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.
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.
Abstract This chapter offers an in-depth look at health politics and the tax-financed health system in Kosovo, a system which is in a process of transition towards social health insurance. It traces the development of Kosovo’s healthcare system, characterized by the establishment of a decentralized free-for-all-at-point-of-delivery health system during communism. After the end of the Kosovo War in 1999, Kosovo started actively seeking independence. Until the declaration of independence in 2008, politics in the country was mainly focused on the state-building process, while health policy was not a priority. Although facilitated by international organizations, legislation for establishing a social health insurance has been passed, the social health insurance system has not been implemented yet. Thus, healthcare services still remain financed by state and municipal budgets, medical professionals are public employees, and the private sector is not integrated into the public insurance system. Key healthcare issues have been high out-of-pocket payments, mainly for pharmaceuticals and private services, inequalities in health access, and high unemployment rates, which are likely to undermine the collection of social insurance contributions in the future.
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.
Noemia Liege Maria da Cunha Bernardo, Luciano Soares, Silvana Nair Leite
The decentralization of the Brazilian health system required that municipalities took responsibility for the local Pharmaceutical Policy and Services (PPS) system. This article presents and analyses an innovative experience of diagnosis of municipal PPS as a sociotechnical system. We adopted a multi-methods approach and various data sources. Sociotechnical theory was the framework of the methodology of evaluation and design of systems, analyzing the External System (health system, stakeholders, financing) and Internal System (goals, management, workforce, infrastructure, processes, technology and culture). The "objective" component of the PPS system was identified as the central element. The lack of a unified objective and of a central coordination and unmanaged pharmaceutical services prevented integrated internal planning and planning with other sectors. Stakeholders and documents referred only to technical elements of the system: Infrastructure, technical process, and technology. The social components of the workforce and culture were not mentioned. The organizational culture established was the culture of isolation: "Each one does his own". The pharmacists working in the municipal health system did not know each other. There was no integration strategy between pharmacists and their work processes. Consequently, the municipal PPS had limited scope as a public policy. It had constrained the characteristics of PPS as a complex and open system. Understanding the municipal PPS as a sociotechnical system can push the development of a new level of policy and practice to ensure the population's right to the access to and rational use of medicines.
Open access
Public Health in Brazil
Health Systems, Economic Evaluations, Quality of Life
The coronavirus disease 2019 (COVID-19) pandemic, with its overlapping public health and economic emergencies, is a global reminder of the importance of addressing social and environmental determinants of health and inequality, and investing in health systems oriented towards primary care, all of which are components of a primary health care (PHC) approach. PHC – the importance of which was famously articulated in the Declaration of Alma-Ata in 1978 and reaffirmed at the 2018 Astana Conference – is recognized as one of the best ways of promoting population health and well-being.[1,2,3] PHC is “a whole-of-society approach to health that aims to ensure the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and preferences (as individuals, families, and communities) as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment”.[4] It promotes a focus on health systems oriented towards primary care, which have been shown to strengthen appropriateness, access, quality and efficiency of care, through their defining focus on people and the delivery of integrated preventive, curative and public health services.[5] However, the efficacy and impact of such primary care is understood to be intrinsically linked to, and embedded within, a broader context that is inclusive of participatory and responsive financing and governance structures, and policies and actions in non-health sectors.[6] In 2020, with the aim of supporting countries to operationalize PHC, the World Health Organization (WHO) launched its Operational framework for primary health care: transforming vision into action.[7] Showcasing evidence-based strategic and operational levers, the framework highlights the need for a whole-of-society approach. Of note, the framework’s emphasis – on more and better multisectoral action, empowerment of people and communities, and the urgency of strengthening primary care as the “service front”[6] and programmatic engine of universal health coverage[2] – overlaps considerably with issues highlighted by the COVID-19 pandemic. In the WHO South-East Asia Region, Member States have articulated a high-level commitment to the vision of PHC as one means by which to improve health and well- being. Even before the COVID-19 pandemic, an estimated 60 million people annually in the region experienced poverty because of out-of-pocket spending on health care. Regionally, various initiatives are seeking to both build primary care capacity and implement policies and strategies that reflect a multisectoral approach. As observed in the WHO Regional Director’s message