Relevance of the research topic. The implementation of medical reform in Ukraine, which provides radical structural changes in the health care system, the transformation of financing mechanisms for services, and at the same time the implementation of budgetary reform, an integral part of which is budget decentralization, makes the issue of assessing the role of local budget spending on health care. Formulation of the problem. In conditions of limited budgetary funds, growing debt and budgetary decentralization, successful implementation of health care reform is impossible without increasing the role of local budgets in financing the industry of development priority areas. Analysis of recent research and publications. The works of I. Chygynova, V. Makogon, M. Pasichnogo, Ju. Markuts, I. Kogut, Y. Pasichnik, V. Tropina [1-6] and others are devoted to the study of issues related to the problems of the article. The results of their own research of some of the indicated problems are presented in [6-8]. Segregation of unexplored parts of a common problem. In the context of deepening budget decentralization, strengthening the financial base of local budgets, expanding the functional powers of local governments, it is necessary to further search for ways to increase the role of local budgets in health care financing. The purpose of the article is to assess the role of expenditures of local budgets of Ukraine on the health care sector in the context of deepening budget decentralization and to develop proposals for improving its financing. Duringresearch, general scientific and special methods were used: analysis and synthesis, the method of generalization, statistical, etc. The article analyzes and evaluates the total expenditures of local budgets for health care, as well as for the regional program "Health of the population of the Dnipropetrovsk region for 2020-2024". The attention is focused on increasing the role of local budget expenditures in the process of changing the health financing model. The basis for expanding the capacity of local governments to finance health care was the deepening of budgetary decentralization, changes in the distribution of taxes to local budgets, etc. Conclusions. In conditions of acute limited financial resources, success in the formation and effective use of funds from local budgets of Ukraine for the development of an appropriate health care system is associated, first of all, with the consistent implementation of the financial and budgetary policy of the state, the coherence of medical and budgetary reforms, priorities, increasing the efficiency of the use of budgetary funds in format of target program budgeting. The results of this study can be applied in the process of forming and implementing social and budgetary policies for the development of the health care system in the country.
The Nigeria State Health Investment Project (NSHIP) was implemented in three Nigerian states between 2013 and 2018. Under the NSHIP, some local government areas were randomly assigned to Performance-Based Financing (PBF) intervention while others received decentralized facility financing (DFF) for comparison. This article evaluates the effect of PBF compared with DFF on health service delivery indicators in Adamawa state, under this quasi-experimental design, using the difference-in-differences technique. The analysis used health facility monthly data collected by the Health Management Information System through the District Health Information Software 2 (DHIS2). The PBF intervention group significantly increased the quantity of most of its service delivery indicators, such as antenatal care visits and deliveries by skilled personnel compared with the comparison group (DFF) after the introduction of NSHIP, although the baseline level of service delivery between PBF and DFF health facilities was statistically identical prior to the introduction of the intervention. We also conducted robustness check analysis to confirm the effect of PBF. Overall, we found a significant positive effect of PBF on most service delivery outcomes, except full vaccinations and post-natal care. One important policy implication is that we should carefully use PBF for targeted indicators.
ABSTRACT For the last three decades, healthcare systems have been under pressure to adapt to a neoliberal world and incorporate market principles. The introduction of market-based instruments, increasing competition among health care providers, introducing publicly -funded private sector provisioning of healthcare through health insurance financing systems to replace public provisioning of health care, promoting individual responsibility for health and finally, the introduction of market relations through privatization, deregulation and decentralization of health care have been some common elements seen globally. These reforms, undertaken under the guise of increasing efficiency and quality through competition and choice, have in fact harmed the physical, emotional and mental health of communities around the world and also contributed to a significant rise in inequities in health and healthcare access. They have weakened the public healthcare systems of countries and led to commercialization of healthcare. This article presents three case studies of resistance, to the commercialization of health care, by the People’s Health Movement (PHM) and associated networks. It aims to contribute to the understanding of the way neoliberal reforms, including those imposed under structural adjustment programmes and some promoted under the Universal Health Coverage (UHC) paradigm, have impacted country-level health systems and access of people to health care, and bring out lessons from the resistance against these reforms.
