Gloria Benny, Jaison Joseph, Hari Sankar, Devaki Nambiar
Abstract Background Palliative care needs are increasing in India, but access remains limited. Kerala is a notable exception, with a widely developed community-based, home-based palliative care approach. Its development coincided with governance reforms, particularly the Peopleâs Planning Campaign (PPC) in 1996, which decentralisation by transferring planning responsibility, decision space, and financial authority to Local Self-Governments (LSGs), while expanding participation in priority-setting. Although Keralaâs palliative care outcomes are well documented, less is known about how decentralised institutions, political priorities, and local histories supported the modelâs emergence and scale-up. This study examines how LSG-level decentralisation created conditions for initiatives, what mechanisms sustained them, and how they gained policy legitimacy, from those who witnessed and shaped these developments. Methods We used Witness Seminar (WS) methods, an oral-history approach bringing together people who witnessed or influenced a historical development to reconstruct events and create an archival record. Three WS were held in 2021 with 22 participants from the health department, LSGs, bureaucracy, civil society, and PPC policy spaces. Inductive thematic analysis was applied to English transcripts using ATLAS.ti 9, followed by realist analysis to develop ContextâMechanismâOutcome (CMO) explanations linking decentralisation processes with the evolution of palliative care in Kerala. Results CMO configurations showed how decentralisation created contexts and mechanisms through which palliative care emerged as a community movement and later gained system-level support. The PPC enabled local planning, participation, and ownership, while community-based, volunteer-led home-care programmes developed across several panchayats. LSGs implemented these programmes through government Primary Health Centres transferred under decentralisation. As the value of the model became evident, the state health department scaled up palliative care, with finance and HRH support from the National (Rural) Health Mission proving critical. Conclusion Palliative care came to be viewed by stakeholders as central to health service delivery in Kerala, contributing to the State Palliative Care Policy in 2008. Decentralisation and sustained community participation can generate legitimacy and political commitment to embed such programmes within services. However, durable implementation also requires system-level enablers such as financing, human resources, and administrative support, alongside local relational foundations including trust, leadership, and shared ownership.
Abdu A. Adamu, Kamal A. Ibrahim, Hyelhirra Adamu, Firdausi Umar-Sadiq
Abstract Under Nigeriaâs 2014 National Health Act, the Basic Health Care Provision Fund (BHCPF) was created as a key health financing mechanism to bolster primary healthcare and promote progress towards Universal Health Coverage (UHC). The BHCPF, disbursed through four gateways, has catalyzed important health systems gains, including improved facility financing predictability and the nationwide creation of State Social Health Insurance Agencies. However, persistent bottlenecks, including weak oversight, lax fiduciary controls, poor accountability, and disparities in implementation quality, have constrained progress. These challenges precipitated a comprehensive set of reforms outlined in the 2025 BHCPF guidelines (BHCPF 2.0). These reforms introduce performance-linked disbursement, tiered direct facility financing, capitation-plus payment systems, and strengthened governance structures. Yet policy reform alone does not guarantee equitable and effective implementation, particularly in Nigeriaâs complex, decentralized, and heterogeneous health system. This Commentary argues that institutionalizing implementation research in BHCPFâs governance framework offers a structured, evidence-driven pathway to bridge the gap between reform intent and real-world outcomes. Specifically, implementation research can: build theory-driven understanding of why and how reforms succeed or fail across diverse subnational contexts; monitor implementation fidelity and outcomes during rollout; distinguish necessary adaptations from fidelity drift; and test context-specific strategies to overcome barriers and promote facilitators. Ultimately, country-led, integrated implementation research is essential for fully realizing the transformative potential of BHCPF.
Abstract This chapter maps the scientific production on health policies and systems in Latin America over the past forty years and highlights the main findings on their reforms and the characteristics that shape the various organizational models. Using bibliometric and scientometric techniques, we find a progressive increase in scientific production over the period, a predominance of authorship among Latin Americans themselves, and a lesser prominence of comparative studies in favour of case studies. In contrast, we identify two waves of reform. The first, in the late twentieth century, reinforced co-participation, privatization, decentralization, and segmentation of publics. The second, which began in the 2000s, prioritizes the universalization and extension of primary care, butâdespite advances in expanding financing, coverage, and benefitsâhas not overcome the segmentation of systems and the low integration between levels of health care that still characterize most countries in the region.
