Dr Abubakar Yakubu Anadavi, Adah Patrick Eneojo, Dr Emmanuel Bola Jonah K
The epidemiologic approach was used to conduct the cross-sectional survey to observe and identify supply-side risks qualitatively and quantitatively linked to the determinants of the outcomes for Basic Health Care Provision Fund (BHCPF) implementation. The data analysis was conducted on survey datasets obtained from the stratified random sampling based on Integrated Supportive Supervision survey, (n=127) that received Decentralized Facility Financing (DFF) not after the 30th of September, 2022 from a population of 220 PHCs eligible for DFF) . Evaluative research is crucial to improving systems and services at 220 BHCPF designated sites, to ensure that strengths are rewarded, weaknesses observed compared to the expectations for outcomes in the intervention linked to risk factors compared to SDGs targets
Yusuf Hassan Wada, Kenneth Okoineme, Jennifer Anyanti, Dayyabu Yusuf · 7 authors
People living in vulnerable conditions have often been neglected or have a low coverage in health insurance which exacerbate poverty, vulnerability and social exclusion. This necessitates building and implementing insurance coverage that fully integrates social protection systems and community-based social care that prioritise the needs of the most vulnerable. To that end, we propose a decentralized system of sustainable financing and management of the vulnerable group fund that is performance driven with multi-stakeholder accountability systems premised on integrated data management. Integrating these elements will ensure that some of the existing gaps in the basic healthcare provision fund implementation in Nigeria are addressed with the following fundamental building blocks for the vulnerable group fund. These recommendations will help governments, resource partners and relevant stakeholders to consider in formulating strategies for operationalizing the vulnerable group funds and decreasing health inequalities among the population. In addition to implementation of this to accelerate universal health coverage and social protection, this will help to mitigate the currents challenges that exacerbate the inequality gaps, and build more resilient health and social protection systems, including the systems within humanitarian crises settings.
OBJECTIVES: The study applies the principal-agent approach to explore providers' experiences before and after the introduction of performance-based financing (PBF) in Cameroon, challenges and facilitators in the implementation process, and mechanisms in place to ensure sustainability. METHODS: The study was an in-depth qualitative study whose goal was to provide multiple descriptions of experiences and insights from a principal-agent analysis perspective. Purposive sampling was used to identify the key characteristics of the participants relevant to the study. A snowballing technique was used to further identify eligible participants. Only healthcare providers who were exposed to the previous system and could reflect on and provide meaningful data that captured the everyday experiences before and after the implementation of PBF were included. Data were collected from three districts in the Southwest region of Cameroon from May 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. RESULTS: A total of 17 interviews and 3 focus group discussions (24 participants) were conducted with healthcare providers and key stakeholders involved in PBF. The respondents described a range of changes that they had experienced since the introduction of PBF. Each of these changes was categorized as either positive or negative. Positive changes were framed into 14 dominant categories: motivation, negotiations, innovation, resource allocation, autonomy, decentralization, transparency, improved quality of care, separation of function, performance, equity considerations, opportunity to recruit, participation in decision-making, and improved access to and utilization of maternal health services. The main challenges (negative experiences) reported were framed into nine categories: management of change, retention issues, conflict of interest, poor understanding of the PBF concept, resistance to change, verification challenges, delays in payment of PBF incentives, data entry and documentation, and challenges in meeting the equity considerations of the poor and vulnerable. Despite the challenges, providers preferred the decentralized approach to the centralized system. CONCLUSION: PBF is a national strategy for achieving universal health coverage in Cameroon, and the experiences of providers provide a vital guide to refine national policy. The introduction of PBF has provided positive changes to providers' quality of care when compared to the previous system. Addressing the delays in PBF payments will help to overcome the challenges to implementation and provide opportunities for health facilities to be more efficient and improve their performance. Despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal).