Health indicators have been gradually improving in India, but health for all is yet to be achieved. The life expectancy is 68.7 years, infant mortality rate is 33/1000 live births, maternal mortality ratio is 130/100,000 live births, and total fertility rate is 2.3 children/woman; however, large inequities by geography, gender, class, caste, religion, and region are seen.[1] Health of the Nation's States Report[2] indicates that despite rising income, poverty and hidden hunger still exist; environmental pollution has increased, more so, in urban areas; sanitation services and clean fuel use have not yet improved to the desired level, especially in the villages. In urban areas, slums have mushroomed, built area has increased, and open spaces have shrunk. Moreover, dietary patterns have changed in favor of more sugar, salt, fat, and alcohol, whereas consumption of vegetables and fruits has declined. Mechanization, especially motorized transport, has encouraged sedentary life styles and a rise in road traffic injuries is noticed. The gap between aspirations and real-life situations has pushed many into addictions and mental health problems. To address these issues, multisectoral public health actions are needed, in addition to the reorientation of health sector. In the last decade, the implementation of the National Health Mission (NHM) did bring back some focus on social determinants of health and encouraged development of a health system based on primary health care.[3] Investments in health system led to improvement in health services. It had an impact on health indicators, but the full potential of NHM is yet to be realized.[4] The recently announced Ayushman Bharat Mission (ABM) has started insurance coverage for selected package of medical and surgical procedures for hospitalized patients belonging to socioeconomically vulnerable families on the lines of Rashtriya Swasthya Bima Yojna though the insurance amount is larger.[5] The development of subcenters into health and wellness centers continues to be under the NHM. These two missions, i.e., NHM and ABM, deal with primary and secondary care, respectively. In the absence of a linkage between these two missions, it may not be possible to maintain a balance. Therefore, the funds earmarked for ABM should flow through the primary health-care system on per capita basis. The primary health-care providers should be empowered to decide which patient to refer, to which hospital (public or private), and at what cost to pay, so that ultimately health services are cashless for the patient. Coordinated actions are required not only within the health and family welfare ministry, but across multiple sectors. Hence, to operationalize multisectoral public health action in a decentralized manner, every village or urban ward should have Arogya Kendra (health center) financed by the state through a village or ward fund, but managed by local volunteers under the guidance of the community it serves, and it should have a decentralized Integrated Health Information System for Universal Health Care supported by Information Communication Technology (ICT), if possible. Devolution of funds to district health societies and decentralization of planning, implementation, and monitoring would build a sustainable system rooted in local sociocultural contexts, which will be able to harness the locally available resources. However, broad policy framework, guidelines, and oversight can remain at the central and state level. Primary health-care teams should be incentivized to invest in prevention and health promotion, so that health literacy improves and spending on illness care can be reduced. Therefore, NHM and ABM should advocate for a comprehensive public health-oriented “whole-of-government” intersectoral health promotion initiative keeping in view “inclusive growth” and “health development” as a social goal of the society. Health impact assessment of all public policies should be mandated by legislation. “Prevention of diseases” is a more cost-effective strategy than the popular approach of “Treatment.” Therefore, several countries have reengineered their health systems in a variety of ways to protect and improve peoples' health. For example, in England, the Health and Social Care Act 2012 reorganized the health services to create National Health Service England and Public Health England,[6] and in Thailand, the National Health Security Act 2002 granted everyone the right to a standard and efficient health service and established National Health Security Office to improve universal health coverage.[7] The World Health Organization has also recently planned a call to countries to set up leadership at all levels to protect the people from public health emergencies, to improve universal health coverage, and to ensure that people enjoy better health and well-being.[8] Indian should also reorganize its health system. Parliament should promulgate Indian Public Health Act with a mandate to protect and promote health of people as a fundamental right to health and health care. An autonomous “Public Health Commission” should be established to implement the provisions of the Act. It should have a public health commissioner with three deputy commissioners to head (a) epidemiology, (b) public policy, and (c) health promotion and education divisions. At state level, an additional public health commissioner should chair the State Public Health Commission which should have three deputy commissioners representing the above-mentioned three divisions, and at district level, a public health officer should head the District Public Health Commission who should be assisted by three additional public health officers. Each municipality should have a deputy public health officer and three public health supervisors. The Panchayat Raj Institutions, at district and community development block