Sylvester KyeiâGyamfi, Prince Boamah Abrah, Frank KyeiâArthur
ABSTRACT This study examines how Ghana's decentralized governance system shapes public social welfare service delivery, with a specific focus on the Department of Social Welfare (DSW). In Ghana, decentralization involves the transfer of administrative and fiscal responsibilities for social services from the central government to Metropolitan, Municipal, and District Assemblies, within which the DSW operates. Using a qualitative caseâstudy design, the study purposively sampled 30 national and regional DSW officers (60% male, 40% female). Data were collected through inâdepth interviews and analyzed thematically. The findings reveal three interrelated challenges: role conflicts arising from dual reporting lines, human resource gaps that undermine effective service delivery, and persistent funding and logistical constraints. In response, officers adopted coping strategies such as informal interâagency collaboration, role multitasking, and internal financing mechanisms. Participants proposed reforms including clarifying institutional mandates, professionalizing social welfare practice, securing sustainable budgetary allocations, and introducing digital monitoring systems to enhance accountability. Overall, the study underscores the need for structural reforms to strengthen decentralized social welfare service delivery in Ghana.
This paper examines the impact of decentralization and partial financing of healthcare through local governments (Panchayats) in India on the health status and income of household members. We construct a healthcare and illness dataset from the nationally representative Rural Economy and Demography Survey (REDS) which is comprised of 14,841 adults from 238 villages. Using this dataset, we examine how various forms of decentralization affect the health status, health-seeking behaviour, and welfare of village residents. Choice of public healthcare is shown to have higher welfare impacts compared to other forms of healthcare providers and the out-of-pocket health expenditures. We show that individuals react not only to the supply-side measures by federal and state governments, but also to mechanisms of decentralized health governance. We also demonstrate that efficient choices concerning healthcare made by household members contribute significantly to the village-level economic activity. The traditional instrumental variable estimates are robust to post-double-selection LASSO specifications.
Abstract Background Tanzaniaâs Direct Health Facility Financing (DHFF) reform was introduced to strengthen primary health care through decentralized financing, autonomy, and accountability, but persistent weaknesses in monitoring and evaluation (M&E) data management and use continue to constrain implementation effectiveness, particularly in rural settings. Methods A convergent mixed-methods design was used to examine how M&E data management and use influence DHFF implementation effectiveness in an urban council (Kinondoni Municipal Council, KMC) and a rural council (Morogoro District Council, MDC), while also assessing the role of stakeholder perceptions of the DHFF M&E framework and contextual variation. Quantitative data were analyzed using descriptive statistics, relative importance indices, regression and ANOVA, while qualitative data from key informant interviews and focus group discussions were thematically analyzed and triangulated with quantitative results. Results Of 233 respondents analysed, 51.1% were from Morogoro District Council, 48.9% from Kinondoni Municipal Council, 51.2% worked in rural settings, 42.9% were from health centres, and 38.2% from dispensaries, providing an analytically useful spread across managerial and frontline contexts relevant to DHFF implementation. Descriptive statistics showed generally favourable perceptions across the five major constructs, with mean scores ranging from 3.09 for M&E capacity to 3.73 for urban-rural M&E practice context, while DHFF implementation effectiveness scored 3.71 overall. Data quality checks showed acceptable factor loadings above 0.4, reliability coefficients above 0.7, bivariate correlations of 0.34-0.76, and VIF values of 1.31-2.95, indicating that the dataset was screened, cleaned and analytically fit for regression and ANOVA modelling. In the aggregated model, the explanatory variables jointly accounted for about 52% of the variation in DHFF implementation effectiveness, with M&E data management and use, stakeholder perceptions of the DHFF M&E framework, and urban-rural context emerging as the most influential predictors. Qualitative testimonies clarified these patterns: one council respondent explained, âWe have DHIS2⊠GoTHOMIS⊠FFARS⊠also PlanRep,â while another facility respondent observed, âWe only add up numbers for the monthly reportâwe donât really analyze what they mean,â illustrating the contrast between data availability and meaningful local use. Conclusions DHFF implementation effectiveness in Tanzania depends substantially on robust M&E data management and use, supportive stakeholder perceptions of the M&E framework, and context-sensitive strategies that address persistent urbanârural inequities. Strengthening technical capacity, digital infrastructure, participatory governance and feedback systems is essential for sustaining DHFF gains and improving equitable service delivery.
Abstract Background Ethiopia has pursued Health Care Financing (HCF) reforms for over two decades as part of its commitment to achieving Universal Health Coverage (UHC). With a health policy anchored in Primary Health Care (PHC) and a decentralized planning framework, the country has introduced numerous interventions to strengthen domestic resource mobilization, enhance autonomy at service delivery points, and build local capacity. Methods This study analyzes PHC budget allocation and expenditure trends in 15 woredas across five regions from 2010 to 2016, using mixed methods. Results Financing of the HSS-PHC system yielded a performance score of 29%, indicating significant challenges in resource allocation and financial management. Two key indicators determined this: Funding and allocation of resources (14%) and purchasing and payment systems (39%). While nominal health budget allocations have increased over time, real-term values adjusted for the non-food consumer price index have declined. The average PHC spending represented 17.3% of general government expenditureâexceeding the Abuja Declaration targetâyet regional disparities were notable, ranging from 9% to 26.4%. Persistent challenges, especially in CBHI implementation, exempted service reimbursement, and provider-level autonomy, were particularly pronounced in pastoralist regions. Conclusions Inadequate budget allocation from the treasury, the expanding need of communities, shocks from different emergencies, and high inflation rates in recent years have led to widening gaps in health financing. Alternative financing mechanisms (CBHI) didnât catch up with the widening gap because of inadequate implementation, low potential as a financing strategy due to low premium rates, and lack of mechanisms to enforce reimbursement of health facilities. These findings underscore the need to reinforce public financial management and leadership capacity at district and facility levels to ensure more equitable, efficient, and transparent PHC financing.