Fortune Benjamin Effiong, Chiemela Prosper Ogbonna, Prosper Ifunanya Agughalam, Miracle O. Okwukwu · 7 authors
Universal health coverage (UHC) is aimed at ensuring that individuals and communities have affordable access to essential health care services without facing financial hardship. Achieving UHC and the third sustainable development goal of the United Nations requires that health systems transition from a vertical, top-down, curative approach toward one that puts people at the core of health care services, such as community-centered health interventions. Nigeria operates a decentralized health care system with the least focus on primary health care, making access to quality, and affordable health care for several citizens a challenge as the major percentage of the Nigerian population relies on primary health care services. The limited number of health care workers, the poor economic state, the inadequate health financing structures and high illiteracy rates have led to challenges such as low health service availability, hesitancy to utilize health interventions, high out-of-pocket expenditure rates, and health misinformation. These can be effectively tackled at the community level by revamping primary health care services, adequate and sustainable health financing, establishing Ward Development Committees, and the involvement of community stakeholders in health policy implementation. Employing such community-based approaches will ensure continuous progress of the Nigerian health care system toward UHC.
The adoption of decentralization by devolution in Tanzania has enabled the implementation of a Direct Health Facility Financing (DHFF) program in the facilities. While copious gains have been reported under DHFF, there are also notable failures to improve health service provision. This study aims to explore the experience of implementing the DHFF program in the rural areas of the Kigoma District Council. An exploratory qualitative study was conducted in Primary Health Care (PHC) facilities of the Kigoma District Council. A purposive sampling technique was used to draw 21 key informants including leaders of health facilities and members of the Health Facility Governing Committees (HFGC). Key Informant Interviews (KII) were used to solicit information from the study participants. Content analysis technique was used to analyze data collected from study participants. Our findings present enablers and barriers in the implementation of DHFF. Successful implementation of DHFF was enabled by the availability of formal training and supportive supervision, adherence to DHFF guidelines, availability of planning guidelines at the health facility, functionality of the HFGC, and adherence to the procurement process. A low sense of ownership of the program, delays and insufficient fund disbursement, shortage of health workers, and inadequate knowledge of DHFF program implementation emerged as the barriers that impeded successful program implementation. Evaluating the implementation experience of the DHFF program requires policymakers at the national level to devise a mechanism for the timely disbursement of funds, reinforcing capacity building to increase the autonomy of health facilities in their daily operations. Furthermore, structural and operational barriers warrant further operational and implementation research.
Anosisye Mwandulusya Kesale, Eliza Mwkasangula, Mikidadi Muhanga, Christopher P. Mahonge
The governance of epidemics is very critical for curbing and responding to several infectious epidemics. This study was conducted to explore the experience of the Health Facility Governing Committees (HFGCs) on the governance strategies they adopted to levarage the COVID 19 epidemic in their primary health facilities in Tanzania. An exploratory qualitative design was employed to study the governance strategies adopted by HFGCs during the COVID19. In this study, fourteen (14) HFGC chairpersons and ninety one (91) HFGC members with experience regulating primary health centers during a COVID 19 pandemic were involved. The study included four (4) governance response metrics that were discovered to be commonly used by HFGCs. These included coordinating responders, providing health information, explaining health hazards, and conducting out health interventions. Despite variations in implementation strategies, only two (2) governance response measures, coordinating responders and implementing, were found to be consistently applied by the majority of HFGCs. The nature of the governance path chosen by the Tanzanian government has been found to have influenced the slow reaction of primary health care governance actors such as HFGCs. Despite being empowered by Direct Health Facility Financing, COVID 19 presented challenges to several HFGCs. Though observed to be autonomous and expected to make judgments based on their circumstances, higher-level governance actors' opinions and actions on epidemics influenced the practices of local-level governance actors, including HFGCs. Indeed, for the HFGCs' potential to be realized, they must be empowered in ways other than fiscal and political decentralization. Other aspects of empowering governance actors, such as capacity building and education level, should be considered in order for them to completely realize their potential.
