymakers aiming to improve or adapt provider payment mechanisms in similar contexts.
Brittany Hagedorn, Jeremy Cooper, Benjamin Loevinsohn, Valentina Martufi
BACKGROUND: To improve service delivery of Nigeria's primary health care (PHC) system, the government tested two approaches for facility-level financing: performance-based financing (PBF) and decentralized facility financing (DFF). Facilities also had increased autonomy, supervision, and community oversight. We examine how the intervention approach and funding level affected breadth of services and structural quality. METHODS: We use health facility surveys previously collected in 2014 and 2017, covering three years of implementation, in which districts were randomly assigned PBF or DFF and compared to matched districts in control states. We use log-linear regressions and non-parametric statistics to estimate the effect size of the financing approach and level of funding per capita. RESULTS: Service availability was highest in PBF facilities, while DFF also outperformed control on most measures. Results showed that structural readiness and service offerings both increased with more funding, especially under DFF. DFF and PBF facilities were better equipped to provide services that they claimed to offer, which was not the case for controls. Overall, PBF outperformed DFF, partially explained by funding levels. The rate of offering complimentary services followed a pattern of easiest-to-hardest to deliver. CONCLUSION: PBF and DFF both improved the breadth and structural quality of services, although DFF performance was more sensitive to funding levels. Improvements were observed at relatively low levels of funding, but larger investments were associated with better performance. Most DFF facilities exceeded the performance of higher-funded controls, implying that funding was more valuable in the context of autonomy, increased supervision, and community oversight.
Silvia Landa, Elisha Y. Sanoussi, Ezechiel Mahamane, Kairou Oudou Bilo Mahamadou · 6 authors
Water, sanitation, hygiene, waste management, and other environmental health services are critical for safe health systems, but global access is lacking. Adequate financing is a key barrier, and understanding resource allocation can help identify solutions in resource-limited contexts. We conducted a qualitative case examining resource allocation in rural Niger. Our objectives were to understand resource allocation processes, key actors and their roles, and contextual factors that influenced resource allocation. We interviewed thirty-three healthcare workers, community leaders, and government officials. We found that resource allocation followed formal and informal processes. Formal processes encompassed annual budgets and monthly supplies through government channels, while informal processes depended on healthcare workers' out-of-pocket expenses, unpaid labor, in-kind community support, healthcare facility revenue, and contributions from non-governmental and United Nations agencies, and the diaspora. Informal resource allocation was critical to fill the gap when formal processes were slow or insufficient. Resource allocation was highly decentralized with minimal influence of national policies and legal frameworks at the local level. Key contextual factors influencing resource allocation included politicization of budgets at the commune level, sometimes leading to inefficiency or inequity. We observed that healthcare facility actors who were most knowledgeable of needs often held the least decision-making power. We concluded that informal processes were complementary to formal processes, not conflicting. In contexts where government funding is severely limited, informal mechanisms may be the only viable short-term option to ensure the availability of services, demonstrating greater flexibility and adaptability. However, ultimately informal processes are an interim solution that should be explored to ensure service delivery without undermining long-term government systems strengthening. We recommend that funders commit to long-term initiatives promoting local government democratic decision-making, account for local actors' capacities and incentives, and acknowledge dynamic formal and informal resource allocations to optimize investments and trade-offs.
The chapter explores the profound impact that blockchain technology can have on the healthcare industry, with a particular focus on its uses, obstacles, and future prospects in the South Asian region. This chapter explores the potential of blockchain technology in addressing the difficulties and presents a range of applications in the healthcare sector. The text explores the possible impact of blockchain technology on electronic health records (EHRs), supply chain management, clinical trials, and billing systems, highlighting its capacity to bring about a revolutionary transformation in these domains. Concrete instances like Medicalchain and Guardtime exemplify effective deployments of blockchain technology, demonstrating its significant influence on the administration of healthcare data and cybersecurity. Moreover, the chapter investigates the nascent patterns in blockchain technology for health care, envisioning the establishment of compatible networks, integration of artificial intelligence, decentralized financial models, and the influence of non-fungible tokens (NFTs) in transforming healthcare financing and recordkeeping. The statement underscores the need for stakeholders to collaborate and form partnerships in order to achieve successful implementation. It emphasizes the significance of coordinated endeavors to address regulatory compliance, integration difficulties, and privacy issues.