Ezinne Victory Kanu, Charles Chibuisi Ehiemere, Ishaku Adamu Akyala, Eric Terkuma Chia · 5 authors
Despite global commitments under SDG-3, maternal mortality rates remain disproportionately high in Sub-Saharan Africa. This review examines how health policies have shaped outcomes between 2014 and 2024 in Nigeria, Rwanda, South Africa, and Gabon. A comparative narrative review was conducted using WHO, World Bank, UNFPA, DHS, and national policy documents. Guided by the Walt & Gilson Policy Triangle and the WHO Health System Building Blocks, policies were assessed for context, content, actors, process, and health system capacity. Data were synthesized thematically to compare implementation and outcomes. Rwanda achieved substantial declines through decentralized financing, performance-based funding, and community health worker integration. South Africa reduced deaths via integration of HIV and maternal services but still faces equity gaps. Gabon improved financial access but rural infrastructure and workforce limitations constrain outcomes. Nigeriaâs fragmented governance and weak PHC financing explain stagnation despite multiple reforms. Implementation quality, not policy presence, drives progress. Strengthening governance, financing transparency, workforce readiness, and community engagement remains crucial for achieving SDG-3. This study highlights cross-country lessons transferable to similar contexts.
BACKGROUND: Noncommunicable diseases (NCDs), including hypertension and diabetes, account for approximately 27% of all deaths in Kenya, with 26% of adults having elevated blood pressure. Despite devolution of health services to county governments in 2013, financing for NCD management at the primary health care (PHC) level remains weak. This study examines financial determinants shaping hypertension and diabetes care in PHC facilities within a devolved county health system in rural Kisumu County, Kenya. METHODS: We conducted a convergent parallel mixed-methods cross-sectional study in seven public PHC facilities in Seme Sub-County, providing new facility-level evidence on how the interaction between devolutionâs financing architecture, facility-level financial autonomy constraints, and resource allocation mechanisms shapes chronic disease care effectiveness in rural Kenya. Quantitative data were collected via structured questionnaires and retrospective document review of financial records (JanuaryâAugust 2024). Qualitative data were gathered through key informant interviews (n = 7) with facility in-charges exploring planning, budgeting, and resource allocation. Descriptive statistics were produced in STATA v16; qualitative data were analyzed thematically in R. RESULTS: All seven facilities prepared annual workplans and budgets, but none achieved comprehensive NCD-specific planning (workplan + budget + dedicated NCD budget line). Funding sources were narrow: 71.4% (n = 5) of the facilities depended on NHIF reimbursements and donor support, while only 28.6% (n = 2) received direct county funding; 57.1% (n = 4) of the facilities relied on only two funding streams. Although all facilities held bank accounts, none had formal financial autonomy and expenditures required county-level approval, typically taking 3â4 weeks (57.1%, n = 4) to over two months (28.6%, n = 2). Combined with unreliable central supplies, this lack of autonomy meant facilities could not procure locally when stockouts occurred; consequently 85.7% (n = 6) of the facilities reported frequent medication stockouts. Facility in-charges attributed these failures to inadequate, unpredictable funding and centralized approval processes that prevented timely local procurement. CONCLUSIONS: Rural PHC facilities operate under structural governance failures in Kenyaâs devolved health financing system that systematically undermine effective NCD care. The centralization of financial authority at county level, absence of ring-fenced NCD budgets, and misalignment between planning processes and resource allocation represent system-level policy contradictions rather than facility-level operational deficiencies. Addressing these governance failures requires not only increased funding but constitutional fiscal decision-space for facilities, mandatory NCD budget protection, and reformed disbursement mechanisms essential for equitable chronic care under Kenyaâs UHC agenda. The sustainability of chronic care depends fundamentally on facility decision space, not only on funding volume. These findings are transferable to other Kenyan counties under the same devolved framework and to decentralized health systems in sub-Saharan Africa facing similar tensions between fiscal accountability and operational autonomy for chronic disease management.
