Madhulika Khanna, Benjamin Loevinsohn, Elina Pradhan, Opeyemi Fadeyibi · 10 authors
BACKGROUND: Health system financing presents a challenge in many developing countries. We assessed two reform packages, performance-based financing (PBF) and direct facility financing (DFF), against each other and business-as-usual for maternal and child healthcare (MCH) provision in Nigeria. METHODS: We sampled 571 facilities (269 in PBF; 302 in DFF) in 52 districts randomly assigned to PBF or DFF, and 215 facilities in 25 observable-matched control districts. PBF facilities received $2 ($1 for operating grants plus $1 for bonuses) for every $1 received by DFF facilities (operating grants alone). Both received autonomy, supervision, and enhanced community engagement, isolating the impact of additional performance-linked facility and health worker payments. Facilities and households with recent pregnancies in facility catchments were surveyed at baseline (2014) and endline (2017). Outcomes were Penta3 immunization, institutional deliveries, modern contraceptive prevalence rate (mCPR), four-plus antenatal care (ANC) visits, insecticide-treated mosquito net (ITN) use by under-fives, and directly observed quality of care (QOC). We estimated difference-in-differences with state fixed effects and clustered standard errors. RESULTS: PBF increased institutional deliveries by 10% points over DFF and 7% over business-as-usual (p<0.01). PBF and DFF were more effective than business-as-usual for Penta3 (p<0.05 and p<0.01, respectively); PBF also for mCPR (p<0.05). Twenty-one of 26 QOC indicators improved in both PBF and DFF relative to business-as-usual (p<0.05). However, except for deliveries, PBF was as or less effective than DFF: Penta3 immunization and ITN use were each 6% less than DFF (p<0.1 for both) and QOC gains were also comparable. Utilization gains come from the middle of the rural wealth distribution (p<0.05). CONCLUSIONS: Our findings show that both PBF and DFF represent significant improvements over business-as-usual for service provision and quality of care. However, except for institutional delivery, PBF and DFF do not differ from each other despite PBF disbursing $2 for every dollar disbursed by DFF. These findings highlight the importance of direct facility financing and decentralization in improving PHC and suggest potential complementarities between the two approaches in strengthening MCH service delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT03890653 ; May 8, 2017. Retrospectively registered.
Zarni Htun, Yingxi Zhao, Hannah Gilbert, Chunling Lu
BACKGROUND: The Global Fund has been a major funding source for HIV/AIDS programs in Myanmar. In this qualitative study, we aim to understand the impact of Global Fund on national HIV/AIDS response in Myanmar during the era of Millennium Development Goals (MDGs). METHODS: We conducted individual in-depth interviews by recruiting key informants through purposive snowball sampling. The respondents were engaged in the national/subnational response to HIV/AIDS in Myanmar and worked for the United Nations agencies, non-governmental organizations (NGOs), and civil society. Interview questions were organized around the role of Global Fund in strengthening national response to HIV/AIDS in the six building blocks of the Myanmar's health system. Transcripts from the key informants were synthesized into specific themes through a deductive approach. RESULTS: We found that the Global Fund has provided substantial support to (1) finance the national HIV/AIDS response in Myanmar, and (2) strengthen leadership and governance at the central level through improving coordination and collaboration, including more stakeholders (e.g. civil society, NGOs) in decision making process, and catalyzing policy changes on scaling-up key interventions. Yet, its role remains limited in addressing new demands at the township level in terms of capacity building, staffing, and medical supply resulting from rapid scale-up of HIV interventions and decentralization of service delivery in the public sector. CONCLUSION: There was a missed opportunity for Myanmar to capitalize on the use of the Global Fund's funding to strengthen the health system. Deliberate planning is required to optimize the use of those scarce resources to provide universal coverage for HIV/AIDS.