level, should have a deputy public health officer and an assistant public health officer. At Panchayat level, a public health supervisor should be appointed. Public Health Commission should have sufficient infrastructure (secretarial support staff, technical staff, equipment, office space, and budget) so that, in coordination with all sectors, a Public Health Action Plan can be prepared, funded, implemented, and monitored periodically. In summary, to achieve the universal health coverage, major challenge in India is promotion of health, prevention of diseases, and provision of health care in a balanced manner, which will require innovative public policies, strategies, and programs in many sectors. Development and implementation of a multisectoral approach to achieve sustainable development goals is the need of the hour. Establishment of a Public Health Commission will go a long way in achieving coordination of various initiatives not only in the Ministry of Health and Family Welfare but also in many other relevant ministries/sectors. At least 5% of the gross domestic product should be earmarked for public health and a responsive governance mechanism as outlined above should be set up, to achieve universal health coverage by 2030 as envisaged in the United Nations sustainable development goals which are also endorsed by the Government of India.[9]
INTRODUCTION: Fiscal federalism and fiscal decentralization are distinct policy options in public services in general and healthcare in particular, with possibly opposed effects on equity, effectiveness, and efficiency. However, the pertinent discourse often reflects confusion between the concepts or conflation thereof. METHODS: This paper performs a narrative review of theoretical literature on decentralization. The study offers clear definitions of the concepts of fiscal federalism and fiscal decentralization and provides an overview of the potential implications of each policy for healthcare systems. RESULTS: The interpretation of the literature identified three different dimensions of decentralization: political, administrative, economic. Economic decentralization can be further implemented through two different policy options: fiscal federalism and fiscal decentralization. Fiscal federalism is the transfer of spending authority of a centrally pooled public health budget to local governments or authorities. Countries like the UK, Cuba, Denmark, and Brazil mostly rely on fiscal federalism mechanisms for healthcare financing. Fiscal decentralization consists of transferring both pooling and spending responsibilities from the central government to local authorities. Contrarily to fiscal federalism, the implementation of fiscal decentralization requires as a precondition the fragmentation of the national pool into many local pools. The restructuring of the pooling system may limit the cross-subsidization effect between high- and low-income groups and areas that a central pool guarantees; thus, severely affecting local equality and equity. With the limited availability of local public resources in poorer regions, the quality of services drops, increasing the disparity gap between areas. Evidence from Italy, Spain, China, and Ivory Coast -countries with a strong fiscal decentralization element in their healthcare services- suggests that fiscal decentralization has positive effects on the infant mortality rate. However, it decreases healthcare resources as well as access to services, fostering spatial inequities. CONCLUSION: If public resources are and remain adequate, allocation follows equitable criteria, and local communities are involved in the decision-making debate, fiscal federalism -rather than fiscal decentralization- appear to be an adequate policy option to improve the healthcare services and population's health nationwide and achieve health sector economic decentralization. HIPPOKRATIA 2020, 24(3): 107-113.
Antonio Nuzzo, Flavia Carle, Eugenio Anessi Pessina
The policies pursued both at the international and national levels have brought to the fore the concept of governance decentralization of health-care systems. In Italy, in particular, with the approval of legislative decree n. 56/2000 on fiscal federalism and the amendments to Title V of the Constitution (Const. Law n. 3/2001), the Regions have obtained wider political, administrative, organizational and management competencies also in health care. At the international level, several studies have examined the issue of equity in a decentralized health-care system. In the Italian context, this also involves the provision of essential levels of health care (LEAs) across Regions. Equity is a constitutional principle, pursued by the central level and monitored through the set of indicators of the “LEA Grid” (Griglia LEA). Starting from the “LEA Grid” indicators, through a multidimensional analysis by principal components, the study analyzes the evolution of inter-regional equity in the provision of health care (prevention, hospital care, outpatient care) between 2001 and 2012, when the process of health-care decentralization became more established. In line with the international literature, this analysis shows a significant inter-regional heterogeneity. In particular, it highlights: 1) an interregional differentiation with respect to the principal components defined “vaccination coverage”, “hospital care performance” and “outpatient care for the disabled”; 2) a persistent differentiation in “hospital care” between central-northern and southern regions; 3) a negative trend for the autonomous regions and provinces both in the provision of “hospital care” and “vaccination coverage”. The results of the study, innovative for equity dimensions explored and data available, justify the central government's intervention as guarantor of territorial equity with respect to the provision of health care.