BACKGROUND Indiaâs health systems reform journey has been marked by institutional innovations that have reshaped service delivery, governance, financing, and beyond. Among these, a foundational yet often overlooked innovation is the creation of a structured ecosystem for health policy guidance: a network of State Health Systems Resource Centres (SHSRCs), supported by the National Health Systems Resource Centre (NHSRC). These institutions were not intended as parallel implementation units. Rather, they were envisioned as embedded policy advisory bodies that are intended to synthesize evidence, support strategic planning, and enable system-wide reforms. While NHSRC continues to serve as the apex technical institution supporting the Ministry of Health and Family Welfare (MoHFW), the SHSRCs were designed to play a decentralized and synergistic role within states. However, they remain variably recognized and underutilized. Unlocking their full potential could substantially enhance the capacity for state-level, evidence-informed decision-making and strategic design. AN INSTITUTIONAL DESIGN WITH PURPOSE Established in 2007, NHSRC functions as the principal technical support agency for MoHFW, with a mandate that includes policy and strategy development, technical assistance to states, and capacity building under the National Health Mission (NHM). Over time, it has played a pivotal role in institutionalizing quality improvement processes, advancing health financing reforms, guiding human resource strategies, strengthening secondary care and governance, innovations in community processes, and improved primary health care. Its enhanced role over the past 5 years, particularly through expanded expertise in evidence generation, implementation research, and the information technology realm, has been well appreciated and acknowledged. The SHSRCs, supported under the NHM and guided by NHSRC, were first envisioned under the National Rural Health Mission as in-house technical institutions to support health systems strengthening and policy development, particularly in the Empowered Action Group states.[1] However, their formation varies widely. Maharashtra and Madhya Pradesh, for instance, have established autonomous SHSRCs with independent governance and operational flexibility. Others, like Kerala, have adopted a fully embedded model within the state health department, with no legal autonomy but strong proximity to decision-making. Gujarat has adopted a hybrid approach, combining knowledge management cells, technical support functions, and programmatic units aligned with NHM priorities. In Chhattisgarh, the model transitioned from a registered society to an outsourced publicâprivate partnership structure. Newer entrants like Meghalaya illustrate growing development partner involvement in SHSRC functions through philanthropic support. In the absence of a unified design, this diversity has led to fragmentation in roles, mandates, and institutional identity. To address this, the MoHFW released a national SHSRC Framework in 2024, formalizing key principles of governance, technical leadership, and accountability.[2] The framework aims to guide states in repositioning SHSRCs as embedded policy support institutions that are context-specific yet aligned with national health priorities. AN UNEVEN LANDSCAPE OF UTILIZATION Despite the clarity of this institutional design, the operational landscape of SHSRCs across India remains uneven. While some centers have emerged as credible partners to their state governments, others face challenges ranging from intermittent staffing and fragmented mandates to unclear positioning within state bureaucracies. In several instances, donor-funded Technical Support Units (TSUs) have taken on overlapping roles. These arrangements may address immediate programmatic needs but often lack the institutional continuity, embedded authority, and public accountability required for long-term reform.[3] Overreliance on donor-funded TSUs risks fragmenting institutional ownership and accountability, weakening the stateâs own capacity to generate and use evidence for policy guidance. Recognizing these risks, NHSRC has begun working with state governments to revitalize SHSRCs and help align them with national and state-level priorities, while safeguarding their role as government-owned and state-anchored policy advisory bodies. EARLY EVIDENCE OF WHAT WORKS Where SHSRCs have been clearly institutionalized, their contributions to health policy and systems strengthening are evident. In Chhattisgarh, SHSRC was central to the design and implementation of the Mitanin program, which later became the foundation for the national ASHA model. Its positioning as a public, in-house technical agency enabled long-term continuity, responsiveness to state-specific challenges, and innovation uptake.[4] In Odisha, the SHSRC has supported district health planning, capacity building, and institutional development initiatives across program areas. In Tamil Nadu, it has supported quality assurance mechanisms and monitoring systems within the health department. These cases suggest that, when adequately structured and supported, SHSRCs can serve as trusted intermediaries that connect evidence, program strategy, and systemic reform. STRENGTHENING SHSRCS FOR HEALTH POLICY GUIDANCE For SHSRCs to fulfil their intended role as policy advisory institutions, four strategic actions are necessary. First, states must clearly define the mandate and governance of SHSRCs based on the MoHFWâs framework. This includes formalizing their distinct identity from TSUs, clarifying reporting structures, and embedding them within state health departments with a long-term vision. Second, sustainable financing should be assured through NHM provisions to reduce dependence on external actors. While TSUs may continue to serve specialized programmatic functions, they should not be equated as substitutes for in-house capacity. Third, investment in technical leadership and multidisciplinary staffing is essential. SHSRCs must attract professionals across epidemiology, public finance, implementation research, health systems, and data analytics. These are all disciplines critical to robust policy guidance. Establishing leadership structures that ensure continuity and accountability will further enhance operational coherence and effectiveness. Fourth, SHSRCs should continually expand their engagement with emerging health system interventions and institutionalize mechanisms. This includes supporting research, evaluation, and evidence-based decision-making. Their potential as platforms for resource optimization and collaboration with academic and public health institutions remains significantly underleveraged. NHSRC, through its existing mandate, can continue to play a catalytic role in this transformation by facilitating peer learning, technical handholding, and capacity strengthening. A STRATEGIC ASSET FOR THE NEXT PHASE OF REFORM As India deepens its health system reforms through initiatives such as Ayushman Bharat, and ongoing programme interventions under NHM, the need for decentralized, embedded policy guidance becomes more urgent. SHSRCs are already positioned to fulfil this role, not as supplementary structures but as enduring public institutions grounded in local systems and aligned with national goals. The imperative now is not to create new structures but to recognize and invest in the institutional capacities already in place. Authorsâ contributions Maj. Gen. (Prof) Dr Atul Kotwal: Conceptualization; Writing â Original Draft, Writing â Review and Editing; Supervision. Dr Tarannum Ahmed: Conceptualization; Writing â Original Draft, Writing â Review and Editing. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest to declare.