Vanessa T. Siy Van, Jhanna Uy, Joy Bagas, Valerie Gilbert Ulep
In recognition of the role of reproductive health in individual and national development, the Responsible Parenthood and Reproductive Health (RPRH) Law of 2012 was passed in the Philippines after 30 years of opposition and debate. Seven years later, this article examined the cohesiveness of national multi-sectoral governance among state and non-state actors and identified challenges in coordination as part of the first comprehensive evaluation of the landmark policy. Using a qualitative intrinsic case study design and guided by the World Health Organization's systems checklist for governing health equity as our theoretical perspective, we conducted 20 semi-structured interviews with national implementers from health agencies (n = 11), non-health agencies (n = 6) and non-state actors (n = 3) that included civil society organizations (CSOs). Key themes identified through thematic analysis were supported with document reviews of policy issuances, accomplishment reports and meeting transcripts of the RPRH National Implementation Team (NIT). The study found that despite aspirations for vibrant multi-sectoral coordination, the implementation of the RPRH Law in the Philippines was incohesive. National leaders, particularly the health sector, were neither able to rally non-health sector actors around RPRH nor strategically harness the power of CSOs. Local resource limitations associated with decentralization were exacerbated by paternalistic financing, coordination, and monitoring. The absence of multi-agency plans fostered a culture of siloed opportunism, without consideration to integrated implementation. This case study shows that for neutral policies without conflicts in sector objectives, the interest and buy-in of non-health state actors, even with a national law, cannot be assumed. Moreover, possible conflicts in interests and perspectives between state and civil society actors must be managed in national governance bodies. Overall, there is need for participatory policymaking and health-sector advocacy to set health equity as an intersectoral goal, involving subnational leaders in developing concrete action plans, and strengthening NIT's formal accountability systems.
expenses for hospitalized patients with chronic liver disease (CLD) poses an economic challenge on affected household in the form of catastrophic health expenditure (CHE), distress financing and impoverishment. OOP Expenses data for hospitalized CLD patients from Bangladesh is scarce. This study aimed to estimate the OOP expenses and resulting CHE, distress financing and impoverishment among hospitalized patients with CLD. This cross-sectional study was conducted among conveniently selected 107 diagnosed CLD patients admitted at Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) aged 18 years and above. Data were collected from the respondents using a semi-structured questionnaire through face to face interview during discharge from hospital. Out of pocket expenditure for chronic liver disease in selected hospitals was Bangladeshi Taka (BDT) 19,262. Direct medical, direct nonmedical and indirect cost was BDT 16,240; 2,165 and 1,510, respectively. Investigation cost and medicine cost contributed to 48.48% and 31.81% of the total OOP expenses, respectively. At 10% threshold level, 29% of the respondents were affected by CHE. 64.5% of the respondents were facing distress financing due to OOP expenses. Among the respondents, 1.9% slipped below the international poverty line of $1.90 (BDT 161.10, in 2019).There was statistically significant (p < 0.05) difference among the mean OOP expenses for different etiological types of chronic liver disease. The study concluded that it requires establishing a more accessible and affordable decentralized health care system for CLD treatment along with the implementation of financial risk protection.
Out-of-pocket (OOP) expenses for hospitalized patients with chronic liver disease (CLD) poses an economic challenge on affected household in the form of catastrophic health expenditure (CHE), distress financing and impoverishment. OOP Expenses data for hospitalized CLD patients from Bangladesh is scarce. This study aimed to estimate the OOP expenses and resulting CHE, distress financing and impoverishment among hospitalized patients with CLD. This cross-sectional study was conducted among conveniently selected 107 diagnosed CLD patients admitted at Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) aged 18 years and above. Data were collected from the respondents using a semi-structured questionnaire through face to face interview during discharge from hospital. Out of pocket expenditure for chronic liver disease in selected hospitals was Bangladeshi Taka (BDT) 19,262. Direct medical, direct non-medical and indirect cost was BDT 16,240; 2,165 and 1,510, respectively. Investigation cost and medicine cost contributed to 48.48% and 31.81% of the total OOP expenses, respectively. At 10% threshold level, 29% of the respondents were affected by CHE. 64.5% of the respondents were facing distress financing due to OOP expenses. Among the respondents, 1.9% slipped below the international poverty line of $1.90 (BDT 161.10, in 2019).There was statistically significant (p < 0.05) difference among the mean OOP expenses for different etiological types of chronic liver disease. The study concluded that it requires establishing a more accessible and affordable decentralized health care system for CLD treatment along with the implementation of financial risk protection.