Abstract Decentralization of health services entails empowering local governments to take the lead on decision-making and governance of health services provided in their districts. If managed properly, decentralization has the potential to strengthen governance, leadership, management, and accountability of the district health system; improve efficiency and responsiveness of the district healthcare system at all levels; and increase investments in human capital. Undergoing decentralization since 1998, Malawi has made significant progress in devolving human resources for health (health workforce), strengthening governance and leadership, and enhancing accountability through devolved health financing and health information systems. However, challenges remain, including lack of clarity on the roles, responsibilities, and the decision-making process within the context of decentralization, insufficiency of funds, and insufficient human resources for health. Using human resources for health as an entry point, and the case example of Malawi, this chapter demonstrates that systems thinking offers a useful framework through which to understand the process of decentralization in a particular context.
Background: Decentralizing health sector, division role, power and authority of decision making in public health issue from top to lower structure, is the key means of improving community health status through which health sector reform of one country is achieved. Hence this study is aimed to address Decentralization and Health sector reform in Ethiopia. Objective: To express health sector reform achieved in Ethiopia as a result of decentralization and list all health reform indicators specifically in human resource and finance during the past three decades. Methods and Materials: This study was conducted using four purposely selected reliable reports and articles as a source by focused on the two main reforms activities that have been achieved through health sector decentralization in Ethiopia; Financial health sector and human resource health sector reform in Ethiopia. Because the rest health sector reforms are included under these two main reform activities. To intensify evidences of this study, additional Federal ministry of health annual reports and other documents were used. After important information was extracted and generalized from these documents, vital points of reforms achieved in the past three decades were summarized at the last literature of this study. Overall parts of this study was accomplished between May 11,- 30, 2020 Findings: The major indicators of Ethiopian health care financing reform include: Retaining and using region’s internally generated revenue, Practice of Outsourcing of nonclinical services in public hospitals, introduction of fee waiver and exemption systems, establishment of a private wing in public hospitals and health facility autonomy through establishment of governing bodies. Human resource reform in Ethiopian health sector include Health Extension Program (HEP) improved community health toward family planning, antenatal care, maternal health care, and hygiene and sanitation significantly, between 2005-2010, task-shifting and scaling-up of mid-level health professionals, which intended to delegate tasks to existing or new cadres who receive either less training or narrowly tailored training, utilization of non-teaching hospitals as training centers: health officers and emergency surgical officers, training mid-level professionals with nurse-level entry, focus on mid-level health professionals and local recruitment. Conclusion: Finding of this study concludes that in Ethiopia, in the past three decades, there was significant health sector reform mainly in the two major dimension; toward financial and human resource. Toward financial, it was aimed to improve community health through affordable cost in the continuous line of service access and availability which guarantees health status of the community. Toward Human resource, HEP, the major avenue for reform, played a major role with succeeded brief indicator of community health service.
John Solunta Smith, Karin Diaconu, Sophie Witter, Stefanie Weiland · 14 authors
Abstract Introduction Neglected tropical diseases (NTDs) are an important global health challenge, however, little is known about how to effectively finance NTD related services. Integrated management in particular, is put forward as an efficient and effective treatment modality. This is a background study to a broader health economic evaluation, seeking to document the costs of integrated care management of NTDs versus standard care in Liberia. In the current study, we document barriers and facilitators to NTD care from a health financing perspective. Methods We carried out key informant interviews with 86 health professionals and 16 national health system policymakers. 46 participants were active in counties implementing integrated case management and 40 participants were active in counties implementing standard care. We also interviewed 16 patients and community members. All interviews were transcribed and analysed using the thematic framework approach. Findings We found that decentralization for NTD financing is not yet achieved – financing and reporting for NTDs is still centralized and largely donor-driven as a vertical programme; government involvement in NTD financing is still minimal, focused mainly on staffing, but non-governmental organisations (NGOs) or international agencies are supporting supply and procurement of medications. Donor support and involvement in NTDs are largely coordinated around the integrated case management. Quantification for goods and budget estimations are specific challenges, given the high donor dependence, particularly for NTD related costs and the government’s limited financial role at present. These challenges contribute to stockouts of medications and supplies at clinic level, while delays in payments of salaries from the government compromise staff attendance and retention. For patients, the main challenges are high transportation costs, with inflated charges due to fear and stigma amongst motorbike taxi riders, and out-of-pocket payments for medication during stockouts and food/toiletries (for in-patients). Conclusion Our findings contribute to the limited work on financing of SSSD services in West African settings and provide insight on challenges and opportunities for financing and large costs in accessing care by households, which is also being exacerbated by stigma.