Esteban Ortiz‐Prado, Isaac Alexander Suárez Sangucho, Wilson Ricardo Cañizares Fuentes, Jorge Vásconez-González · 5 authors
In the past three decades, Ecuador's health system has faced frequent ministerial turnover, often appointing leaders with limited training in public health policy and management. Although many ministers have strong clinical backgrounds, their lack of public health expertise has hindered a cohesive vision, raising concerns about the leadership's capacity to tackle the nation's complex health challenges effectively. The Ministry of Health is responsible for upholding the right to health, promoting health, preventing diseases, overseeing surveillance, and providing integrated care. It also develops clinical protocols and management guidelines, delivers health services, and conducts studies comparing national and international health management best practices [5,6]. To adequately fulfill these responsibilities, a master's degree in public health should be the minimum requirement for those considered for the position of Minister of Health. While ministers are indeed supported by technical personnel, they must have enough training to understand technical matters and not be overly reliant on staff or influenced by conflicts of interest [7]. Advanced public health training equips leaders with essential knowledge about financing, management, cost-effectiveness, and health communication, enabling them to evaluate and implement comprehensive health policies [8,9].A health minister requires both managerial skills to oversee health services and advocacy skills to ensure that potential effects on population health are integrated into the work of other government departments and ministries [10]. Helath Ministers require strong knowledge of epidemiology and public health preparedness, highlighted by challenges from global health crises like COVID-19. However, the Ministry faces internal issues impacting ministerial effectiveness, including overlapping responsibilities in regulations, unclear accountability, fragmented technical programs, and departments prioritizing specific professions over broader functions [11]. Furthermore, governance within the health sector is heavily influenced by institutional power dynamics. This lack of governance can severely hinder the performance of the Ministry of Health, contributing to systemic failures [12,13].Over the past 30 years in Ecuador, most health ministers have lacked advanced degrees or experience in key areas such as public health, epidemiology, or health systems management (see Table 1). This absence of qualifications hinders effective public health leadership, which demands an integrated, evidence-based approach to address social, environmental, and behavioral health determinants [1][2][3][4].Although the primary role of a health minister is to manage and oversee the national health system, their responsibility also extends to proposing public policies that can be evaluated through tangible improvements in health indicators, such as infant mortality. We believe that this is a significant issue for health governance.Therefore, we conducted an analysis based on the significant reductions in infant mortality during specific periods, identifying the ministers in charge and the outcomes associated with their tenure, highlighting changes that could reflect the impact of effective leadership and policy implementation (Figure 1). In Ecuador, significant milestones in public health were achieved, particularly before the year 2000. Key figures during their tenure led important vaccination campaigns and successfully managed the 1991 cholera outbreak, reducing infant mortality and advancing the Comprehensive Family and Community Health Program [14]. Between 1990 and 2006, the country saw critical reforms, such as the decentralization of health management to municipalities, the formation of Cantonal Health Councils, and the proposal of Universal Health Insurance in 2005-2006 [15]. However, in 2009, these decentralization efforts were reversed with the re-centralization of the health management system [16], undoing much of the progress that had been made.During 2014, the introduction of new food labeling regulations, which made nutritional information more accessible and positioned Ecuador as a global reference in non-communicable disease prevention was an important contrbution. However, this period was also marked by controversial decisions, including the closure of the National Institute of Hygiene and Tropical Medicine, the elimination of the National Service for the Eradication of Malaria (SNEM), and the shutdown of vaccine production in Ecuador [17]. Despite these public health initiatives, the reduction in infant mortality rates (IMR) during this period was less pronounced compared to other periods. While some improvements were made, the IMR did not decrease as significantly as might have been expected, highlighting a period where public health outcomes did not fully align with the scale of reforms introduced.