Ătienne V Langlois, Andrew McKenzie, Helen Schneider, Jeffrey W. Mecaskey
Primary health care offers a cost-effective route to achieving universal health coverage (UHC). However, primary health-care systems are weak in many low- and middle-income countries and often fail to provide comprehensive, people-centred, integrated care. We analysed the primary health-care systems in 20 low- and middle-income countries using a semi-grounded approach. Options for strengthening primary health-care systems were identified by thematic content analysis. We found that: (i) despite the growing burden of noncommunicable disease, many low- and middle-income countries lacked funds for preventive services; (ii) community health workers were often under-resourced, poorly supported and lacked training; (iii) out-of-pocket expenditure exceeded 40% of total health expenditure in half the countries studied, which affected equity; and (iv) health insurance schemes were hampered by the fragmentation of public and private systems, underfunding, corruption and poor engagement of informal workers. In 14 countries, the private sector was largely unregulated. Moreover, community engagement in primary health care was weak in countries where services were largely privatized. In some countries, decentralization led to the fragmentation of primary health care. Performance improved when financial incentives were linked to regulation and quality improvement, and community involvement was strong. Policy-making should be supported by adequate resources for primary health-care implementation and government spending on primary health care should be increased by at least 1% of gross domestic product. Devising equity-enhancing financing schemes and improving the accountability of primary health-care management is also needed. Support from primary health-care systems is critical for progress towards UHC in the decade to 2030.
In the implementation of decentralization, the Special Allocation Fund (DAK) for health is given to certain areas of Indonesia to support health financing. The performance of this financing, along with national health development prioritiesâ achievements, is illustrated through the indicators of coverage of deliveries in health care facilities (PF) and coverage of first neonatal visits (KN1). Yearly increases in the health DAK budget have not been accompanied by increases in these coverages, and there are still significant disparities between regions. Using secondary data at the district/city level for 2014â2017, this study aims to investigate the impact of health DAK on coverage of PF and KN1. The analytical method deployed is linear regression of panel data using a fixed-effects model. The results show that in the short term, health DAK has a positive but insignificant effect on PF and KN1 coverage. However, health DAK has a positive and significant impact on PF coverage in the second year. Impact on KN1 coverage is unfeasible, even over a period of two years. These results indicate that the processes of planning, budgeting, and administering of health DAK require improvement so that benefits can be felt in the short term through better innovations in health programs. Nevertheless, given that our findings are based on a short period of study, the results from such analyses should consequently be treated with the utmost caution Therefore, future research should target a longer period of data collection to detect more trusty lagged effects and structural breaks of a policy intervention.
Ha Nguyen Thi Thu, Ha Nguyen Thi Thu, Anh Quynh Nguyen, Phuong Nguyen · 7 authors
Objectives: To examine the financing trend for HIV/AIDS programme for 2011â2019 and to explore the potential options to fill funding gap and sustain the programme.Methods: Using mixed methods, including literature review and qualitative interview (16 in-depth interviews with key informants from the Ministry of Health, Ministry of Planning and Investment, Vietnam Authority of HIV/AIDS Control and related departments of Bac Ninh and Dien Bien Provinces).Results: The total fund for 2011â2019 was 22,243 billion VND (USD317.3 million) with the largest contribution of external funding (67%). The share of government budget remains quite low (9%). HIV/AIDS programme is focusing on shifting the finance of HIV/AIDS services from programme/projects to the health insurance fund; increasing the contribution of local government budget and diversifying other domestic sources. It is important for the programme to promote the integration of HIV/AIDS services into the current healthcare system and decentralization of HIV/AIDS services into primary healthcare facilities.Conclusion: To fill the funding gap for HIV/AIDS programme, it requires increasing contribution from local goverment budget for prevention activies as well as social health insurance for treatment. Lessons learnt from HIV/AIDS programme could suggest for other priority public health programmes to sustain their achievements in the upcoming years.
Agnes Nanyonjo, Edmound Kertho, James Tibenderana, Karin KĂ€llander
INTRODUCTION: Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition. METHODS: We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas. FINDINGS: In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level. CONCLUSION: Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.