Mohammed Shadrul Alam, Shahnoor Islam, AKM Khairul Basher
In Bangladesh, Government is trying to find a perfect health system that best serves its population. Here, we present the results of our study with aim to assess the opinion of various stakeholders about: what are the 1) high-priority areas, 2) moderate priority areas, and 3) low-priority areas to reform the health sectors for Bangladesh. We conducted a cross-sectional, exploratory and anonymous population-based e-survey from February to June, 2021 among individuals aged above 26 years. A semi-structured questionnaire was designed and incorporated into the Google survey tool (Google Forms) and a shareable link was generated and disseminated to physicians, Academicians/ Clinicians of Medical Colleges/ Universities, Health System administrators etc. Respondents were also given space to comment on each topic. Comments & reactions of all respondents were categorized into three main headings. These were 1) high-priority areas, 2) moderate priority areas, and 3) low-priority areas to reform the health sectors for Bangladesh. Out of 483 respondents, 476 respondents (80.5% males and 19.5% female) completed the entire survey. The mean age of respondents is 44.70 SD± 10.07 with age range 26-86 years. About 27% of the respondents were from faculties from medical colleges /medical universities and 1.7% were health system administrators. The high prioritized areas where the majority (>60%) of our respondents strongly agreed upon, for instance, good governance, structural referral system should be establishment, and reformation of existing health care procurement & purchasing policy. The moderate prioritized areas where 50 - 60% of our respondents strongly agreed upon, such as securing sustainable financing for health care, further development of existing health infrastructure, and establishment of Health Academy of planning and development (HAPD). The low prioritized areas where less than 50% of our respondents strongly agreed upon, such as decentralization and autonomous health system, public health-oriented infection prevention and control (IPC) program, and implement the national health insurance system (NHIS) under a separate authority etc. Good governance in health departments & health care provider organizations are essential elements for health sector reform. Health sector reform should be sustained, purposeful, planned and evidence-based and fundamental change addressing significant, strategic dimensions of health systems. J Bangladesh Coll Phys Surg 2022; 40: 84-94
BACKGROUND: This article addresses how health institutions operate in Algeria. It deals with the problem of the management of health institutions in Algeria between centralization and decentralization. This means are there spaces for health institutions in the formulation of local health policies? Algeria seeks to establish local health institutions in response to current demographic growth. AIM: This study evaluates the Algerian legislature’s success in developing a legal framework for the administrative organization of health care institutions. METHODS: This comparative study focuses on legal texts, using data from the national statistical office, the World Bank, and the official Algerian news agency. RESULTS: The study finds a close relationship between free health services and the dominance of central health authorities that finance all public health institutions, including residents’ medical expenses, screening, surgery, and rehabilitation. Non-resident patients are compensated for treatment by state insurance funds (CNAS and CASNOS). There are no charitable hospitals. Therefore, civil society and humanitarian, charitable institutions are invited to launch initiatives regarding charitable hospitals, because they will contribute to relieving pressure in public health institutions and will also help in promoting public health in Algeria. The Ministry of Health controls central health services. CONCLUSION: Algerian health law mixes central and decentralized management but does not encourage local health institutions to seek funding and administrative independence. Algeria’s health system needs to be reformed.