Results-Based Financing (RBF) has been promoted as an innovative health financing mechanism to improve service delivery and health outcomes in low-resource settings. However, evidence on its impact within devolved health systems remains limited. This study examines how RBF influences key performance indicators (KPIs) in Zambia's devolved district health services. An embedded multiple-case study was conducted across 12 districts in Northern Province, Zambia. Mixed methods were employed, combining qualitative interviews with 44 stakeholders and quantitative analysis of health facility data. The study focused on maternal and child health indicators, service utilization patterns, and health worker motivation following RBF implementation. RBF implementation was associated with improvements in several KPIs: maternal health outcomes (100% of facilities reported improvements), medicine availability (91%), and the quality of primary healthcare services (67%). Health worker motivation increased, with 42% agreeing and 24% strongly agreeing that RBF positively affected service delivery. Community-based volunteers responded positively to incentive structures. However, challenges included delayed fund disbursement (91.7% reported), inadequate funding (83.3%), and monitoring gaps (50%). RBF can enhance key health indicators in devolved systems when properly designed and implemented. Success depends on timely incentive disbursement, robust monitoring systems, and integration with existing community health structures. The study provides evidence for policymakers considering RBF scale-up in decentralized health systems.
Open access
Global Maternal and Child Health
Health Systems, Economic Evaluations, Quality of Life
Zambia has implemented significant health-sector decentralization since 1992, culminating in the devolution of district health services to local authorities under the 2016 Constitutional Amendment. Results-Based Financing (RBF) has been piloted as a performance incentive mechanism, but its institutionalization within devolved structures remains largely unexplored. This study explores the opportunities and challenges of embedding RBF within Zambia's devolved health system, with a focus on Northern Province. A qualitative case study design was used, involving forty-four participants from twelve districts. Purposive sampling selected health workers from provincial and district health offices, local authority representatives, and national stakeholders. Data collection included semi-structured interviews, document reviews, and observations, with thematic analysis conducted using NVivo 9. Most respondents (82%) reported involvement in RBF implementation, and fifty-three% believed that increased Constituency Development Fund (CDF) allocations improved district health services. Key benefits cited were increased accountability (81.8%) and greater community participation (77.3%). Challenges included insufficient funding (83.3%), delays in disbursing funds (91.7%), and limited understanding among local authority implementers. Infrastructure development and procurement of medical equipment were identified as primary areas for CDF improvements (56%). Respondents also agreed (53%) that the Ministry of Health and the Ministry of Local Government would support the institutionalization of RBF. Effective integration of RBF into devolved systems requires harmonizing policies between health and local government ministries, building capacity within local authorities, and aligning RBF with other domestic financing mechanisms, such as CDFs. A phased approach to integration, with clearly defined governance structures, is recommended to ensure sustainable scaling.
Open access
Global Maternal and Child Health
Primary Care and Health Outcomes
Health Systems, Economic Evaluations, Quality of Life
Lukman Ademola Adepoju, Oyetunji Oyewale, Odekunle Bola Odegbemi, Ifeoluwa Abraham Adeagbo · 5 authors
Over 40 years after the identification of human immunodeficiency virus (HIV), Nigeria remain one of the highest burdens of HIV infections in the world, accounting for almost 10% of new infections in sub-Saharan Africa. Despite significant investments and technical supports from different foreign donors including the United States Presidentâs Emergency Plan for AIDS Relief (PEPFAR), the Global Fund, and bilateral partners. The persistent structural, financial, and programmatic gaps continue to hamper the countryâs HIV response. This assessment of HIV-related interventions in Nigeria examines what has been achieved, what still need to be done, and how to establish a sustainable and domestically owned HIV care. The review summarizes evidence from peer-reviewed literature (2018â2025) and major institutional reports (UNAIDS, NACA, WHO, PEPFAR) to assess five key domains: coverage and access, funding and sustainability, health system strengthening, monitoring and evaluation, and sociocultural barriers. Evidence shows that while substantial progress has been achieved in testing, antiretroviral therapy (ART) coverage, and community-based care, the HIV response remains heavily donor-dependent, urban-centered, and fragmented across vertical program streams. The review concludes that to achieve long-term epidemic control (EC) and universal health coverage (UHC) in Nigeriaâs HIV care and programming with there is a need for domestic financing, health system integration, decentralized service delivery, and data-driven accountability frameworks.