Alebachew Abebe, Carlyn Mann, Workie Mitiku, Peter Berman
The following sections are included:Implementation of fiscal decentralization has had limited success in terms of creating fiscal space with woreda (district) resources more âtiedâ than federal and regional governmentsâ as most of their resources go to recurrent budget, especially for salaries.Domestic resource mobilization through user fees, including retention and utilization of user fees, was effective, both in terms of the number of facilities in which it is implemented and in the magnitude of resources being generated and used for quality improvement at the facility level.Ethiopia developed a series of financing arrangements and modalities to effectively align external support with government priorities for health and used these resources to reach the very poor and deliver results â indicating the value for money. This encouraged other development partners to support Ethiopiaâs health sector.The impact of OOP on utilization, especially by the poor remains a concern, but introduction and scale-up of CBHI should alleviate the burden of OOP at the point of use with evidence suggesting that this insurance scheme minimizes catastrophic spending and impoverishment.There is evidence of significant inefficiency in services delivery, but more evidence about its causes and remedies is needed
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.
BACKGROUND: The Philippines decentralized government health services through devolution to local governments in 1992. Over the years, opinions varied on the impact of devolved governance to decision-making for local health services. The objective of this study was to analyze decision-makers' perspectives on who should be making decisions for local health services and on their preferred structure of health service governance should they be able to change the situation. METHODS: We employed a mixed methods approach that included an online survey in one region and in-depth interviews with purposively-selected decision-makers in the Philippine health system. Study participants were asked about their perspectives on decision-making in the functions of planning, health financing, resource management, human resources for health, health service delivery, and data management and monitoring. Analysis of survey results through visualization of data on charts was complemented by the themes that emerged from the qualitative analysis of in-depth interviews based on the Framework Method. RESULTS: We received 24 online survey responses and interviewed 27 other decision-makers. Survey respondents expressed a preference to shift decision-making away from the local politician in favor of the local health officer in five functions. Most survey participants also preferred re-centralization. Analysis of the interviews suggested that the preferences expressed were likely driven by an expectation that re-centralization would provide a solution to the perceived politicization in decision-making and the reliance of local governments on central support. CONCLUSIONS: Rather than re-centralize the health system, one policy option for consideration for the Philippines would be to maintain devolution but with a revitalized role for the central level to maintain oversight over local governments and regulate their decision-making for the functions. Decentralization, whether in the Philippines or elsewhere, must not only transfer decision-making responsibility to local levels but also ensure that those granted with the decision space could perform decision-making with adequate capacities and could grasp the importance of health services.
Pneumonia, the leading infectious killer of children under five, has been called a âforgotten killer,â âa neglected tragedy,â and a âglobal cause without champions.â1, 2 Despite causing 800 000 child deaths, more than HIV/AIDS, tuberculosis and malaria combined, pneumonia has never attracted the levels of support commensurate with its burden.3 Less than 5% of international Development Assistance for Health and just 3% of all infectious disease research spending, are allocated to pneumonia.4 While the Global Action Plan for Diarrhoea and Pneumonia (GAPPD)5 launched by World Health Organization and UNICEF in 2013 did set a global target of three child pneumonia deaths per 1000 live births by 2025, no government had developed a national strategy to achieve this target by 2019.a The lack of funding and planning have contributed to slow progress meeting the target and just two countriesâBangladesh and Indonesiaâof the 20 with more than 10 000 annual child pneumonia deaths are on track to achieve the GAPPD pneumonia target.6 At current rates of progress, an estimated 6.3 million children will die from pneumonia by 2030 and many low- and middle-income countries (LMICs) will fail to achieve the sustainable development goal for child survival. The solution is not another vertical program channeling billions of dollars to tackle a single disease. There would be little appetite from national governments or the global health and development community for such a mechanism, which might undermine efforts to expand the reach of integrated community case management (iCCM) and integrated management of childhood illness (IMCI) and strengthen primary health care services to deliver Universal Health Coverage (UHC). Experience suggests that further reductions in child mortality in LMICs will require approaches that are sensitive to the complex patterns of comorbidity between pneumonia, diarrhea, malaria and malnutrition, and cognizant of the rising challenges of rapid urbanization, vaccine hesitancy, air pollution, and the double burden of under and overnutrition. The case for harnessing existing mechanisms such as Gavi, the Global Fund, Unitaid, and the Global Financing Facility to better integrate vaccine delivery, nutrition, and community case management is increasingly compelling, and much more work is needed to align the efforts of international agencies engaged in child survival in the high-burden countries.7 The Every Breath Counts Coalition (EBCC; https://stoppneumonia.org/) was officially launched in November 2017 to provide a platform for governments and international health agencies to work together to achieve the GAPPD target. In an acknowledgment of the progress achieved by the Global Fund and Gavi, the 40 member EBCC is a public-private partnership with representation from UN agencies, nongovernmental organizations (NGOs), private foundations, pharmaceutical and medical technology companies, and universities. Each member has made a written commitment to support government