While the health grants to local governments recommended by Fifteenth Union Finance Commission in the wake of Covid 19 pandemic lays emphasis on the trust-based approach to local governments and decentralization of health, the danger of Mission Creep can undo the potential and effectiveness of the grants to strengthen the primary health care sector. Lack of sensitization towards local governments; the misconception that local governments and its stakeholders are illiterate, weak and corrupt entities; absence of an institutional monitoring mechanism to conduct a follow-up of the recommendations made by the respective Finance Commissions; lack of co-ordination between various Ministries of union and state governments; and the erosion of cooperative federalism can all contribute to health grants falling prey to the vicious cycle of Mission Creep Syndrome.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Decentralization reforms through Direct Health Facilities Financing (DHFF) have empowered Health Facility Governing Committees (HFGCs) to participate in different governance aspects to improve service delivery at the facility level. However, there is little research on how empowered HFGCs perform in the context of the DHFF. The purpose of this study was to evaluate the functionality of HFGCs under DHFF in Tanzanian primary health care facilities that had variation of performance in 2018. To collect both qualitative and quantitative data, the study used a cross-section design. The study had a sample size of 280 respondents, who were chosen using a multistage cluster sampling technique from 32 primary health care facilities that were practicing DHFF. Data was collected via a closed-ended structured questionnaire, in-depth interviews with chairpersons of HFGCs, and Focus Group Discussions. To examine the functionality of HFGCs, researchers used descriptive and theme analysis. In the 2018-star rating assessment, the study discovered that HFGCs functioned well in both high and low-performing health facilities. When HFGCs from high-performing health facilities were compared to HFGCs from low-performing health facilities, it was discovered that HFGCs from the high-performing health facilities had comparatively high functionality. The functionality of HFGCs in Tanzania has thus been impacted by the DHFF context.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
User committees, such as Health Facility Governing Committees, are popular platforms for representing communities and civil society in holding service providers accountable. Fiscal decentralization via various arrangements such as Direct Health Facility Financing is thought to strengthen Health Facility Governing Committees in improving accountability in carrying out the devolved tasks and mandates. The purpose of this study was to analyze the status of accountability of Health Facility Governing Committees in Tanzania under the Direct Health Facility Financing setting as perceived by the supply side. In 32 different health institutions, a cross-sectional design was used to collect both qualitative and quantitative data at one point in time. Data was collected through a closed-ended questionnaire, an in-depth interview, and a Focus Group Discussion. Descriptive statistics, multiple logistic regression, and theme analysis were used to analyze the data. According to the findings, Health Facility Governing Committees' accountability is 78%. Committees have a high level of accountability in terms of encouraging the community to join community health funds (91.71%), receiving medicines and medical commodities (88.57%), and providing timely health services (84.29%). The health facility governance committee's responsibility was shown to be substantially connected with the health planning component (p = 0.0048) and the financial management aspect (p = 0.0045). This study found that the fiscal decentralization setting permits Committees to be accountable for carrying out their obligations, resulting in improved health service delivery in developing nations.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Abstract Background In Lower and Middle‐Income Countries (LMICs), decentralization has dominated the agenda for reforming the organization of service delivery (LMICs). The fiscal decentralization challenge is a hard one for decentralization. As they strive to make decisions and use health facility funding, primary healthcare facilities encounter the obstacles of fiscal decentralization. LMICs are currently implementing fiscal decentralization reforms to empower health facilities and their Health Facility Governing Committees (HFGCs) to improve service delivery. Given the scarcity of systematic evidence on the impact of fiscal decentralization, this study examined the functionality of HFGCs and their associated factors in primary healthcare facilities in Tanzania that were implementing fiscal decentralization through Direct Health Facility Financing (DHFF). Methods To collect both qualitative and quantitative data, a cross‐sectional approach was used. The research was carried out in 32 primary healthcare facilities in Tanzania that were implementing the DHFF. A multistage sample approach was utilized to pick 280 respondents, using both probability and nonprobability sampling procedures. A structured questionnaire, in‐depth interviews, and focus group discussions were used to gather data. The functionality of HFGCs was determined using descriptive analysis, and associated factors for the functioning of HFGCs were determined using binary logistic regression. Thematic analysis was used to do qualitative research. Result HFGC functionality under DHFF has been found to be good by 78.57%. Specifically, HFGCs have been found to have good functionality in mobilizing communities to join Community Health Funds 87.14%, participating in the procurement process 85%, discussing community health challenges 81.43% and planning and budgeting 80%. The functionality of HFGCs has been found to be associated with the planning and budgeting aspects p value of 0.0011, procurement aspects p value 0.0331, availability of information reports p value 0.0007 and Contesting for HFGC position p value 0.0187. Conclusion The study found that fiscal decentralization via DHFF increases the functionality of HFGCs significantly. As a result, the report proposes that more effort be placed into making financial resources available to health facilities.
