Helenitta Melo da Silva Alves, Juliana Reis de Alcantara, Simonia Mara De Oliveira, Karen de Fátima Figueroa Bohórquez · 8 authors
Brazil's Unified Health System (Sistema Único de Saúde-SUS) represents one of the world's largest publicly funded universal healthcare systems, providing comprehensive healthcare services to more than 200 million citizens. Established through the 1988 Federal Constitution and regulated by subsequent legislation, the SUS is founded on the principles of universality, comprehensiveness, equity, decentralization, regionalization, and social participation. These principles have enabled substantial advances in health indicators, expanded access to essential services, and reduced historical inequalities in healthcare provision. Nevertheless, the system currently faces increasingly complex challenges associated with demographic transitions, epidemiological changes, chronic underfunding, regional disparities, technological innovation, workforce shortages, judicialization of healthcare, and the growing demand for high-cost medical technologies. This academic essay critically examines the constitutional principles underlying the SUS and analyzes the contemporary barriers that threaten the effective realization of universal access to healthcare in Brazil. By integrating theoretical discussions with institutional and policy perspectives, the essay explores how structural, political, economic, managerial, and demographic factors influence the sustainability of universal health coverage. The discussion also reflects upon future strategies capable of strengthening governance, financing, digital transformation, and public management while preserving the constitutional commitment to health as a fundamental social right.
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 People’s 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 Kerala’s palliative care outcomes are well documented, less is known about how decentralised institutions, political priorities, and local histories supported the model’s 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 Context–Mechanism–Outcome (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 Nigeria’s 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 Nigeria’s complex, decentralized, and heterogeneous health system. This Commentary argues that institutionalizing implementation research in BHCPF’s 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.
José Ângelo Machado, Natália Guimarães Duarte Sátyro, Ana Luiza Martins de Medeiros
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, but—despite advances in expanding financing, coverage, and benefits—has not overcome the segmentation of systems and the low integration between levels of health care that still characterize most countries in the region.
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.
Background: Early childhood caries remains a major public health burden in Thailand, particularly among preschool children, despite the implementation of national oral health policies. With the decentralization of child development centers (CDCs) to local adminis-trative organizations (LAOs), understanding system-level determinants of oral health ser-vice effectiveness has become critical. This study aimed to identify key determinants in-fluencing the effectiveness of oral health care systems for preschool children within CDCs in northeastern Thailand. Methods: A cross-sectional analytical study was conducted among 270 stakeholders across urban, peri-urban, and rural CDCs in Ubon Ratchathani Province. Participants were selected using multi-stage random sampling. Data were col-lected between November 2023 and January 2024 using a structured questionnaire with established content validity (IOC > 0.50) and reliability (Cronbach’s alpha = 0.71–0.77). Variables were organized within an Input–Process–Output (IPO) framework. Descriptive statistics, Pearson’s correlation, and multiple linear regression analyses were performed to identify significant predictors of system effectiveness. Results: The oral health care system demonstrated strong performance in preventive service delivery, including universal oral health examinations and fluoride varnish application (100%), and high personnel readi-ness (99.63%). However, critical gaps were identified in monitoring and evaluation sys-tems (8.15%), budget adequacy (60.37%), and continuity of treatment follow-up (48.89%). The prevalence of dental caries among preschool children was 57.83%. Multiple regression analysis revealed that service delivery processes (β = 0.458, p < 0.001) and home visits by public health and dental personnel (β = 0.303, p = 0.008) were significant determinants of system effectiveness, jointly explaining 11.1% of the variance (R² = 0.111). Conclusions: The effectiveness of preschool oral health care systems in decentralized settings is driven pri-marily by the quality of service delivery processes and the integration of proactive commu-nity outreach through home visits. Strengthening monitoring and evaluation mechanisms, ensuring sustainable financing, and enhancing continuity of care between CDCs and households are essential for improving oral health outcomes. These findings provide ac-tionable evidence for policymakers and local health administrators seeking to optimize oral health systems under decentralized governance structures.
Abstract Background Tanzania’s 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, “We have DHIS2… GoTHOMIS… FFARS… also PlanRep,” while another facility respondent observed, “We only add up numbers for the monthly report—we don’t really analyze what they mean,” 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 urban–rural 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 expenditure—exceeding the Abuja Declaration target—yet 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) didn’t 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.
