Eeshani Kandpal, Benjamin Loevinsohn, Christel M. J. Vermeersch, Elina Pradhan · 7 authors
In response to slow progress in improving health service delivery, the Government of Nigeria requested World Bank support in testing performance-based financing (PBF) and decentralized facility financing (DFF) as part of the Nigeria State Health Investment Project (NSHIP). PBF provides funding directly to health facilities based on the quantity and quality of services they deliver. Funds are transferred electronically to each facility’s bank account and they have substantial autonomy in how they use the funds. Up to half the funds can be used to pay performance bonuses to staff. Supervision was substantially strengthened. DFF was similar to PBF except that facility earnings were NOT based on the quantity and quality of services they delivered, they could not pay performance bonuses to health workers and the amount they received was, by design, half the amount earned by PBF facilities. This paper reports an impact evaluation (IE) of the PBF-DFF pilot.
BACKGROUND: Universal health coverage (UHC) assures all types of health service and protects all citizens financially in any conditions due to illness. Globally, the UN sustainable development goal (SDG) provides high priority for UHC as a health related goal. The National health system of Nepal has prioritized in similar way. The aim of this study is to explore the challenges and opportunities on the road to UHC in Nepal. METHOD: We used varieties of search terminologies with popular search engines like PubMed, Google, Google Scholar, etc. to identify studies regarding Nepal's progress towards UHC. Reports of original studies, policies, guidelines and government manuals were taken from the web pages of Ministry of Health and its department/division. Searches were designed to identify the status of service coverage on UHC, financial protection on health particularly, health insurance coverage with its legal status. Other associated factors related to UHC were also explored and presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. RESULTS: We found 14 studies that were related to legal assurance, risk pulling and financing of health service, 11 studies associated to UHC service coverage status and, 7 articles linked to government stewardship, health system and governance on health care. Constitutional provision, global support, progress on the health insurance act, decentralization of health service to the grass root level, positive trends of increasing service coverage are seen as opportunities. However, existing volunteer types of health insurance, misleading role of trade unions and high proportion of population outside the country are main challenges. The political commitment under the changing political context, a sense of national priority and international support were identified as the facilitating factors towards UHC. CONCLUSION: To achieve UHC, service and population coverage of health services has to be expanded along with financial protection for marginalized communities. Government stewardship, support of stakeholders and fair contribution and distribution of resources by appropriate health financing modality can speed up the path of UHC in Nepal.
The 2012 national health policy is the \n overarching health policy framework in Zambia. The policy \n takes a human rights approach to health care provision, \n where all citizens are entitled to basic health care \n (Ministry of Health 2012). The policy is actualized through \n successive five-year national health strategic plans. \n Operationally, Zambia’s health system is centralized, with \n delegated responsibilities from the center to lower levels \n of the health care delivery system. The Ministry of Health \n plays a dual role of policy formulation and strategic \n planning and delivery of health services, with provincial \n and district health offices being upwardly accountable to \n the Ministry of Health headquarters. Going forward, Zambia \n is in the process of launching two major reforms which will \n further affect the organization of the health sector. These \n are (a) implementation of the National Decentralization \n Policy, and (b) introduction of a National Health Insurance \n (NHI) scheme. The PHC function (including transfer of PHC \n staff to local government authorities) is among the front \n runner for decentralization. If national decentralization is \n fully implemented, it will affect the way health services \n are organized, delivered, and financed in the country. Thus, \n adequate preparations in the health sector are required to \n minimize challenges. Secondly, Zambia enacted the NHI Act in \n April 2018 which provides the legal mandate to establish the \n NHI management authority, and the NHI scheme. At the time of \n this study, it was envisaged that implementation of the NHI \n scheme will be done in a phased manner with a view of \n covering the entire population in the medium to long term. \n However, depending on the final design and implementation \n process, the NHI will have a substantial effect on the \n financing and delivery of health programs and services in \n Zambia. One of the immediate challenges will be providing \n insurance cover to the informal sector and indigent people \n in rural areas.