Dr Muâazu Omeiza Musa, Professor Olugbenga-Bello Adenike, MBBS, PhD, Adah Patrick Eneojo, Dr Onoja-Alexander Mary Ojonema, MBBS, PhD FWACP · 7 authors
Strengthening Primary Health Care (PHC) financing, governance, and operational readiness is fundamental to achieving resilient health systems and sustainable health security in low- and middle-income countries. Between 2022 and 2025, the Kogi State Government implemented a package of PHC reforms comprising Decentralized Facility Financing (DFF), the Minimum Service Package (MSP), and Continuous Quality Improvement (CQI) interventions to improve service delivery, strengthen facility readiness, stabilize commodity supply systems, and expand equitable access to vulnerable and hard-to-reach populations. We evaluated the Health Systems for Health Security success coefficients in Kogi State using a facility month DHIS2 panel of n=96 PHCs (January 2019âDecember 2025) and BHCPF Monthly Report Forms (2024â2025). The quasi experimental mixed methods design combined an augmented two way fixed effects Difference in Differences (DiD) estimator for average treatment effects, Interrupted Time Series (ITS) segmented regression to decompose immediate (level) and sustained (slope) impacts, multilevel mixed effects models for heterogeneity, and bootstrap causal mediation to quantify operational pathways. Models adjusted for seasonality, HRH density, environmental risk, and facility fixed effects; inference used cluster robust standard errors and bootstrap confidence intervals. Primary analysis used R (4.3.2) with lme4, fixest, brms/rstanarm, INLA, MatchIt/WeightIt, CausalImpact, sf, spdep; confirmatory DiD and event study checks used Stata/MP 18.0. All code was versioned in Git and analysis notebooks and key outputs were archived. DFF with CQI produced statistically and programmatically meaningful gains across core BMPHS indicators: DPT3 +6.2 percentage points (95% CI 3.9â8.5); ANC1 +5.1 pp (95% CI 2.8â7.4); SBA +4.8 pp (95% CI 1.9â7.7); PNC +4.3 pp (95% CI 1.6â7.0). ITS decomposition for DPT3 showed an immediate level increase of +3.7 pp (95% CI 1.9â5.5) and a sustained slope of +0.12 pp/month (95% CI 0.06â0.18). Mediation analysis attributed large shares of the DPT3 gain to facility readiness, functional Ward Development Committees, tracer drug availability, and IPC compliance as the largest contributors. Predictable facility financing coupled with CQI and targeted investments in readiness, governance, and supply chain resilience yields rapid and sustained improvements in immunization and maternal health coverage. Policy priorities include protecting cold chain and tracer drug lines, institutionalizing WDC governance and IPC audits, and targeting surge HRH and outreach financing to high risk LGAs to close equity gaps. The findings demonstrate the predictability of decentralized financing combined with CQI, governance strengthening, outreach expansion, and operational readiness investments towards the improvement of PHC utilization, immunization coverage, maternal health services, and health system resilience. The study provided epidemiologic evidence to test integrated PHC financing reforms relevance in the strengthening of Health Systems for Health Security (HSFORSHS) in improving accessibility, equity, preparedness, surveillance functionality, and continuity of essential services in vulnerable populations.