[Insert Table 2 here ] The COVID-19 pandemic highlighted Ecuador's severe shortage of public health expertise, resulting in one of the world's highest excess death rates. Health ministers, often lacking local experience, communication skills, and disease management knowledge, struggled to provide clear public health messaging. This was worsened by significant mismanagement and corruption, including inflated prices for essential medications and supplies, which deepened the crisis [19,20].Corruption has long plagued the health sector, with some ministers facing serious allegations. For example, several scandals have involved the procurement of ambulances and other essential supplies at inflated prices, breaching public procurement laws [21][22][23].Ecuador's health leadership has historically been marked by high ministerial turnover, driven by political interests. This instability, coupled with instances of corruption and controversial policies, has hindered effective public health initiatives and created fragmented health policies. While some achievements exist, persistent leadership issues have led to high malnutrition rates and ineffective campaigns on issues like traffic accidents and drug abuse, contrasting sharply with the successes of neighboring countries like Peru.Appointing leaders focused solely on clinical medicine without a robust public health background poses several risks:• Fragmented Policies: Lacking public health foundations can lead to ineffective, fragmented policies [4,24,25].• Curative Bias: Overreliance on treatment instead of prevention perpetuates unsustainable healthcare costs [26].• Insufficient Emergency Preparedness: COVID-19 underscored the need for leaders skilled in epidemiology and crisis management [27][28][29].To better manage Ecuador's health system, technical skills and public health experience should be prioritized over political considerations in minister selection. Ideal candidates would possess:• Advanced public health qualifications.• Proven experience in public health policy formulation and evaluation.• Active public health research engagement.• Strong leadership and communication skills to articulate a public health vision and make informed, evidence-based decisions.Recent ministers have lacked communication competencies, resulting in fewer public health campaigns and diminishing the perception of health ministers as public health advocates.Selecting health ministers is a nuanced task influenced by social, political, and contextual variables, particularly in developing nations like Ecuador. However, the logic and some of the evidence underscores that this process must be approached thoughtfully, prioritizing technical expertise over political considerations, to ensure sustainable public health progress. While the public often expects a Minister of Health to be an effective administrator, adept at managing public procurement and addressing operational challenges, what Ecuador urgently requires is a leader with expertise in prevention, health promotion, and ensuring equitable access to healthcare services. These competencies are often lacking in physicians focused on curative, private-sector roles. This commentary highlights systemic issues, not as a complaint but as a reflection on persistent shortcomings.For example, despite a 25-year national malnutrition prevention program, Ecuador still has one of the region's highest malnutrition rates. Even during economic booms, investment favored hospital infrastructure over essential primary healthcare. This manuscript urges Ecuadorian authorities to address these issues and adopt the recommended steps for strengthening national health leadership, shifting towards a comprehensive public health focus for sustainable health improvements.
Ahmad Shirjang, Leila Doshmangir, Mohammad Bazyar, Vladimir Sergeevich Gordeev
BACKGROUND: Demographic transitions, societal changes, and evolving population health needs are placing increasing pressure on healthcare systems, necessitating ongoing reforms. Primary health care (PHC) is a foundational component of Universal Health Coverage (UHC) and sustainable health systems. Many countries have undertaken PHC reforms aimed at improving population health. This review explores the objectives, implementation mechanisms, challenges, and outcomes of these reforms. METHODS: We conducted a systematic review of studies sourced from five databases (PubMed, Scopus, Proquest, Embase, and Science Direct), applying the World Health Organization's Health Systems Framework for deductive content analysis. The PRISMA guidelines were followed to ensure transparency and rigour in summarizing the published literature. RESULTS: A total of 147 types of interventions were identified, with most targeting service delivery and financing. Key reform objectives included expanding access to care, improving financing and payment systems, scaling up family physician programmes, increasing government health expenditure, leveraging private sector capacities, and strengthening the PHC workforce. These interventions resulted in expanded public health coverage, enhanced access to PHC, increased utilization of services among low-income populations, broader social insurance coverage, and improved service quality, contributing to better community health outcomes. CONCLUSION: The success of PHC reforms depends on their alignment with political, social, and cultural contexts, as well as consideration of the social determinants of health. Strong governmental support, managerial stability, decentralization, and regional capacity building are essential for sustainable implementation. Reforms should be gradual, supported by accurate forecasting, adequate and sustainable resources, and evidence-based strategies, drawing on international experiences.