efforts to accelerate reductions in child pneumonia deaths according to their capabilities along with the prevention, protection, diagnosis, and treatment continuum. EBCC works with governments to develop data-based pneumonia control strategies, delivered as part of national primary health care strengthening and UHC efforts. The EBCC has prioritized support to four large âtransnationalâ clusters with large populations of children at heightened risk of death from pneumonia including, (a) Chad, Nigeria, Niger, and Mali, (b) Democratic Republic of Congo and Angola, (c) Ethiopia and Somalia, and (d) Pakistan and Afghanistan, the ambition of which is to support the development of bespoke pneumonia control strategies in each country. At the global level, three EBCC teams drive progress towards specific childhood pneumonia âglobal public goodsâ including: The development of routine indicators to measure access to pneumonia diagnosis and treatment; a set of agreed research priorities; and robust advocacy and communications activities. As Nigeria has the largest population of children at greatest risk of death from pneumonia, the EBCC supported the Nigerian Federal Ministry of Health (FMoH) to develop a pneumonia control strategy between January 2019 and 2020. Coalition members including USAID, the Nigerian offices of Dalberg, Save the Children, UNICEF, and the Clinton Health Access Initiative (CHAI) joined forces to support the process. To better understand the barriers preventing faster progress on reducing child pneumonia deaths in Nigeria, the Family Health Department within the FMoH invited 75 participants to a strategy workshop in Abuja in January 2019. Following this workshop, approximately 40 interviews with national and global stakeholders, supplemented by desk research and analysis of state-level policies and data on the burden of pneumonia deaths, were conducted by the strategy firm Dalberg on behalf of the FMoH. By early March 2019, the FMoH and the EBCC had developed a draft pneumonia control strategy, and the FMoH invited 30 partners to meet in Abuja in April 2019 to review the strategy and align the contents with the RMNCAH+N Strategy. EBCC and the FMoH then worked together to develop a more detailed implementation plan and an estimation of the financial resources needed to implement the strategy. Less than 7 months after the process began, a final workshop to validate the strategy took place in Abuja in July 2019. In October 2019, the Minister of Health officially approved the strategy and the strategy was officially launched in Nigeria on January 2020. This strategy development process generated several key lessons. The pneumonia control strategy development process elevated the status of childhood pneumonia as a key public health challenge in Nigeria. Bringing together a range of public (eg, Federal and State Ministries of Health and donor government missions), private (eg, manufacturers of vaccines, medical devices, and antibiotics), faith-based organizations, and civil society actors demonstrated an appetite for a greater focus on pneumonia and drew attention to the gaps and barriers in pneumonia control that were impeding progress to Nigeria's child survival target. Despite many competing priorities in health, stakeholders involved in the process became champions for pneumonia control. Two NGOs, Save the Children and CHAI even decided to integrate parts of the pneumonia control strategy into their own newborn and child health programming. The pneumonia control strategy development process also showed that it is possible to focus on a specific cause of child death, while promoting integrated case management of childhood illnesses at community and facility levels (ie, iCCM and IMCI). By emphasizing that pneumonia should be accorded a level of attention commensurate with its disease burden, the FMoH and EBCC were able to reposition and prioritize pneumonia as a major killer, deserving of at least the same levels of investment as other leading but much better resourced killers (eg, malaria). The process to develop the pneumonia control strategy enhanced cross-sectoral and interministerial collaboration across all levels of government in Nigeria. Effective pneumonia control depends on the coordinated actions of different federal, state, and local government agencies to prevent, diagnose, and treat pneumonia at all levels of the health care system. The Nigerian FMoH had to work closely with the Agriculture, Energy, and Environment Ministries to prevent pneumonia by improving vaccination, nutrition, and clean air. In addition, the FMoH must find ways to influence State and Local Government health actors to improve the diagnosis and treatment of childhood pneumonia in primary health care and hospital services, as these are decentralized responsibilities. The FMoH and EBCC were able to bring these various government actors together for the first time to talk about pneumonia control and offer the support of private and nonprofit sector partners. Lastly, and critically, the experience in Nigeria highlights the importance of taking a data-driven approach that puts the most vulnerable populations of children first. While it is still challenging to map child pneumonia deaths at national and subnational levels, data are improving rapidly and governments have new tools to identify childhood pneumonia âhotspotsâ where deaths concentrate.8 In Nigeria, the subnational child pneumonia maps released by the Institute for Health Metrics and Evaluation in 2019 revealed âhotspotsâ in several northern states. Targeting pneumonia control efforts to these children represents the most cost-effective path to reduce pneumonia deaths and achieve the GAPPD target. The EBCC is committed to sharing these new tools with governments so that they can help direct scarce resources in ways that maximize the number of child pneumonia deaths prevented. These maps not only enable governments to prioritize the most vulnerable children but also to require their international health and development partners to do the same. Nigeria is pioneering a new approach to achieving the GAPPD target. Its pneumonia control strategy will need to be monitored and evaluated over the next 5 years to assess results, to ensure that partners are held accountable for delivering on their commitments and to capture learnings that can inform other governments. If successful, the Nigerian pneumonia control strategy could become a blueprint for other countries struggling with heavy burdens of child pneumonia deaths to achieve the GAPPD target and strengthen integrated newborn and child health policies and programs.