Nigeria continues to face one of the highest maternal mortality burdens globally, a situation that is closely linked to the low utilization of essential maternal and child health services. To address this challenge, the Nigeria State Health Investment Project (NSHIP) introduced two innovative financing mechanisms Performance-Based Financing (PBF) and Decentralized Facility Financing (DFF) aimed at improving the performance of primary healthcare facilities. This study compared the effectiveness of these financing approaches in enhancing service utilization while accounting for the selection bias commonly associated with non-experimental research designs. The study adopted a retrospective quantitative approach and analyzed data from 216 Primary Health Care (PHC) facilities located in Adamawa, Nasarawa, and Ondo States between 2022 and 2025. Propensity Score Matching (PSM) was used to create comparable groups of facilities based on important characteristics such as staffing levels and bed capacity. Thereafter, Analysis of Covariance (ANCOVA) and Welchâs ANOVA were employed to examine differences in service utilization across key maternal and child health indicators, including Outpatient Department (OPD) attendance, Antenatal Care (ANC) visits, Skilled Deliveries, Family Planning (FP) uptake, and Complete Vaccination Coverage (CVC). The results revealed that facilities operating under the PBF model consistently recorded higher utilization rates than those supported through DFF in several critical service areas. Specifically, PBF facilities achieved significantly better outcomes in OPD attendance (Mean Difference = 3,276; p < .01; Partial Eta Squared = 0.19), Skilled Deliveries (Mean Difference = 322; p < .001; Partial Eta Squared = 0.34), and Family Planning uptake (Mean Difference = 1,180; p < .001; Partial Eta Squared = 0.36). These findings indicate that PBF had a substantial positive influence on services that require active provider engagement and community mobilization. In contrast, no statistically significant difference was found between PBF and DFF in Complete Vaccination Coverage (p = .70), suggesting that both financing approaches were equally effective in supporting routine immunization services. The study concludes that PBF offers a clear advantage for demand-driven maternal and reproductive health services, whereas DFF provides comparable results for supply-driven programmes such as routine immunization. These findings highlight the importance of adopting a differentiated financing strategy within Nigeriaâs primary healthcare system. Rather than relying on a single financing model, policymakers should consider a hybrid approach that combines the strengths of both PBF and DFF to maximize health outcomes while ensuring efficient use of available resources. However, as this study focused solely on service volumes, future research is recommended to evaluate the impact of these financing models on clinical quality of care, maternal mortality outcomes, and cost-effectiveness across broader geographic settings.
Adah Patrick Eneojo, Olorunmaiye Theophilus, Dr Emmanuel Bola Jonah K, Adah William Arome · 7 authors
Uptake of the Basic Minimum Package of Health Services (BMPHS) in Kogi State has been limited by supplyâside constraints, demandâside barriers, and placeâbased vulnerabilities concentrated in riverine and rural LGAs. The IMPACT rollout (2022â2025) combined Decentralized Facility Financing (DFF) with bundled Continuous Quality Improvement (CQI) supports to strengthen facility responsiveness, stabilize commodities, and expand outreach. We used a quasiâexperimental, mixedâmethods design on a facilityâmonth DHIS2 panel (2019â2025; n = 96 PHCs). Quantitative inference triangulated three counterfactual generators: augmented twoâway fixedâeffects DifferenceâinâDifferences (DiD) for average effects, Interrupted Time Series (ITS) segmented regression to decompose immediate (level) and sustained (slope) impacts, and facilityâlevel counterfactuals via synthetic control and matrix completion for robustness. Multilevel mixedâeffects models estimated heterogeneity; causal mediation (bootstrap, 5,000 sims) quantified pathways (coldâchain uptime, outreach frequency, commodity availability). Qualitative interviews and supervision records explained fidelity and contextual moderators. Costing used activityâbased methods with probabilistic sensitivity analysis. DFF plus CQI produced both rapid operational gains and durable system strengthening. Primary policyârelevant estimates: DiD DPT3 +6.2 percentage points, ITS immediate level change αâ = +3.7pp, and ITS slope αâ = +0.12 pp/month. Mediation attributed ~41% of the DPT3 gain to improved coldâchain uptime; outreach and commodity availability explained large shares of ANC1 and IPTp3 gains. Results are robust across laggedâoutcome DiD, matrix completion, generalized synthetic control, eventâstudy checks, and autocorrelation corrections. Costâeffectiveness benchmarks show programâlevel ICERs consistent with high probability of value for money for composite BMPHS gains. To maximize equitable BMPHS gains, prioritize coldâchain resilience, predictable and timely disbursements, and earmarked outreach financing for highâenvironmentalârisk LGAs. Embed both the ITS level (αâ) and slope (αâ) as complementary KPIs in routine dashboards: αâ signals rapid operational fixes; αâ signals durable system strengthening. Scaleâup should pair DFF with CQI, protected commodity lines, and contextâsensitive outreach modalities to sustain and equitably distribute gains.
The research focuses on the mechanisms, challenges, and consequences that UHC reform in Kenya has, conceptualizing UHC as a long-term government policy project that cuts across the governance, financing, and state capacity nexus. Based on theoretical frameworks of policy learning, incrementalism, and institutional capacity, the article evaluates the effects of Kenya's devolved system of health and strategic purchasing mechanism on UHC implementation and equity outcomes. Using qualitative policy analysis of government reports and academic publications, the research unveils structural constraints of the social health insurance program over time, the presence of inequalities in the delivery of services, and constraints of governance that mitigate the effects of reforms. These results bring into focus the necessity to strengthen the institutional capacity, strategic purchasing, and intergovernmental mobilization to achieve equitable and sustainable UHC. The article is a policy theory contribution to intricate social reforms through the way in which iterative policy learning and governance structure frame reform paths in a lower- and middle-income setting.