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.
Mohsin Raza Khan, Muhammad Arsalan Nazir, Sabeen Afzal
PURPOSE: This study aims to analyze the challenges in financing the healthcare system of Pakistan and develop a comprehensive health financing strategy aimed at achieving universal health coverage (UHC). DESIGN/METHODOLOGY/APPROACH: The paper utilizes World Health Organization (WHO) framework on health financing to build the argument. It uses qualitative research design involving focus group discussions and in-depth interviews with key stakeholders, including Federal Board of Revenue, Ministry of Finance, Planning Commission, development partners, academia and health ministries at federal and provincial levels, as well as social health insurance entities. FINDINGS: The research findings highlight several critical issues within Pakistan's healthcare system: Firstly, health spending is inadequate to provide financial protection to 24 million people. Secondly, the available health funding is allocated in clusters and caters primarily to specific groups, which exacerbates inequities in healthcare provision. Thirdly, the existence of multiple purchasing agents who operate concurrently to buy health services results in duplication and wastage of resources. Fourthly, the public financial management system, intended to support the swift distribution of public funds to health facilities, is not aligned with the requirements of the health system. Lastly, the devolved health setup has led to governance issues in managing the health sector. ORIGINALITY/VALUE: This study fills a significant gap in the literature on health financing within Pakistan and proposes a unique empirical approach using WHO's framework in a decentralized healthcare context. It also provides actionable recommendations for policymakers to develop strategies that improve the effectiveness of public financial management and health service delivery.
Background: Health financing is one of the focuses in the National Health System Reform major project in the 2022 Government Work Plan. However, obstacles have been found in health financing in Indonesia, including a lack of promote and preventive financing; less non-governmental involvement; and weak development of national health insurance (JKN) services. Purpose: To understand the principles of health financing for the realization of universal health coverage. This principle uses the concept of Kutzin et al (2017) and Atim et al (2021), namely revenue raising; pooling revenues; purchasing services; benefit design and rationing mechanism; and governance and institutional arrangements, including decentralization. Method: Focuses on the principles of health financing by utilizing secondary data sources through qualitative methods. The data sources were obtained from scientific journals, official government reports, related web pages, and others. Results: The effectiveness of increasing income for health financing cannot yet be measured. Revenue collection was found to overlap with health financing sources. There was a deficit for the JKN budget, and the community was not disciplined in paying contributions in purchasing services and distribution mechanisms. For the principle of decentralization, regional governments still depend on the central government in planning and budgeting health financing. Conclusion: The principles of health financing in Indonesia are not yet optimal in practice. This article contributes to looking at the gaps in information regarding the government's commitment to universal health coverage.
This article analyzes Brazil's Unified Health System (SUS), established by the 1988 Constitution. The article initially presents the previous trajectory of national health policy and the context of democratization in the 1980s, which favored health reform and created a public, universal, and comprehensive health system. It then explores the advances and contradictions recorded in more than three decades of implementation of the SUS. The main advances observed were the creation of institutional mechanisms compatible with the federative arrangement and social participation, political and administrative decentralization, the national expansion of access to health, changes in the health care model, including strengthening primary care, and improvements in health indicators. On the other hand, the persistence of structural problems and disputes between different health agendas, with differences between governments, led to contradictions in financing and public-private relations in health. Despite the differences between countries, the analysis of the Brazilian case provides lessons on the challenges in building universal health systems in Latin America.
The 2008 Great Recession deteriorated the Spanish health system, although no significant impact on health indicators was found. But other aspects amplified the damage of austerity: the unspecific and thoughtless governance mechanisms that were put in place (linear cuts and budget rationing) and some dysfunctional features of the healthcare organization whose reforms had been long postponed. The radical decentralization of healthcare in 17 Autonomous Communities, completed in 2002, showed the difficulty of health authorities in leading common resilient responses; the lack of wise health governance during the crisis was replaced by a direct takeover by the economic authorities of the central government. The 2020 COVID-19 pandemic showed the failures in resilience generated by the austerity policies of a decade ago, applied in a system with structural weaknesses not addressed by the necessary reforms and ill managed due to poor governance. Therefore, where there seems to be a resilient response from a health system, there may be damage that manifests itself later. The current crisis in primary care, which has been an essential element of the Spanish model, is one of the most worrying problems.