Haiti announced in 2018 its aim to achieve universal health coverage. In this paper, we discuss what this objective means for the country and what next steps should be taken. To contextualize the notion, we framed Haiti en route to the 2030 goal and analyzed qualitatively the status quo in terms of geographic, financial, and service access. For each dimension, we focused on the context, the government's policies and political agendas, their implementation progress, and key influential factors. Our analysis found little progress and numerous challenges. Geographic access was limited due principally to the insufficient number of facilities, difficulties in reaching health facilities, and local customs. Financial coverage was low because of the government's insufficient budgets, inefficient budget allocation, and ineffective management. Service access also had room for significant improvement for a lack of basic infrastructure and resources, gaps between the essential service package guidelines, health professionals' skills, and the needs, as well as deficiencies in people-centered care. These factors affected not only health service coverage but also its quality. We found that the root causes of these issues were composed of unstable financing mechanisms, opportunistic resource allocation, and ineffective management control systems. We suggest that to overcome these issues and achieve universal health coverage with decent service quality, Haiti's health system needs to be reformed by implementing strategic financing, decentralized management systems, and community engagement in primary health care.
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 Peopleâs 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 âwhole-of-governmentâ intersectoral health promotion initiative keeping in view âinclusive growthâ and âhealth developmentâ as a social goal of the society. Health impact assessment of all public policies should be mandated by legislation. âPrevention of diseasesâ is a more cost-effective strategy than the popular approach of âTreatment.â 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 âPublic Health Commissionâ 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]
Zambia has been using output-based approaches for over two decades to finance whole or part of the public health system. Between 1996 and 2006, performance-based contracting (PBC) was implemented countrywide with the Central Board of Health (CBoH) as the provider of health services. This study reviews the association between PBC and equity of access to maternal health services in Zambia between 1996 and 2006. A comprehensive document review was undertaken to evaluate the implementation process, followed by a trend analysis of health expenditure at district level, and a segmented regression analysis of data on antenatal care (ANC) and deliveries at health facilities that was obtained from five demographic and health survey datasets (1992, 1996, 2002, 2007 and 2014). The results show that PBC was anchored by high-level political support, an overarching policy and legal framework, and collective planning and implementation with all key stakeholders. Decentralization of health service provision was also an enabling factor. ANC coverage increased in both the lower and upper wealth quintiles during the PBC era, followed by a declining trend after the PBC era in both quintiles. Further, the percentage of women delivering at health facilities increased during the PBC era, particularly in rural areas and among the poor. The positive trend continued after the PBC era with similar patterns in both lower and upper wealth quintiles. Despite these gains, per capita health expenditure at district level declined during the PBC era, with the situation worsening after the PBC era. The study concludes that a nationwide PBC approach can contribute to improved equity of access to maternal health services and that PBC is a cost-efficient and sustainable policy reform. The study calls for policymakers to comprehensively evaluate the impact of health system reforms before terminating them.
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.