Financing is a major challenge and concern for the future of family planning (FP) programs. As countries commit to increasing access to and quality of FP services and to universal health care (UHC), it is crucial that UHC schemes include FP and other reproductive health services. This brief aims to: 1) document trends in UHC and health financing, drawing out implications for policymakers and programmers; and 2) identify opportunities for the FP community of practice to advocate for the inclusion of quality FP services within UHC and health financing discussions. With this brief, we aim to highlight experiences in Kenya, given that there is a body of experience with health financing reforms and UHC schemes and a relatively strong national FP program. The Kenya case study is instructive for other countries with decentralized and mixed health systems as they seek to integrate FP within their own UHC initiatives and health financing reforms.
Nathaniel Mason, Charles O. Oyaya, Julia Boulenouar
Abstract Motivation Across the Global South, unclear institutional frameworks undermine progress in improving services. Often, ongoing decentralization reforms reduce clarity further. Policy professionals working on institutional reform lack comparative models. Purpose To identify key challenges for the institutional arrangements for urban sanitation in decentralizing contexts, in Kenya and elsewhere, and to propose possible responses. Approach and methods We use key informant interviews and literature review in a problem‐driven analysis, drawing from three comparative case studies: South Africa, Indonesia and Tamil Nadu State. The analysis builds upon research on institutional effectiveness—co‐operation, collaboration and co‐ordination—rooted in game theory and elaborated in the 2017 World Development Report. Findings Three key problems in Kenya are identified: overlaps and competition around sector leadership at national and devolved levels; weak incentives for county governments to commit policy attention and finance, despite devolution; and limited regulatory oversight. Policy implications We identify a range of options for urban sanitation policy‐makers: (a) to engage non‐sectoral authorities in co‐ordinating multi‐sectoral issues across all levels of government; (b) to encourage political commitment to pro‐poor sanitation services at decentralized levels; and (c) to use incentive‐based and risk‐based approaches to regulate decentralized entities and strengthen local capacity for monitoring and enforcement.
BACKGROUND: Decentralization is promoted as a strategy to improve health system performance by bringing decision-making closer to service delivery. Some studies have investigated if decentralization actually improves the health system. However, few have explored the conditions that enable it to be effective. To determine these conditions, we have analyzed the perspectives of decision-makers in the Philippines where devolution, one form of decentralization, was introduced 25 years ago. METHODS: Drawing from the "decision space" approach, we interviewed 27 decision-makers with an average of 23.6 years of working across different levels of the Philippine government health sector and representing various local settings. Qualitative analysis followed the "Framework Method." Conditions that either enable or hinder the effectiveness of decentralization were identified by exploring decision-making in five health sector functions. RESULTS: These conditions include: for planning, having a multi-stakeholder approach and monitoring implementation; for financing and budget allocation, capacities to raise revenues at local levels and pooling of funds at central level; for resource management, having a central level capable of augmenting resource needs at local levels and a good working relationship between the local health officer and the elected local official; for program implementation and service delivery, promoting innovation at local levels while maintaining fidelity to national objectives; and for monitoring and data management, a central level capable of ensuring that data collection from local levels is performed in a timely and accurate manner. CONCLUSIONS: The Philippine experience suggests that decentralization is a long and complex journey and not an automatic solution for enhancing service delivery. The role of the central decision-maker (e.g. Ministry of Health) remains important to assist local levels unable to perform their functions well. It is policy-relevant to analyze the conditions that make decentralization work and the optimal combination of decentralized and centralized functions that enhance the health system.
Moritz Piatti-Fünfkirchen, Magnus Lindelöw, Katelyn Jison Yoo
Progress toward universal health care (UHC) in Africa will require sustained increases in public spending on health and reduced reliance on out-of-pocket financing. This article reviews trends and patterns of government spending in the East and Southern Africa regions and points out methodological challenges with interpreting data from the World Health Organization's (WHO) Global Health Expenditure Database (GHED) and other sources. Government expenditure for health has increased for most countries, albeit at a slower rate than gross domestic product (GDP). In most countries there has been a prioritization away from health in government budgets, putting the onus on the private sector and donors to fill the gap. Donor support is important in the region but reliance on external spending is not consistent with countries' stated ambitions of universal health coverage. A number of methodological challenges with estimating health expenditures are identified. Capturing health expenditures adequately across agencies and levels of decentralization can be challenging, and off-budget funds and arrears are evasive. Measurement error can be significant because actual expenditure information can be hard to come by and is often dated and unreliable. Furthermore, how external financing is captured will affect government health expenditure estimates. These factors have contributed to differences in expenditure estimates between the WHO GHED and country-specific public expenditure reviews and complicate interpretation. The article concludes that it is critical to strengthen national data capacity and international efforts to promote quality and consistency of data. The GHED is an invaluable resource for monitoring and benchmarking health expenditures. It is best used in combination with deep dive country expenditure assessments.