Introduction: The decentralization of Subdistrict Health Promoting Hospitals (SHPHs) to Provincial Administrative Organizations (PAOs) in Thailand represents a significant structural reform with direct implications for nurses working in primary healthcare settings. This study aimed to develop a competency model for nurses employed in SHPHs under PAO jurisdiction, ensuring alignment with decentralization policies and local health system needs. Methods: A mixed-methods design was used in 2 phases. Phase 1 employed qualitative methods to explore current nursing roles through in-depth interviews and thematic analysis. Phase 2 involved developing the competency model using quantitative data and the Delphi technique with expert consensus. Results: Findings from phase one indicated that nurses continue to play a vital role in community-based health promotion and care for vulnerable populations. Following decentralization, nurses have adapted to new responsibilities involving local workforce coordination, budgeting, and health information systems, necessitating expanded competencies. The competency model delineates stratified expectations by facility size: small SHPHs require generalist proficiency for autonomous service delivery; medium SHPHs necessitate specialized and collaborative competencies for programmatic functions; and large SHPHs demand advanced skills in systems management, strategic planning, and specialized care to align with institutional complexity. Conclusion: Although nursesâ core responsibilities in primary care remain central, decentralization has introduced new demands requiring advanced clinical, technological, data management, and interprofessional collaboration competencies. These expanded roles have strengthened nursesâ contributions to local health governance under the PAO system.
Decentralization is widely promoted as a governance reform to improve efficiency, accountability, and responsiveness in public service delivery, particularly in the health sector. In Pakistan, the 18th Constitutional Amendment of 2010 marked a significant shift in governance by devolving health sector responsibilities from the federal government to provincial governments. This reform substantially transformed Public Financial Management (PFM) arrangements in the health sector, affecting budgeting, expenditure control, and accountability mechanisms. This paper examines the impact of decentralization on health sector PFM in Pakistan by situating the reform within broader theoretical and empirical literature. It analyzes changes in health financing, governance, and service delivery outcomes while identifying persistent institutional and fiscal challenges. The study argues that although decentralization has enhanced provincial autonomy and policy responsiveness, weaknesses in public financial management capacity, coordination, and equity continue to limit its effectiveness. Strengthening PFM systems is therefore essential for translating decentralized governance into improved health outcomes in Pakistan.
The decentralization of Emergency Medical Services (EMS) to local administrative organizations is a critical policy initiative in Thailand aimed at enhancing service responsiveness and community participation. This study applied a prospective Health Impact Assessment (HIA) to identify positive and negative health impacts of EMS decentralization in Chonburi Province and develop evidence-based policy recommendations to guide the transition from the Ministry of Public Health to local governance. A mixed-methods approach was designed based on the six-step HIA framework. The study involved 562 participants, including EMS providers, recipients, and policymakers. Qualitative participants were selected through purposive sampling for interviews and focus groups, and quantitative participants through stratified random sampling for surveys. Qualitative data were thematically analyzed, and quantitative data were analyzed descriptively. Findings revealed both positive and negative impacts across four pre-hospital care activity domains (dispatch, incident response, referral, and administrative management) and four dimensions of well-being (physical, mental, social, and spiritual). Positive impacts included improved responsiveness, collaboration, and staff motivation, while negative impacts involved personnel shortages, communication gaps, and limited budgets. The derived policy recommendations emphasize structured workforce planning, upgraded communication systems, sustainable financing, and participatory monitoring to strengthen decentralized EMS. The use of HIA provided a systematic and participatory process that translated empirical evidence into actionable policy guidance for health service decentralization in Thailand and similar contexts.
The withdrawal of the USA from the World Health Organization and the freeze on USAID are among the major events in the realm of U.S. foreign policy under the U.S. president. Within his broader âAmerica Firstâ policy, aimed at reducing the U.S.âs international commitments and rethinking its role in global organizations and foreign aid, this review attempts to make a case for Africa by examining the implications of recent reductions in U.S. funding. We conducted a comparative case study of Nigeria, Ghana, Zambia, and Rwanda, selected for their aid volume, exposure to disruption events, and availability of outcome data. Using process tracing and critical narrative synthesis, we analyzed policy documents, expenditure reports and peer-reviewed studies to assess how each country responded to aid disruptions and what structural factors shaped their resilience or fragility. Three dominant patterns emerged: acute service interruptions (Nigeria, Zambia), structural fragmentation (Ghana), and resilient adaptation (Rwanda). Key drivers of vulnerability included overreliance on tied aid, SAP-era health system legacies, and underdeveloped domestic financing mechanisms. Rwandaâs ability to maintain high ART coverage and reduce malaria deaths by 88% during funding cuts reflects a deliberate break from aid dependency through community-based insurance, decentralized governance, and regional procurement strategies. Donor transitions are not neutral events; they expose and exacerbate pre-existing structural weaknesses. Current models that frame aid withdrawal as empowerment risk, replicating past harm unless coupled with institutional reform and reciprocal accountability. This study suggests assessing transition readiness and reorienting global health partnerships toward equitable, resilient, and sovereign systems.