Leadership and management skills are critical for health programs to deliver high-quality interventions in complex systems. In malaria-eliminating countries, national and subnational health teams are reorienting strategies to address focal transmission while preventing new cases and adapting to decentralization and declines in external financing. A capacity-strengthening program in two regions in Namibia helped malaria program implementers identify and address key operational, political, and financial challenges. The program focused on developing skills and techniques in problem-solving and teamwork, engaging decision-makers, and using financial evidence to prioritize domestic resources for malaria through participatory approaches. Results of the program included an observed 40% increase in malaria case reporting, 32% increase in reporting and tracing of imported malaria cases, 10% increase in malaria case management, integration of malaria activities into local operational plans, and an increase in subnational resources for malaria teams. To promote program sustainability beyond the implementation period, key program aspects were institutionalized into existing health system structures, program staff were trained in change leadership, and participants integrated the skills and approaches into their professional roles. A capacity-strengthening program with joint focus on leadership, management, and advocacy has potential for application to other health issues and geographies.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Abstract Background: Decentralization has dominated the agenda for the reforms of the organization of service delivery in Lower and Middle-Income Countries (LMICs). Decentralization faces a formidable challenge of fiscal decentralization in primary healthcare facilities. Of now, LMICs are implementing fiscal decentralization reforms to empower health facilities and their Health Facility Governing Committees (HFGCs). Given the paucity of the impact of fiscal decentralization, this study was conducted to assess the functionality of HFGCs and their associative factors in primary health care facilities implementing fiscal decentralization through Direct Health Facility Financing (DHFF) in Tanzania. Methods: A cross-sectional design was employed to gather both qualitative and quantitative data. The study was conducted in 32 selected primary health facilities implementing DHFF in Tanzania. Probability and nonprobability sampling procedures were employed, in which a multistage sampling procedure was used to select 280 respondents. Data were collected through a structured questionnaire, in-depth interviews and focus group discussions. Descriptive analysis was employed to determine the functionality of HFGCs and binary logistic regression was employed to determine associated factors for the functionality of HFGC. Qualitative analysis was done through thematic analysis. Result: HFGC functionality under DHFF has been found to be good by 78.57%. Specifically, HFGCs have been found to have good functionality in mobilizing communities to join Community Health Funds 87.14%, participating in the procurement process 85%, discussing community health challenges 81.43% and planning and budgeting 80%. The functionality of HFGCs has been found to be associated with the planning and budgeting aspects p-value of 0.0011, procurement aspects p-value 0.0331, availability of information reports p-value 0.0007 and Contesting for HFGC position p-value 0.0187. Conclusion: The study has revealed that fiscal decentralization through DHFF significantly improves the functionality of HFGCs. Therefore, the study recommends more effort be put into facilitating the availability of finances to the health facilities.