Global Health Care Issues
Regional Development and Policy
Health Systems, Economic Evaluations, Quality of Life
Low- and middle-income countries (LMICs) face many challenges and competing demands in the health sector, including maternal and newborn mortality. The allocation of financial and human resources for maximum health impact is important for social and economic development. Governments must prioritize carefully and allocate scarce resources to maximum effect, but also in ways that are politically acceptable, financially and institutionally feasible, and sustainable. Political economy analysis (PEA)-that gets what, when and why-can help explain that prioritization process. We used PEA to investigate how four Asian LMICs (Bangladesh, Indonesia, Nepal and the Philippines) allocate and utilize resources for maternal, newborn and child health (MNCH). Using mixed research methods including a literature review, field interviews at national and sub-national level, and policy, process and budget analysis in each country, we examined three political economy issues: (1) do these countries demonstrably prioritize MNCH at policy level; (2) if so, is this reflected in the allocation of financial and other resources and (3) if resources are allocated to MNCH, do they achieve the intended outputs and outcomes through actual programme implementation? We also considered the influence of transnational developments. We found that all four countries demonstrate political commitment to health, including MNCH. However, the health sector receives comparatively low public financing, governments often do not follow through on plans or pronouncements, and capacity for related action varies widely. Poor governance and decentralization, lack of data for monitoring and evaluation of progress, and weak public sector human resource capacity were frequent problems; engagement of the private or non-government sectors is an important consideration. Opportunities exist to greatly improve equity and MNCH outcomes in these nations, using a mix of evidence, improved governance, social engagement and the media to influence decisions, increase resource allocation to and improve accountability in the health sector.
A mainstream motivation for decentralized government is to enable public service investments to better align with political preferences that may differ by geographical region. This paper examines how political preferences determine local government provision of hospital services. We find that local governments in areas more supportive of public insurance expansion responded to such state action by increasing expenditures on hospitals, whereas those in areas that voted against such expansions used the savings to reduce property taxes. This finding suggests that local government financial responses indeed align with political preferences.
Cinzia Di Novi, Massimiliano Piacenza, Silvana Robone, Gilberto Turati
Recent theories on fiscal decentralization support the view that sub-national governments who finance a larger share of their spending with taxes raised locally by themselves are more accountable towards their citizens. Whilst evidence on improvements in spending efficiency is relatively common, little is known about the effects on inequalities amongst the population. In this paper we exploit a reform aimed at increasing regional tax autonomy in Italy to provide quasi-experimental evidence on the impact of fiscal decentralization on health disparities between- and within-regions. Our findings, robust to a number of robustness checks, support the view that fiscal decentralization does not impact on between-regional inequalities but can help to reduce inequalities within regions. However, this last effect depends on the degree of economic development: richer regions are better than poorer ones in containing inequalities.
Abstract Primary health care (PHC) represents one of the most important parts of any health system, and consists of first-contact medical services (preventive, curative and rehabilitation) for the patients. Our study analyses the family physicians' opinions related to a series of measures that could improve Romania's healthcare system through an online survey. We identified three components, first one related to control over spendings, increase of medicine market efficiency and transparency in using public funds, second one related to standardization of care processes, accreditation, implementation of guidelines and control over utilization of specialty services and component number three related to type of insurance houses, with competition among them, better decentralization and integrated provision of medical services. The conclusions of the survey emphasize the fac that primary care health is affected by sub optimal financing, with a need of better support for its development through investments in health promotion, services integragion and human resources as means of increasing general health status of the population.
Trisya Rakmawati, Reece Hinchcliff, Jerico Franciscus Pardosi
The local-level impacts of decentralizing national health systems are significant yet infrequently examined. This review aims to assess whether localized health services delivery in Indonesia, which commenced a health system decentralization process in 2001, achieved its objectives or could be enhanced. A systematic review was undertaken to collate published evidence regarding this topic and synthesize key findings holistically using the six building blocks framework of the World Health Organization (WHO) to categorize health system performance. Four research databases were searched in 2016 for relevant evidence published between 2001 and 2015. The inclusion criteria were relevance to the topic of decentralization impacts at the district level, original research, and published in English. Included articles were appraised for quality using a standardized tool, with key findings synthesized using the WHO building blocks. Twenty-nine articles met the inclusion criteria and categorized under the WHO building blocks categories. The findings highlight problematic impacts of decentralization related to three building blocks: service delivery, health financing, and workforce. In the 15 years of post-decentralization in Indonesia, the service delivery, health workforce, and health financing blocks should be prioritized for further research and policy evaluation to improve the overall health system performance at the district level.