accompanying this special issue, since 2014, achieving universal health coverage has been one of the flagship priorities across the South-East Asia Region, with service coverage improving from an average of 47% a decade ago to more than 61% in 2020. However, many challenges remain; the COVID-19 pandemic has provided opportunities for innovation and adaptation but has also presented new problems or compounded problems in relation to Member States’ efforts to operationalize PHC. In this supplement, South-East Asia Region authors and others reflect on the challenges and lessons learned regarding PHC during the first 12 months of the COVID-19 pandemic, highlighting among other things examples of the rapid review and extension of health workforce capability; the expedited introduction of technological solutions to maintain and strengthen health care access; and newly decentralized governance arrangements designed to enable the integration of public health functions into front-line services.[8,9] Addressing the critical issue of access to essential services, for example, Reddy et al.[10] present findings from the analysis of routine facility data in India’s Telangana state, which show a positive association between a highly decentralized model of hypertension care that brings follow-up services and medicines closer to communities and indicators of service uptake and hypertension outcomes. Although identifying some decreases in service access during the pandemic-induced lockdown, the same study suggests a potentially protective effect on access to and use of hypertension follow-up services in populations covered by decentralized services compared with those covered by non-decentralized services. Zangmo et al.[11] similarly describe various adaptations to traditional models of antenatal care employed to ensure continuity of this vital service in country settings experiencing widespread social and economic lockdowns. Bezbaruah et al.[12] and Zakoji and Sundararaman[13] observe the critical importance of integrating emergency response capabilities and functions with routine community engagement and health workforce functions in support of effective and sustained emergency response measures that can be led by local stakeholders and are trusted by local populations. Bahl[14] et al. describe how, despite the reduction in immunization services and surveillance for vaccine-preventable diseases across the South-East Asia Region early in the pandemic, rapid adaptation of guidelines and action plans meant that, in most countries, immunization coverage recovered during July–September 2020 to levels seen during the corresponding months in 2019. In fact, this was observed in Bangladesh, as reported by Wangmo et al.,[15] where the rate of fully immunized children fell by 46% between January and April 2020 but recovered to 100% by June 2020. The benefits of long-term community engagement (a key pillar of comprehensive PHC), including through investment in community health workers, is evident in several contributions (Bezbaruah et al.,[12] Zakoji and Sundararaman,[13] Reddy et al.[10]). These contributions provide further evidence of the critical role of primary care services not only in ensuring access to essential health care during public health emergencies but also in providing a platform for long-term and sustained efforts to strengthen national and subnational health systems through community engagement.[3] Even with examples of innovation and adaptation, multiple challenges to progressing PHC in the South-East Asia Region remain, particularly in the new context of the COVID-19 crisis. Zapata et al.[16] and Tangcharoensathien[17] note that, despite several decades of investment by Member States in human resources for health, huge health workforce challenges remain, with only two countries currently meeting the revised WHO threshold of 44.5 health workers per 10 000 population. The pandemic has highlighted the need to prioritize locally appropriate actions in the delivery of primary care, yet health budgets are overstretched and, as Kwon[18] points out, health governance and financing systems are too often unresponsive in the face of shifting health needs. Tandon et al.[19] observe that, in many South-East Asia Region countries, low levels of public spending on health and tied donor funding inhibit investment in primary care or the types of multisectoral action needed to realize PHC. Alongside the political economy of pharmaceutical research, development and sales, such budget constraints can influence the availability of medicines, which, despite the remarkable efforts behind the COVAX initiative, will affect the ability of different countries to access and roll out COVID-19 vaccines. Reflecting on a long-standing challenge, Khan et al.[20] observe how, despite mixed health systems being the norm in the region, attention to, and investment in, effective regulatory mechanisms to ensure the quality and affordability of nongovernment (private for-profit and not-for-profit) services remain weak. Reflecting on issues of health governance, Tangcharoensathien[17] and Guisset et al.[21] observe how, often, decisions about health service type and availability are driven by siloed governance and financing systems that are distant, if not disconnected, from the realities of both patients and frontline providers. Looking at the intersection of such governance and regulatory issues, Rajbhandary et al.