Background: The concept of devolution has always presented significant controversy in African unitary states. It is often viewed with inherent suspicion and skepticism based on the lack of mutual trust between the people and the government. While proponents see it as a form of empowerment, resistant groups in society view the decentralization of government powers and responsibilities as a gateway to success. Despite the devolution agenda being a major component of local governance in the Zimbabwean Constitution of 2013, it would not be practically implemented until the new dispensation that rose into power in 2018. However, the coming in of the COVID-19 pandemic has significantly marred the take-off of devolution implementation in Zimbabwe. Whilst COVID-19 cases continue to escalate on the globe, African countries continue to battle not only with the second wave of the pandemic but also with the new COVID-19 variants. Already fragile economies of these countries, the governments were forced to prioritize the national budgets in response to the pandemic; consequently, other social and developmental issues were left behind. Objective: This study discusses the contemporary status of devolution in Zimbabwe to ascertain the extent of implementation; provide supportive legislation for devolution structures through recommendations; analyze devolution disbursements from 2019 before COVID-19 to date; assess the local authorities’ initial requests versus the disbursements in 2019 and 2020. Method: The researcher carried out a desk review and followed the principles of case study design by analyzing financial statements, reports and data coming in from the Councils and relevant Government ministries. The meaning was also derived by critically reviewing, organizing and interpreting related information from books and articles published in newspapers and journals. Result: Despite Section 264(1) of the Constitution providing for devolution of power to the three tiers of the Government, there is no supporting legislature in place as yet to actualize this key element. The Government Budgetary Allocation of 5% is not meeting local authority demands. Conclusion: The onset of the COVID-19 pandemic in late 2019 reduced the pace of the devolution process because the funds were channeled to fight against the virus. If properly practiced, devolution may be one of the solutions to the development of the Zimbabwean economy since the devolution program is largely founded on the principle of empowering provincial government councils and Local Authorities to spearhead economic and social development projects in their areas by leveraging on local resources. It may also solve issues of corruption in many local councils in Zimbabwe by improving accountability mechanisms, especially where sub governments are permitted to progressively compete with each other to establish innovative ways of delivering public services efficiently and inexpensively. Implications: The findings imply that the Government policies can affect the social and economic well-being of citizens, however, the COVID-19 pandemic has far outweighing impacts. Secondly, the coronavirus outbreak has proved how much the Government of Zimbabwe is ill-prepared to deal with a pandemic of this dimension. Policymakers should ensure that finances are set in the national budget for unseen events so as not to derail other Government projects. Originality: This paper is original and not sent anywhere for publication.
In the last two decades, developing countries have increasingly engaged in improving the governance of their health systems and promoting policy design to strengthen their health governance capacity. Although many well-designed national policy strategies have been promulgated, obstacles to policy implementation and compliance among localities may undermine these efforts, particularly in decentralized health systems. Studies on health governance have rarely adopted a central-local analysis to investigate in detail local governments' distinct experiences, orientations and dynamics in implementing the same national policy initiative. This study examines the policy orientations of prefectural governments in strengthening governance in health financing in China, which has transitioned from emphasizing the approach of fiscal resource input to that of marketization promotion and cost-containment regulation enforcement at the national level since 2009. Employing text-mining methodologies, we analysed health policy documents issued by multi-level governments after 2009. The analysis revealed three salient findings. Firstly, compared to higher-level authorities, prefectural governments generally opted to use fiscal resource input over marketization promotion and cost-containment regulation enforcement between 2009 and 2020. Secondly, policy choices of prefectural governments varied considerably in terms of enforcing cost-containment regulations during the same period. Thirdly, the extent of the prefectural government's orientation toward marketization promotion or cost-containment regulation enforcement was not only determined by the top-down orders of higher-level authorities but was also incentivized by the government's fiscal dependency and the policy orientations of peer governments. These findings contribute to the health governance literature by providing an overview of local discretion in policy choices and the political and fiscal dynamics of local policy orientations in promoting health governance in a decentralized health system.