BACKGROUND & OBJECTIVES: Numerous studies have highlighted the regressive and immiserating impact of out-of-pocket (OOP) health spending in India. However, most of these studies have explored this issue at the national or up to the State level, with an associated risk of overlooking intra-State diversities in the health system and health-seeking behaviour and their implication on the financial burden of healthcare. This study was aimed to address this issue by analyzing district level diversities in inequity, financial burden and impoverishing impact of OOP health spending. METHODS: A household survey of 62,335 individuals from 12,134 households, covering eight districts across three States, namely Gujarat, Haryana and Rajasthan was conducted during 2014-2015. Other than general household characteristics, the survey collected information on household OOP [sum total of expenditure on doctor consultation, drugs, diagnostic tests etc. on inpatient depatment (IPD), outpatient depatment (OPD) or chronic ailments] and household monthly consumption expenditure [sum total of monthly expenditure on food, clothing, education, healthcare (OOP) and others]. Gini index of consumption expenditure, concentration index and Kakwani index (KI) of progressivity of OOP, catastrophic burden (at 20% threshold) and poverty impact (using district-level poverty thresholds) were computed, for these eight districts using the survey data. The concentration curve (of OOP expenditure) and Lorenz curve (of consumption expenditure) for the eight districts were also drawn. RESULTS: The distribution of OOP was found to be regressive in all the districts, with significant inter-district variations in equity parameters within a State (KI ranges from -0.062 to -0.353). Chhota Udepur, the only tribal district within the sample was found to have the most regressive distribution (KI of -0.353) of OOP. Furthermore, the economic burden of OOP was more pronounced among the rural sample (CB of 19.2% and IM of 8.9%) compared to the urban sample (CB of 9.4% and IM of 3.7%). INTERPRETATION & CONCLUSIONS: The results indicate that greater decentralized planning taking into account district-level health financing patterns could be an effective way to tackle inequity and financial vulnerability emerging out of OOP expenses on healthcare.
Adelyne Maria Mendes Pereira, Luciana Dias de Lima, Cristiani Vieira Machado
This article discusses the processes of de centralization and regionalization of health policy in Brazil and Spain between 1980 and 2015. The study was developed with contributions of the historical institutionalism and of the historical com parative method, by means of three dimensions of analysis: State context; trajectory and institution ality of the decentralization and regionalization of health; and constraints. The study showed that,in both countries, the more general context of re-democratization and decentralization of the State conditioned the reforms of health systems and their political-administrative organization. In addition, historical, institutional and political factors have had a specific impact in each case, influencing the regional organization of services, the balance of power and the division of responsibilities between the governmental spheres in the management, financing and coordination of health policy. The study suggests that the way these factors interrelated over time is important for understanding the decentralization and regionalization of health systems in different contexts.
Background: Governments engage in setting health sector priorities among competing interests to maximize health system goals within the available resources. This is important as misalignment between health priorities and budget allocations can lead to low budget allocations and underspending in the health sector.\nGoal: The goals of the study are twofold. First, measure the extent of alignment between a stated government priority and actual government expenditure. Second, if there is misalignment, explain the underlying bottlenecks including institutions, structures, and capacities.\nMethod: The study focuses on one stated health sector priority shared between Kenya and Mozambique, which is improving geographical equity of governmental resources for health. An explanatory mixed methods design is used, in which quantitative analysis is followed by a qualitative assessment. In quantitative analysis, Gini index is used to summarize the differences in per capita health expenditures across regions. In addition, health expenditure is decomposed as a product of total budget, health budget priority, and health budget execution to identify whether resource allocation or resource utilization lead to geographical inequity. The qualitative assessment consisted of 23 semi-structured key informant interviews, 10 for Kenya, 11 for Mozambique, to explain the quantitative results.\nResults: In both Kenya and Mozambique there is geographical inequity in government health spending, which is inconsistent with the stated government priority (Gini greater than zero). The decomposition of health expenditure suggests that, in Kenya, the misalignment is driven by both resource allocation and utilization processes; in Mozambique, it is driven largely by the resource allocation process. \nThe qualitative analysis reveals several bottlenecks that are common between the two countries. At the institutional level, there is institutional separation between planning and budgeting, decision-making is ad hoc, and difficult decisions on hard choices and tradeoffs are left to the end of the budget process. At the structural level, rapid and unplanned decentralization in Kenya and the deconcentration model in Mozambique have led to inadequate structures to align planning and budgeting. At the capacity level, there are too many administrative demands on planning and budgeting staff, who also lack technical expertise and adequate data to make evidence-based decisions.