[22] describe the need for urgent investment to strengthen health information systems in the South-East Asia Region, noting the growing capacity for the collection and collation of health information within regional Member States but also the still underdeveloped capacity for analysing and utilizing these data at subnational and particularly facility levels, where it is arguably most needed. Walcott and Akinola[23] reflect on the power of digital technologies, including data capture from rapidly expanding telemedicine applications, to inform on better targeted interventions and advance the universal health care agenda. Wangmo et al. present data illustrating the positive role that health information systems, and especially the collection and use of routine data, have played in Bangladesh, to help identify and inform the government response, down to the health facility level, on early reductions in coverage of essential services during the first months of the COVID-19 pandemic. Providing an important synthesis of many of these issues, Peiris et al.[24] review the literature to highlight how, even when accounting for some welcome pandemic-related health service adaptations, country-level attention to strategic functions that would strengthen underlying health systems in support of PHC remains generally weak. Challenges include many of the strategic areas identified in WHO’s operational framework, such as leadership, governance and policy, funding and allocation of resources, and engagement of communities and other stakeholders.[7] Around the globe, the COVID-19 pandemic has laid bare the devastating impact of both structural inequities and suboptimally designed health systems. The pandemic has highlighted the pressing need to move away from brittle, uncoordinated and disease-specific responses and to reorient health systems towards a PHC approach. “Building back better” in the South-East Asia Region and beyond means taking stock of current weaknesses in often fragmented health systems and service functions and making changes to improve responsiveness, resilience and the capability to deliver better and more equitable health outcomes. This collection speaks to emerging insights and opportunities created by the willingness to adapt in the context of the COVID-19 pandemic but also to an urgent need to pay more attention to and invest more in PHC, before the health and economic impacts of the pandemic slow or reverse the progress made in recent decades. We hope that this collection serves to reinforce the need for enacted commitment to the vision of health for all, through investment in well-aligned governance, financing and structural reforms.
The article deals with the impact of the COVID-19 pandemic on the financing of the health care system, and the main challenges to the stability of the financial mechanisms of post-pandemic health care development have been identified. The author substantiates the peculiarities of the crisis of health care financing in the conditions of the current pandemic, further economic recession and decreased fiscal sustainability. The global practice of fiscal response to the manifestations of the COVID-19 pandemic has been systematized and the volumes of the corresponding financing in the countries with insurance and budgetary systems of health care financing have been estimated. The article identifies mechanisms for the transformation and expansion of the fiscal space in the context of expanded financing of the growing need for medical care in the face of new epidemic risks in different countries. Most often, the expansion of a country's fiscal space is carried out by: redistributing the existing amount of government expenditure for health care and redirecting funding flows from financing certain types of medical care to financing programs to overcome and combat COVID-19; changes in the priority of government health expenditure to combat COVID-19 compared to other budget expenditures on the social sphere and economic development; and using national reserve funds and emergency funds. It has been found that in the field of health care, the vast majority of countries have reduced the economic and territorial deprivation of all population groups in access to the diagnosis and treatment of COVID-19. The author emphasizes the weaknesses of insurance based and decentralized health financing mechanisms to respond to the growing need for health care and financial stability during the pandemic. Substantiated the necessity to expand the fiscal space needed to cover the fiscal gap in Ukraine caused by the requirement to increase health care financing in response
Étienne 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 priorities’ 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 2014–2017, 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.
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 “tied” than federal and regional governments’ 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 — indicating the value for money. This encouraged other development partners to support Ethiopia’s 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.
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.
Sharing medical data with numerous stakeholders for varied purposes is a perplexing problem facing healthcare systems throughout the world. All this needs to be done, whilst ensuring patient and health data privacy and data integrity. Through this paper, an attempt has been made to present a novel distributed digital health record management system. The blockchain framework has been built using the tools provided by hyper ledger, an open source project. This system empowers patients with a comprehensive, secure, immutable, and easily accessible digital record of their health. Also, this information is available across multiple practitioners and healthcare providers throughout the world. This system can therefore empower the emergence of health data economics, empowering researchers with the health data and giving patients an opportunity to share their health data without losing anonymity. The purpose of this paper is to introduce a prototype of a health data management system utilising blockchain.