Anosisye Mwandulusya Kesale, Christopher P. Mahonge, Mikidadi Muhanga
Abstract Users Committees such as Health Facility Governing Committees (HFGCs) are one of the popular mechanisms used to represent communities and civil societies in holding service providers into account. This study embarked on assessing the status of accountability of HFGCs under the DHFF context in Tanzania as experienced by the supply side (HFGCs members). A cross-sectional design was employed in collecting both qualitative and quantitative data at one point in time in 32 selected health facilities. A closed-ended questionnaire, in-depth interview and FGDs were employed to collect data. Data were analyzed through descriptive statistics and Multiple logistics regression, and thematic analyses. The study found high accountability of HFGCs by 78%. specifically, HFGCs have high accountability in mobilizing the community to join community health funds 99.71%, receiving medicines and medical commodities 88.57% and timely health services 84.29%. It was reviled that the accountability of the health facility governance committee was significantly associated with the health planning aspect (p=0.0048) and financial management aspect (p=0.0045). This study concluded that the fiscal decentralization context empowers HFGCs to be accountable in accomplishing their responsibilities hence improving health service delivery in developing countries. This study recommends more efforts to be directed in supporting HFGCs addressing challenges of managing health facilities works and mobilization of resources from other stakeholders.
Noncommunicable diseases (NCDs) are leading causes of death globally and in Nigeria they account for 29% of total deaths. Nigeria's health system is decentralized. Fragmentation in governance in federalised countries with decentralised health systems is a well-recognised challenge to coherent national health policymaking. The policy response to the rising NCD burden therefore requires strategic intent by national and sub-national governments. This study aimed to understand the implementation of NCD policies in Nigeria, the role of decentralisation of those policies, and to consider the implications for achieving national NCD targets. We conducted a policy analysis combined with key informant interviews to determine to what extent NCD policies and strategies align with Nigeria's decentralised health system; and the structure and process within which implementation occurs across the various tiers of government. Four inter-related findings emerged: NCD national policies are 'top down' in focus and lack attention to decentralisation to subnational and frontline care delivery levels of the health system; there are defective coordination mechanisms for NCD programmes which are underpinned by weak regional organisational structures; financing for NCDs are administratively burdensome and fragmented; and frontline NCD service delivery for NCDs are not effectively being integrated with other essential PHC services. Despite considerable progress being made with development of national NCD policies, greater attention on their implementation at subnational levels is needed to achieve more effective service delivery and progress against national NCD targets. We recommend strengthening subnational coordination mechanisms, greater accountability frameworks, increased and more efficient funding, and greater attention to integrated PHC service delivery models. The use of an effective bottom-up approach, with consideration for decentralization, should also be engaged at all stages of policy formulation.
INTRODUCTION: Faced with the coronavirus disease (COVID-19) pandemic, governments worldwide instituted lockdowns to curtail virus spread. Health facility closures and travel restrictions disrupted access to antiretroviral (ARV) therapy for people living with HIV. This report describes how HIV programs in Indonesia, Laos, Nepal, and Nigeria supported treatment continuation by introducing home delivery of ARVs. METHODS: Staff supporting the programs provided accounts of when and how decisions were taken to support ARV home delivery. They captured programmatic information about home delivery implementation using an intervention documentation tool. The 4 country experiences revealed lessons learned about factors favoring successful expansion of ARV home delivery. RESULTS: Three of the countries relied on existing networks of community health workers for ARV delivery; the fourth country, Indonesia, relied on a private sector courier service. Across the 4 countries, between 19% and 51% of eligible clients were served by home delivery. The experiences showed that ARV home delivery is feasible and acceptable to health service providers, clients, and other stakeholders. Essential to success was rapid mobilization of stakeholders who led the design of the home delivery mechanisms and provided leadership support of the service innovations. Timely service adaptation was made possible by pre-existing differentiated models of care supportive of community-based ARV provision by outreach workers. Home delivery models prioritized protection of client confidentiality and prevention measures for COVID-19. Sustainability of the innovation depends on reinforcement of the commodity management infrastructure and investment in financing mechanisms. CONCLUSION: Home delivery of ARVs is a feasible client-centered approach to be included among the options for decentralized drug distribution. It serves as a measure for expanding access to care both when access to health services is disrupted and under routine circumstances.