Ermyas Birru, Melino Ndayizigiye, George Wanje, Tholoana A. Marole · 14 authors
BACKGROUND: Lesotho experienced high rates of maternal (566/100,000 live births) and under-five mortality (72.9/1000 live births). A 2013 national assessment found centralized healthcare management in Ministry of Health led to fragmented, ineffective district health team management. Launched in 2014 through collaboration between the Ministry of Health and Partners In Health, Lesotho's Primary Health Care Reform (LPHCR) aimed to improve service quality and quantity by decentralizing healthcare management to the district level. We conducted a qualitative study to explore health workers' perceptions regarding the effectiveness of LPHCR in enhancing the primary health care system. METHODS: We conducted 21 semi-structured key informant interviews (KII) with healthcare workers and Ministry of Health officials purposively sampled from various levels of Lesotho's health system, including the central Ministry of Health, district health management teams, health centers, and community health worker programs in four pilot districts of the LPHCR initiative. The World Health Organization's health systems building blocks framework was used to guide data collection and analysis. Interviews assessed health care workers' perspectives on the impact of the LPHCR initiative on the six-health system building blocks: service delivery, health information systems, access to essential medicines, health workforce, financing, and leadership/governance. Data were analyzed using directed content analysis. RESULTS: Participants described benefits of decentralization, including improved efficiency in service delivery, enhanced accountability and responsiveness, increased community participation, improved data availability, and better resource allocation. Participants highlighted how the reform resulted in more efficient procurement and distribution processes and increased recognition and status in part due to the empowerment of district health management teams. However, participants also identified limited decentralization of financial decision-making and encountered barriers to successful implementation, such as staff shortages, inadequate management of the village health worker program, and a lack of clear communication regarding autonomy in utilizing and mobilizing donor funds. CONCLUSION: Our study findings indicate that the implementation of decentralized primary health care management in Lesotho was associated a positive impact on health system building blocks related to primary health care. However, it is crucial to address the implementation challenges identified by healthcare workers to optimize the benefits of decentralized healthcare management.
While the importance of primary health care (PHC) as a foundation for a strong healthcare system is widely accepted, the policies needed to achieve it remain deeply controversial. Some proponents call for a greater role for market and user choice in expanding and strengthening PHC, whereas others recommend a greater role for the government in directing its development. The objective of this paper is to assess these arguments by comparing the experience of China and Thailand in strengthening PHC. We find that tight government steering of the healthcare system in Thailand has produced better integration and eventually outcomes than the more decentralized and competitive system in China. The Chinese government’s massive administrative and fiscal efforts to strengthen PHC have been undermined by systemic barriers in the wider health system, notably fee-for-service and out-of-pocket financing that distort the incentives of healthcare providers. A key conclusion to emerge from the analysis is that central stewardship and steering accompanied by appropriate incentives to promote integration are critical to building effective primary health care.
The comment highlights the intricate health issues in Indonesia, emphasizing urban-rural gaps, healthcare financing challenges, and the government's dedication to Universal Health Coverage (UHC). The country's geographical layout amplifies the struggle of providing healthcare to rural areas, resulting in substantial health concerns like high tuberculosis rates and financial vulnerability for the impoverished. The concern raised underscores the paradox of low state healthcare spending despite high household expenditures, leading to individual payment reliance and underutilization of insurance. The analysis advocates a comprehensive healthcare approach, emphasizing prevention and curative actions. It also stresses the importance of decentralizing decision-making power to local governments for optimizing healthcare funds. The comment concludes by emphasizing the need for innovative solutions in Indonesia's healthcare landscape. It envisions a future where transformative approaches reshape the system, ensuring better health outcomes. Innovation, especially in medical technology, digital health, and healthcare delivery models, is identified as a central theme. The recommendation underscores the importance of creative solutions to address healthcare service limitations and advocates for leveraging advancements in preventive measures, education, and tackling lifestyle issues. The overall aim is to navigate Indonesia through its current healthcare challenges towards a more sustainable and effective system for the benefit of its population.
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.