Mehdi Jafarı, Amin Habibirad, Arefeh Pourtaleb, Mohammad Hossein Salarianzadeh
BACKGROUND: Since the early 1990s, Iran has initiated structural and decentralization reforms in the hospital system. This policy led to the formation of a Board of Trustees (BOTs) for the governing of public educational hospitals and making important modifications in hospitals' financing. This study was conducted to identify the barriers in implementing this policy. METHODS: All the Iranian Medical Sciences Universities and hospitals involved in the policy implementation were included in this qualitative study. The data were analyzed by using content analysis. RESULTS: In total, 403 problems were divided into 9 classes including problems related to implementing regulation, financial problems in policy implementation, problems related to faculty members, ambiguity in executive regulation, problems related to the BOTs, authority level, hospital structure, the quality and quantity of hospital human resources, and fee for services. CONCLUSION: It appears that "implementing regulation" and "financial problems" embrace over 50% of the barriers. Apparently, the new approach to hospitals' autonomy has not achieved the desired goals. Considering the contextual factor, the evidence and identification of the clear role of various stakeholders should be essential determinants. Partial implementation of this policy without paying attention to the other aspects would end in failure. The results showed insufficient budget to be the most influential factor that posed a dilemma in implementing the BOTs' policy. However, BOTs in Iranian health system need to strive toward a higher level of performance that will improve effectiveness and efficiency now more than ever.
For countries looking to implement multisectoral nutrition plans, it is critical to understand what works and how programs should be delivered and scaled-up in each context. Programs can learn from each other on how to adapt to new information, evidence and events related to scaling-up and district stakeholders can play important roles in implementation of this multisectoral plan. As part of "Pathways-to-Better Nutrition" (PBN) case study conducted by USAID/SPRING Project, this research set out to explore district leaders' perceptions of the nutrition situation, programs and opportunities for integration. Qualitative data were collected through key-informant interviews and focus group discussions. Thirty-five district and local leaders belonging to district and sub-county multisectoral nutrition committees in Kisoro and Lira were interviewed. Grounded Theory Approach was used to identify themes for coding and key domains included: learning, adoption and evidence of scale-up; adoption of innovations/interventions to local context, financing of nutrition-sensitive activities and long-term planning. Additionally, quantitative data collected by Feed the Future Innovation Lab for Nutrition were analyzed in each of the districts to provide nutrition snapshots. Malnutrition in the study districts was worse than the national average for stunting, anemia and women's underweight. The majority (91%) of respondents were not familiar with these nutrition statistics. Both study areas have formed nutrition multisectoral working groups (District Nutrition Coordinating Committees) and have developed management structures to implement interventions. Government stakeholders from every nutrition-sensitive sector referred to the lack of clear government programs that support nutrition directly in local policy environment. Key agricultural-related programs are focusing on wealth creation, value-addition or increasing agricultural productivity without nutrition lens (not "nutrition sensitive"). Nutrition is not on the 'list' of key priorities of district health departments unlike HIV/AIDS, malaria or sexual reproductive health. About 69% respondents believe they lack operational capacities and soft-power skills to design, implement and manage nutrition interventions such as leveraging of resources and being able to convey evidence. The understanding of "Scaling-up Nutrition" also differed by respondent, and this has resulted in different goals and measurements. Challenges related to nutrition financing were also noted, including fiscal decentralization, use of Output-Based Financing mechanisms, limited flexibility to re-allocate funds for nutrition, and lack of standard reporting procedures or implementation strategy. Efforts to address malnutrition need to be multisectoral, coupled with increased coordination of different sectors and ministries for sustained impact on nutrition outcomes.