BACKGROUND: Universal health coverage (UHC) assures all types of health service and protects all citizens financially in any conditions due to illness. Globally, the UN sustainable development goal (SDG) provides high priority for UHC as a health related goal. The National health system of Nepal has prioritized in similar way. The aim of this study is to explore the challenges and opportunities on the road to UHC in Nepal. METHOD: We used varieties of search terminologies with popular search engines like PubMed, Google, Google Scholar, etc. to identify studies regarding Nepal's progress towards UHC. Reports of original studies, policies, guidelines and government manuals were taken from the web pages of Ministry of Health and its department/division. Searches were designed to identify the status of service coverage on UHC, financial protection on health particularly, health insurance coverage with its legal status. Other associated factors related to UHC were also explored and presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. RESULTS: We found 14 studies that were related to legal assurance, risk pulling and financing of health service, 11 studies associated to UHC service coverage status and, 7 articles linked to government stewardship, health system and governance on health care. Constitutional provision, global support, progress on the health insurance act, decentralization of health service to the grass root level, positive trends of increasing service coverage are seen as opportunities. However, existing volunteer types of health insurance, misleading role of trade unions and high proportion of population outside the country are main challenges. The political commitment under the changing political context, a sense of national priority and international support were identified as the facilitating factors towards UHC. CONCLUSION: To achieve UHC, service and population coverage of health services has to be expanded along with financial protection for marginalized communities. Government stewardship, support of stakeholders and fair contribution and distribution of resources by appropriate health financing modality can speed up the path of UHC in Nepal.
The 2012 national health policy is the \n overarching health policy framework in Zambia. The policy \n takes a human rights approach to health care provision, \n where all citizens are entitled to basic health care \n (Ministry of Health 2012). The policy is actualized through \n successive five-year national health strategic plans. \n Operationally, Zambia’s health system is centralized, with \n delegated responsibilities from the center to lower levels \n of the health care delivery system. The Ministry of Health \n plays a dual role of policy formulation and strategic \n planning and delivery of health services, with provincial \n and district health offices being upwardly accountable to \n the Ministry of Health headquarters. Going forward, Zambia \n is in the process of launching two major reforms which will \n further affect the organization of the health sector. These \n are (a) implementation of the National Decentralization \n Policy, and (b) introduction of a National Health Insurance \n (NHI) scheme. The PHC function (including transfer of PHC \n staff to local government authorities) is among the front \n runner for decentralization. If national decentralization is \n fully implemented, it will affect the way health services \n are organized, delivered, and financed in the country. Thus, \n adequate preparations in the health sector are required to \n minimize challenges. Secondly, Zambia enacted the NHI Act in \n April 2018 which provides the legal mandate to establish the \n NHI management authority, and the NHI scheme. At the time of \n this study, it was envisaged that implementation of the NHI \n scheme will be done in a phased manner with a view of \n covering the entire population in the medium to long term. \n However, depending on the final design and implementation \n process, the NHI will have a substantial effect on the \n financing and delivery of health programs and services in \n Zambia. One of the immediate challenges will be providing \n insurance cover to the informal sector and indigent people \n in rural areas.
BACKGROUND: Decentralization is promoted as a strategy to improve health system performance by bringing decision-making closer to service delivery. Some studies have investigated if decentralization actually improves the health system. However, few have explored the conditions that enable it to be effective. To determine these conditions, we have analyzed the perspectives of decision-makers in the Philippines where devolution, one form of decentralization, was introduced 25 years ago. METHODS: Drawing from the "decision space" approach, we interviewed 27 decision-makers with an average of 23.6 years of working across different levels of the Philippine government health sector and representing various local settings. Qualitative analysis followed the "Framework Method." Conditions that either enable or hinder the effectiveness of decentralization were identified by exploring decision-making in five health sector functions. RESULTS: These conditions include: for planning, having a multi-stakeholder approach and monitoring implementation; for financing and budget allocation, capacities to raise revenues at local levels and pooling of funds at central level; for resource management, having a central level capable of augmenting resource needs at local levels and a good working relationship between the local health officer and the elected local official; for program implementation and service delivery, promoting innovation at local levels while maintaining fidelity to national objectives; and for monitoring and data management, a central level capable of ensuring that data collection from local levels is performed in a timely and accurate manner. CONCLUSIONS: The Philippine experience suggests that decentralization is a long and complex journey and not an automatic solution for enhancing service delivery. The role of the central decision-maker (e.g. Ministry of Health) remains important to assist local levels unable to perform their functions well. It is policy-relevant to analyze the conditions that make decentralization work and the optimal combination of decentralized and centralized functions that enhance the health system.