For the past 15 years, several donors have promoted performance-based financing (PBF) in Africa for improving health services provision. European and African experts known as 'diffusion entrepreneurs' (DEs) assist with PBF pilot testing. In Mali, after participating in a first pilot PBF in 2012-13, the Ministry of Health and Public Hygiene included PBF in its national strategic plan. It piloted this strategy again in 2016-17. We investigated the interactions between foreign experts and domestic actors towards PBF diffusion in Mali from 2009 to 2018. Drawing on the framework on DEs (Gautier et al., 2018), we examine the characteristics of DEs acting at the global, continental and (sub)national levels; and their contribution to policy framing, emulation, experimentation and learning, across locations of PBF implementation. Using an interpretive approach, this longitudinal qualitative case study analyses data from observations (N = 5), interviews (N = 33) and policy documentation (N = 19). DEs framed PBF as the logical continuation of decentralization, contracting policies and existing policies. Policy emulation started with foreign DEs inspiring domestic actors' interest, and succeeded thanks to longstanding relationships and work together. Learning was initiated by European DEs through training sessions and study tours outside Mali, and by African DEs transferring their passion and tacit knowledge to PBF implementers. However, the short-time frame and numerous implementation gaps of the PBF pilot project led to incomplete policy learning. Despite the many pitfalls of the region-wide pilot project, policy actors in Mali decided to pursue this policy in Mali. Future research should further investigate the making of successful African DEs by foreign DEs advocating for a given policy.
Global Maternal and Child Health
Healthcare Systems and Reforms
Health Systems, Economic Evaluations, Quality of Life
Liliana A. Ponguta, Carlos Aggio, Kathryn M. Moore, Elisa A. Hartwig · 9 authors
We conducted a qualitative study in four countries of the Europe and Central Asia (ECA) region and explored the Early Childhood Education (ECE) policy landscape with an emphasis on the challenges and opportunities decentralization has presented for the provision of services. We content-analyzed ECE policies and documents to map national approaches to ECE. Key informant interviews were conducted to assess the implementation of decentralized ECE governance. An analytical framework that combined core constructs of ECE systems and key domains of decentralization (autonomy, institutional capacity and accountability) was developed and applied. Our analysis points to four overarching processes that contribute to the perpetuation and possible increase of inequitable ECE including (1) sparse mechanisms for participatory and autonomous policy formulation, with few systematic efforts to strengthen local institutional capacities; (2) fragmented policy approaches to promote the assessment and strengthening of quality at scale; (3) funding frameworks and financing schemes that tend to benefit enrolment in contexts of higher levels of economic development; and (4) few mechanisms for coordination to ensure operational coherence across the ECE sector.
<ns4:p> <ns4:bold>Background:</ns4:bold> Health sector decentralization, defined as the transfer of decision making over health sector resources from a central to a peripheral entity; has been and continues to be a widely adopted health system reforms in many low and middle-income countries (LMICs). However, its reported effects have been varied. Nevertheless, decentralization reforms aimed at providing public hospital management autonomy are increasing in prevalence in many LMICs. The range and form of this autonomy because of these reforms has often produced mixed effects. We set out to understand the range of financial management autonomy that has been granted to public hospitals in decentralized health systems in LMICs, and what forms of accountability arrangements have been used to facilitate this autonomy. </ns4:p> <ns4:p> <ns4:bold>Methods:</ns4:bold> We systematically searched PubMed, Google Scholar, Web of Science and CINAHL databases for published articles on this subject. We only included articles that reported empirical findings on hospital level financing and financial management in the context of decentralization in LMICs and/or those that included findings on hospital level finance management accountability arrangements. After a systematic search we found four articles that met our inclusion criteria. We undertook a thematic synthesis of the data and narrative reporting of our findings. </ns4:p> <ns4:p> <ns4:bold>Results:</ns4:bold> From the review â we find that decentralization reforms did not result in improved funding flows, finance management autonomy or accountability mechanisms and for public hospitals. These outcomes were irrespective of the mode and form of decentralization reform adopted. </ns4:p> <ns4:p> <ns4:bold>Conclusion:</ns4:bold> From our review, it is evident that though health sector decentralization reforms have been widely promoted and adopted in the past few decades across LMICs, there is minimal evidence that these reforms have improved funding flows to public hospitals, improved financial management autonomy or accountability mechanisms; so as to enhance the performance of these hospitals at sub-national level. </ns4:p>
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.