Marcelo Battesini, Carla Lourenço Tavares de Andrade, Marismary Horsth De Seta
Health Surveillance carries out a set of actions to prevent health risks related to the consumption of products and the provision of services under the Unified Health System (SUS). The implementation of Health Surveillance actions relies heavily on the federal funding policy, which induces its decentralization. This text aims to analyze the federal funding of Health Surveillance to States and Municipalities from the scheduled onlendings in the period 2005-2012. Among the main results are the increase of per capita values, steady at around the mean value of R$ 1.25/inhabitant/year; the increased number of municipalities that agreed to carry out strategic actions; and a stable trend in the proportions of each federated entity at around 50% to Municipalities, 25% to state federated entities and 20% to the Central Public Health Laboratories (LACENs). Results show that the adoption of unified nationwide per capita values caused distortions that indicate inequity among state territories, pointing to the need to clarify the concept of equity in financing under the National Health Surveillance System and to broaden the discussion on the currently used allocation criteria.
Edwine Barasa, Anthony Muchai Manyara, Sassy Molyneux, Benjamin Tsofa
BACKGROUND: In 2013, Kenya transitioned into a devolved system of government with a central government and 47 semi-autonomous county governments. In this paper, we report early experiences of devolution in the Kenyan health sector, with a focus on public county hospitals. Specifically, we examine changes in hospital autonomy as a result of devolution, and how these have affected hospital functioning. METHODS: We used a qualitative case study approach to examine the level of autonomy that hospitals had over key management functions and how this had affected hospital functioning in three county hospitals in coastal Kenya. We collected data by in-depth interviews of county health managers and hospital managers in the case study hospitals (n = 21). We adopted the framework proposed by Chawla et al (1995) to examine the autonomy that hospitals had over five management domains (strategic management, finance, procurement, human resource, and administration), and how these influenced hospital functioning. FINDINGS: Devolution had resulted in a substantial reduction in the autonomy of county hospitals over the five key functions examined. This resulted in weakened hospital management and leadership, reduced community participation in hospital affairs, compromised quality of services, reduced motivation among hospital staff, non-alignment of county and hospital priorities, staff insubordination, and compromised quality of care. CONCLUSION: Increasing the autonomy of county hospitals in Kenya will improve their functioning. County governments should develop legislation that give hospitals greater control over resources and key management functions.
Rwanda is a good example of how a country can overcome challenges and obstacles to improve the socioeconomic well-being of citizens. With no reliable healthcare system in 1994, after the genocide against the Tutsi, the country has come a long way in building a decent healthcare system for its people. The purpose of this research is to analyze the changing PPP mixed in health care sector in Rwanda. The study was carried out to reflect/reveal or bring to light the perennial problems of the healthcare mixes within a period of six months. This work looked at the public-private sector mixes in healthcare system using Rwanda as a case study. In Rwanda, the ministry of health began health sector reforms in accordance with the Lusaka declaration in 1995. These reforms included decentralization of the health system, development of the primary healthcare system, and community participation in managing health service financing. Rwanda is one of the few African countries with 90% coverage in all Districts for immunization and access to critical health services including TB treatment and access to ARVs for HIV patients. Within a very short period of 23 years, Rwanda has built a working health system in which even the poor and disadvantaged have access to quality medical care through the Community Based Health Insurance.
Hilaire Zon, Milena Pavlova, Koiné Maxime Drabo, Wim Groot
'Four' types of decentralization are distinguished in health care: deconcentration when the shift in authority is to regional or district offices; devolution when the shift is to state, provincial or municipal governments; delegation when semi-autonomous agencies are granted new powers; and privatization when ownership is granted to private entities. This article systematically reviews the experiences of local governments of Sub-Saharan African countries with the provision of health services during and after decentralization reforms. The article highlights the achievements, challenges and issues associated with decentralization. The review shows that most countries have mainly focused on the process by enacting numerous policies, regulations and standards with mixed outcomes for health services delivery. Decentralization in general, and resource transfer from the central to local governments in particular, are a highly political issue that influences the health reform strategy on decentralization. The literature shows the complexity of implementing decentralization schemes which strongly impact the health service organization and delivery. The theory of decision space applied in a comparative analysis found that some functions, particularly financing, remain under the control of the central state. Despite the numerous challenges, this review identifies some good practices in resources transfer, key determinants being the type of decentralization and the government's will to make legislative and administrative changes required for the effectiveness of decentralization. The literature search, even though systematic, resulted in a limited number of relevant publications with evidence on the link between decentralization and health services delivery. This is a largely unexplored research area, especially the use of financial resources by local governments, the factors that drive local decision-making processes and the effects of decentralization on health care sector performance.