Moritz Piatti-Fünfkirchen, Magnus Lindelöw, Katelyn Jison Yoo
Progress toward universal health care (UHC) in Africa will require sustained increases in public spending on health and reduced reliance on out-of-pocket financing. This article reviews trends and patterns of government spending in the East and Southern Africa regions and points out methodological challenges with interpreting data from the World Health Organization's (WHO) Global Health Expenditure Database (GHED) and other sources. Government expenditure for health has increased for most countries, albeit at a slower rate than gross domestic product (GDP). In most countries there has been a prioritization away from health in government budgets, putting the onus on the private sector and donors to fill the gap. Donor support is important in the region but reliance on external spending is not consistent with countries' stated ambitions of universal health coverage. A number of methodological challenges with estimating health expenditures are identified. Capturing health expenditures adequately across agencies and levels of decentralization can be challenging, and off-budget funds and arrears are evasive. Measurement error can be significant because actual expenditure information can be hard to come by and is often dated and unreliable. Furthermore, how external financing is captured will affect government health expenditure estimates. These factors have contributed to differences in expenditure estimates between the WHO GHED and country-specific public expenditure reviews and complicate interpretation. The article concludes that it is critical to strengthen national data capacity and international efforts to promote quality and consistency of data. The GHED is an invaluable resource for monitoring and benchmarking health expenditures. It is best used in combination with deep dive country expenditure assessments.
This article analyses the impact of state decentralization on one aspect of territorial diversity, specifically on the policy discretion of regions, as an expression of their political autonomy for self-government. Our interest focuses on the factors that determine the decisions and actions of regional governments in developing their policies. We ask: why do regional governments take different public policy options? Conceding that several factors help explain policy decisions (such as productive structure, government ideology, social capital, political context, budgetary resources), we choose to explore the impact of two of them, by asking: in what way, and to what extent, are policy decisions and actions conditioned by the financing model and by their different ideologies? We present quantitative and qualitative comparative evidence from two contrasting case studies: two regions in decentralized Spain that have developed their own policies of income and spending, and have translated them into differing public management policies and regulatory models for providing health services. These governments are ideologically different and have undergone different degrees of recent ideological changes, but the resources provided to them by the financing model have also been different. We show how resources determine the scope of governments’ actions, while ideology determines their direction.
Background: Governments engage in setting health sector priorities among competing interests to maximize health system goals within the available resources. This is important as misalignment between health priorities and budget allocations can lead to low budget allocations and underspending in the health sector.\nGoal: The goals of the study are twofold. First, measure the extent of alignment between a stated government priority and actual government expenditure. Second, if there is misalignment, explain the underlying bottlenecks including institutions, structures, and capacities.\nMethod: The study focuses on one stated health sector priority shared between Kenya and Mozambique, which is improving geographical equity of governmental resources for health. An explanatory mixed methods design is used, in which quantitative analysis is followed by a qualitative assessment. In quantitative analysis, Gini index is used to summarize the differences in per capita health expenditures across regions. In addition, health expenditure is decomposed as a product of total budget, health budget priority, and health budget execution to identify whether resource allocation or resource utilization lead to geographical inequity. The qualitative assessment consisted of 23 semi-structured key informant interviews, 10 for Kenya, 11 for Mozambique, to explain the quantitative results.\nResults: In both Kenya and Mozambique there is geographical inequity in government health spending, which is inconsistent with the stated government priority (Gini greater than zero). The decomposition of health expenditure suggests that, in Kenya, the misalignment is driven by both resource allocation and utilization processes; in Mozambique, it is driven largely by the resource allocation process. \nThe qualitative analysis reveals several bottlenecks that are common between the two countries. At the institutional level, there is institutional separation between planning and budgeting, decision-making is ad hoc, and difficult decisions on hard choices and tradeoffs are left to the end of the budget process. At the structural level, rapid and unplanned decentralization in Kenya and the deconcentration model in Mozambique have led to inadequate structures to align planning and budgeting. At the capacity level, there are too many administrative demands on planning and budgeting staff, who also lack technical expertise and adequate data to make evidence-based decisions.