ABSTRACT For the last three decades, healthcare systems have been under pressure to adapt to a neoliberal world and incorporate market principles. The introduction of market-based instruments, increasing competition among health care providers, introducing publicly -funded private sector provisioning of healthcare through health insurance financing systems to replace public provisioning of health care, promoting individual responsibility for health and finally, the introduction of market relations through privatization, deregulation and decentralization of health care have been some common elements seen globally. These reforms, undertaken under the guise of increasing efficiency and quality through competition and choice, have in fact harmed the physical, emotional and mental health of communities around the world and also contributed to a significant rise in inequities in health and healthcare access. They have weakened the public healthcare systems of countries and led to commercialization of healthcare. This article presents three case studies of resistance, to the commercialization of health care, by the People’s Health Movement (PHM) and associated networks. It aims to contribute to the understanding of the way neoliberal reforms, including those imposed under structural adjustment programmes and some promoted under the Universal Health Coverage (UHC) paradigm, have impacted country-level health systems and access of people to health care, and bring out lessons from the resistance against these reforms.
Health indicators have been gradually improving in India, but health for all is yet to be achieved. The life expectancy is 68.7 years, infant mortality rate is 33/1000 live births, maternal mortality ratio is 130/100,000 live births, and total fertility rate is 2.3 children/woman; however, large inequities by geography, gender, class, caste, religion, and region are seen.[1] Health of the Nation's States Report[2] indicates that despite rising income, poverty and hidden hunger still exist; environmental pollution has increased, more so, in urban areas; sanitation services and clean fuel use have not yet improved to the desired level, especially in the villages. In urban areas, slums have mushroomed, built area has increased, and open spaces have shrunk. Moreover, dietary patterns have changed in favor of more sugar, salt, fat, and alcohol, whereas consumption of vegetables and fruits has declined. Mechanization, especially motorized transport, has encouraged sedentary life styles and a rise in road traffic injuries is noticed. The gap between aspirations and real-life situations has pushed many into addictions and mental health problems. To address these issues, multisectoral public health actions are needed, in addition to the reorientation of health sector. In the last decade, the implementation of the National Health Mission (NHM) did bring back some focus on social determinants of health and encouraged development of a health system based on primary health care.[3] Investments in health system led to improvement in health services. It had an impact on health indicators, but the full potential of NHM is yet to be realized.[4] The recently announced Ayushman Bharat Mission (ABM) has started insurance coverage for selected package of medical and surgical procedures for hospitalized patients belonging to socioeconomically vulnerable families on the lines of Rashtriya Swasthya Bima Yojna though the insurance amount is larger.[5] The development of subcenters into health and wellness centers continues to be under the NHM. These two missions, i.e., NHM and ABM, deal with primary and secondary care, respectively. In the absence of a linkage between these two missions, it may not be possible to maintain a balance. Therefore, the funds earmarked for ABM should flow through the primary health-care system on per capita basis. The primary health-care providers should be empowered to decide which patient to refer, to which hospital (public or private), and at what cost to pay, so that ultimately health services are cashless for the patient. Coordinated actions are required not only within the health and family welfare ministry, but across multiple sectors. Hence, to operationalize multisectoral public health action in a decentralized manner, every village or urban ward should have Arogya Kendra (health center) financed by the state through a village or ward fund, but managed by local volunteers under the guidance of the community it serves, and it should have a decentralized Integrated Health Information System for Universal Health Care supported by Information Communication Technology (ICT), if possible. Devolution of funds to district health societies and decentralization of planning, implementation, and monitoring would build a sustainable system rooted in local sociocultural contexts, which will be able to harness the locally available resources. However, broad policy framework, guidelines, and oversight can remain at the central and state level. Primary health-care teams should be incentivized to invest in prevention and health promotion, so that health literacy improves and spending on illness care can be reduced. Therefore, NHM and ABM should advocate for a comprehensive public health-oriented “whole-of-government” intersectoral health promotion initiative keeping in view “inclusive growth” and “health development” as a social goal of the society. Health impact assessment of all public policies should be mandated by legislation. “Prevention of diseases” is a more cost-effective strategy than the popular approach of “Treatment.” Therefore, several countries have reengineered their health systems in a variety of ways to protect and improve peoples' health. For example, in England, the Health and Social Care Act 2012 reorganized the health services to create National Health Service England and Public Health England,[6] and in Thailand, the National Health Security Act 2002 granted everyone the right to a standard and efficient health service and established National Health Security Office to improve universal health coverage.