BACKGROUND: The concept of decision space holds appeal as an approach to disaggregating the elements that may influence decision-making in decentralized systems. This narrative review aims to explore the functioning of decision space and the factors that influence decision space. METHODS: A narrative review of the literature was conducted with searches of online databases and academic journals including PubMed Central, Emerald, Wiley, Science Direct, JSTOR, and Sage. The articles were included in the review based on the criteria that they provided insight into the functioning of decision space either through the explicit application of or reference to decision space, or implicitly through discussion of decision-making related to organizational capacity or accountability mechanisms. RESULTS: The articles included in the review encompass literature related to decentralisation, management and decision space. The majority of the studies utilise qualitative methodologies to assess accountability mechanisms, organisational capacities such as finance, human resources and management, and the extent of decision space. Of the 138 articles retrieved, 76 articles were included in the final review. CONCLUSION: The literature supports Bossert's conceptualization of decision space as being related to organizational capacities and accountability mechanisms. These functions influence the decision space available within decentralized systems. The exact relationship between decision space and financial and human resource capacities needs to be explored in greater detail to determine the potential influence on system functioning.
David Houéto, Graziella Ghesquiere, Maurice Agonnoudé, Amavi Hounouvi · 6 authors
Introduction According to Canavan et al. [1], results-based financing (RBF) is a method of financing focused on the assumption that linking motivations to the performance would help to improve accessibility, quality and equity in the provision of health services. Blanchett quoted by Canavan et al., [1] argues that its impact would vary
The promulgation of the new constitution in Kenya in August 2010 effectively ushered in devolution as the latest and highest form of decentralization in Kenya. The health sector was the largest service sector to be devolved under this new governance arrangement. The rationale for devolving the sector was to allow the county governments to design innovative models and interventions that suited the unique health needs in their contexts, encourage effective citizen participation and make autonomous and quick decisions on resource mobilization and management possible issues. However, the sector in nearly all counties is currently bedevilled with monumental challenges ranging from capacity gaps, human resource deficiency, lack of critical legal and institutional infrastructure, rampant corruption and a conflictual relationship with the national government. The net effect of these challenges is the stagnation of healthcare and even a reversal of some gains according to health indicators. No doubt what is needed to guarantee an all-inclusive rights-based approach to health service delivery is its proper institutionalization to ensure good governance and effective community participation. This must however be accompanied by wider governance reforms as envisaged in the new constitution for the sustainability of Healthcare Reforms. Key Words : Devolution, Healthcare Delivery, Healthcare Financing, Health Workforce, health governance.
BACKGROUND: Universal Health Coverage (UHC) has emerged as a major goal for health care delivery in the post-2015 development agenda. It is viewed as a solution to health care needs in low and middle countries with growing enthusiasm at both national and global levels. Throughout the world, however, the paths of countries to UHC have differed. South Africa is currently reforming its health system with UHC through developing a national health insurance (NHI) program. This will be practically achieved through a decentralized approach, the district health system, the main vehicle for delivering services since democracy. METHODS: We utilize a review of relevant documents, conducted between September 2014 and December 2015 of district health systems (DHS) and UHC and their ideological underpinnings, to explore the opportunities and challenges, of the district health system in achieving UHC in South Africa. RESULTS: Review of data from the NHI pilot districts suggests that as South Africa embarks on reforms toward UHC, there is a need for a minimal universal coverage and emphasis on district particularity and positive discrimination so as to bridge health inequities. The disparities across districts in relation to health profiles/demographics, health delivery performance, management of health institutions or district management capacity, income levels/socio-economic status and social determinants of health, compliance with quality standards and above all the burden of disease can only be minimised through positive discrimination by paying more attention to underserved and disadavantaged communities. CONCLUSIONS: We conclude that in South Africa the DHS is pivotal to health reform and UHC may be best achieved through minimal universal coverage with positive discrimination to ensure disparities across districts in relation to disease burden, human resources, financing and investment, administration and management capacity, service readiness and availability and the health access inequalities are consciously implicated. Yet ideological and practical issues make its achievement problematic.