To what extent do the World Health Organization, the World Trade Organization, and the World Bank remain central today and how much influence do they still wield in shaping the global agenda? While several studies have traced the development of various intergovernmental organizations (IGOs), charting their growth and influence in international affairs, and assessing their prospects, few if any have compared IGOs across various fields. This paper aims to fill this gap by taking a closer look at three different policy fields to better understand the current architecture of global governance, the centrality of IGOs, the role of new and other actors, as well as the strengths and weaknesses of this "new" architecture. The authors find that, first, the emergence of new private players has significantly eroded the centrality of IGOs such that the course of global governance in health, trade, and development finance has changed irreversibly. Second, regional arrangements have overtaken global ones and nonstate actors have assumed more prominent roles. Third, this multiplicity of powerful players has led to some positive outcomes but also greater inefficiencies and redundancies. Fourth, developed countries have been pivotal in eroding the centrality of IGOs, but developing countries are taking on a greater role in global governance. Fifth, the new architecture can be described as one of diversification in global health governance, fragmentation in global trade, and variation in multilateral development finance. Global governance in the 21st century is thus characterized by a proliferation of actors and a decentralization of authority, an erosion of IGO centrality accompanied by a greater role for nonstate actors, developing countries, and by increased regionalism. Depending on the sector of governance, its inherent aims, and the nature of the actors involved, the new architecture may be one of variation, fragmentation, or diversification. While this new architecture is complex and might possibly lead to inefficiencies and redundancies, it allows a greater number of actors to participate, making it more representative of the current world order and making it possible to mobilize more resources to promote development.
A major challenge to achieve health coverage in Nigeria is expansion of health access to the poor, vulnerable and informal sectors, which constitute over 70% of the population of more than 186 million. Evidence from other countries suggests that it is difficult for contributory insurance schemes to achieve universal health coverage in such conditions, especially with such a large informal sector. In fact, Nigeria's national social health insurance program has provided coverage to less than 5% of the population since its implementation in 2005, private voluntary health insurance has shown poor potential to extend coverage, and community-based health insurance has failed to expand access to poor, vulnerable and informal sector populations as well. Decentralization of health insurance to the states has limited potential to expand health insurance coverage for the poor, vulnerable and those in the informal sector. Furthermore, social health insurance in many developed countries has taken many years to achieve universal health coverage. This paper suggests that policy makers should consider adopting a tax-based, noncontributory, universal health-financing system as the primary funding mechanism to accelerate progress toward universal health coverage. Social health insurance and its decentralization to states for formal sector workers should serve as a supplement, while private voluntary health insurance should cover better-off groups. Simultaneously, it is critical to tackle issues of poor governance structures, mismanagement of funds, corruption, and lack of transparency and accountability within regulatory and implementing agencies, to ensure that monies allocated for expanded health insurance coverage are well managed. Although the proposed universal health coverage reform may take some years to achieve, it is more feasible to collect taxes, improve tax administration and expand the tax base than to enforce payment of contributions from nonsalaried workers and those who cannot afford to pay for health insurance or for services out of pocket.
Brian M. Till, Alexander W. Peters, Salim Afshar, John G. Meara
Blockchain technology and cryptocurrencies could remake global health financing and usher in an era global health equity and universal health coverage. We outline and provide examples for at least four important ways in which this potential disruption of traditional global health funding mechanisms could occur: universal access to financing through direct transactions without third parties; novel new multilateral financing mechanisms; increased security and reduced fraud and corruption; and the opportunity for open markets for healthcare data that drive discovery and innovation. We see these issues as a paramount to the delivery of healthcare worldwide and relevant for payers and providers of healthcare at state, national and global levels; for government and non-governmental organisations; and for global aid organisations, including the WHO, International Monetary Fund and World Bank Group.
The Spanish National Health System (SNHS) was legally defined in 1986. There are many well documented studies on how its basic traits (universality, accessibility, decentralization, integrated public health networks, public and private provision, financed by taxes, social premiums and copayments, etc.) have evolved since then.
This paper explains how the SNHS facilities and functions are deeply decentralized and how the recent economic crisis has changed this picture, with central health planning basically located into the Ministry of Finance and mainly guided by deficit control considerations.