[7] The World Health Organization has also recently planned a call to countries to set up leadership at all levels to protect the people from public health emergencies, to improve universal health coverage, and to ensure that people enjoy better health and well-being.[8] Indian should also reorganize its health system. Parliament should promulgate Indian Public Health Act with a mandate to protect and promote health of people as a fundamental right to health and health care. An autonomous “Public Health Commission” should be established to implement the provisions of the Act. It should have a public health commissioner with three deputy commissioners to head (a) epidemiology, (b) public policy, and (c) health promotion and education divisions. At state level, an additional public health commissioner should chair the State Public Health Commission which should have three deputy commissioners representing the above-mentioned three divisions, and at district level, a public health officer should head the District Public Health Commission who should be assisted by three additional public health officers. Each municipality should have a deputy public health officer and three public health supervisors. The Panchayat Raj Institutions, at district and community development block level, should have a deputy public health officer and an assistant public health officer. At Panchayat level, a public health supervisor should be appointed. Public Health Commission should have sufficient infrastructure (secretarial support staff, technical staff, equipment, office space, and budget) so that, in coordination with all sectors, a Public Health Action Plan can be prepared, funded, implemented, and monitored periodically. In summary, to achieve the universal health coverage, major challenge in India is promotion of health, prevention of diseases, and provision of health care in a balanced manner, which will require innovative public policies, strategies, and programs in many sectors. Development and implementation of a multisectoral approach to achieve sustainable development goals is the need of the hour. Establishment of a Public Health Commission will go a long way in achieving coordination of various initiatives not only in the Ministry of Health and Family Welfare but also in many other relevant ministries/sectors. At least 5% of the gross domestic product should be earmarked for public health and a responsive governance mechanism as outlined above should be set up, to achieve universal health coverage by 2030 as envisaged in the United Nations sustainable development goals which are also endorsed by the Government of India.[9]
INTRODUCTION: Fiscal federalism and fiscal decentralization are distinct policy options in public services in general and healthcare in particular, with possibly opposed effects on equity, effectiveness, and efficiency. However, the pertinent discourse often reflects confusion between the concepts or conflation thereof. METHODS: This paper performs a narrative review of theoretical literature on decentralization. The study offers clear definitions of the concepts of fiscal federalism and fiscal decentralization and provides an overview of the potential implications of each policy for healthcare systems. RESULTS: The interpretation of the literature identified three different dimensions of decentralization: political, administrative, economic. Economic decentralization can be further implemented through two different policy options: fiscal federalism and fiscal decentralization. Fiscal federalism is the transfer of spending authority of a centrally pooled public health budget to local governments or authorities. Countries like the UK, Cuba, Denmark, and Brazil mostly rely on fiscal federalism mechanisms for healthcare financing. Fiscal decentralization consists of transferring both pooling and spending responsibilities from the central government to local authorities. Contrarily to fiscal federalism, the implementation of fiscal decentralization requires as a precondition the fragmentation of the national pool into many local pools. The restructuring of the pooling system may limit the cross-subsidization effect between high- and low-income groups and areas that a central pool guarantees; thus, severely affecting local equality and equity. With the limited availability of local public resources in poorer regions, the quality of services drops, increasing the disparity gap between areas. Evidence from Italy, Spain, China, and Ivory Coast -countries with a strong fiscal decentralization element in their healthcare services- suggests that fiscal decentralization has positive effects on the infant mortality rate. However, it decreases healthcare resources as well as access to services, fostering spatial inequities. CONCLUSION: If public resources are and remain adequate, allocation follows equitable criteria, and local communities are involved in the decision-making debate, fiscal federalism -rather than fiscal decentralization- appear to be an adequate policy option to improve the healthcare services and population's health nationwide and achieve health sector economic decentralization. HIPPOKRATIA 2020, 24(3): 107-113.
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.
Lara Gautier, Abdourahmane Coulibaly, Manuela De Allegri, Valéry Ridde
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
<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 – 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>