Background: The Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) is the largest publicly financed health insurance program globally, covering over 12 crore vulnerable families in India. The program empaneled hospitals throughout the country, both government and private. Within the geographical boundaries of a state, State Health Agencies (SHAs) have administered the scheme, however hospitals run by various Government of India (GoI) ministries (e.g., Railways, Defence, Labour/ESIC, Coal, Steel, Petroleum) were directly overseen by the National Health Authority (NHA), creating a dual administrative structure within a state. On 23 June 2025, the Government of India issued a notification transferring the AB - PMJAY operations of all GoI hospitals under AB PM-JAY from the NHA to respective SHAs. Methodology: This review critically analyzes official policy documents, existing literature on federal health governance, and operational guidelines of AB PM-JAY. Comparative assessment was undertaken to examine the pre- and post-policy administrative structures with respect to the above-mentioned notification. Key themes including efficiency, accountability, resource utilization, and cooperative federalism were explored. Results: The transition of administrative authority from the NHA to SHAs is expected to streamline hospital empanelment, claims processing, and grievance redressal by better integration of GoI hospitals into state health systems. Anticipated benefits include improved efficiency, stronger accountability, better beneficiary experience, and enhanced utilization of centrally managed facilities. However, significant challenges were identified, such as inter-ministerial coordination gaps, variation in SHA capacities across states, IT system interoperability issues, claims management delays, and risks of grievance escalation. Conclusion: The transfer of GoI hospital management to SHAs represents a pivotal step in strengthening cooperative federalism in Indian health governance. The policy demonstrates the Government of India’s commitment to decentralization while retaining national-level oversight. Mitigation strategies-including capacity building for SHAs, IT standardization, robust centre-state coordination, and proactive beneficiary communication-are essential for ensuring a smooth transition. If implemented effectively, this reform could serve as a model for integrated governance in large-scale health insurance programs and contribute significantly to India’s progress toward Universal Health Coverage (UHC).
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 devolution’s 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 (January–August 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 3–4 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 Kenya’s 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 Kenya’s 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 India’s 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 public–private 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 state’s 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 MoHFW’s 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. Authors’ contributions Maj. Gen. (Prof) Dr Atul Kotwal: Conceptualization; Writing – Original Draft, Writing – Review and Editing; Supervision. Dr Tarannum Ahmed: Conceptualization; Writing – Original Draft, Writing – Review and Editing. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest to declare.
Dr Mu’azu 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 2019–December 2025) and BHCPF Monthly Report Forms (2024–2025). 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 3.9–8.5); ANC1 +5.1 pp (95% CI 2.8–7.4); SBA +4.8 pp (95% CI 1.9–7.7); PNC +4.3 pp (95% CI 1.6–7.0). ITS decomposition for DPT3 showed an immediate level increase of +3.7 pp (95% CI 1.9–5.5) and a sustained slope of +0.12 pp/month (95% CI 0.06–0.18). 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 Welch’s 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 Nigeria’s 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.
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.
Background: Mental health accounts for an estimated 14% of the global disease burden yet receives less than 2% of health budgets in most countries, with even lower investment in low- and middle-income settings. This study examines federal mental health financing trends from 2021-2025 to assess whether legislative reform translated into fiscal prioritization. Methods: A mixed-methods policy analysis was conducted, combining quantitative analysis of federal budget appropriation documents (2021-2025) with qualitative documentary review and comparative case studies. Mental health allocations were assessed by recurrent and capital expenditure, institutional distribution, and proportional share of total federal health spending. WHO reports, national policy documents from Ghana and Kenya, and peer-reviewed literature informed comparative analysis. Results: Federal mental health allocations increased from ₦23.33 billion in 2021 to ₦88.24 billion in 2025, a 278% nominal rise. However, the sector’s share of the total health budget declined from 3.67% to 3.12%, indicating relative marginalization. Over 90% of funding supported recurrent expenditures in ten federal neuropsychiatric hospitals, with minimal investment in community-based services or primary care integration. In contrast, Ghana and Kenya more effectively leveraged legislation, fiscal decentralization, and insurance mechanisms to expand access. Conclusion: Despite legislative reform, Nigeria’s mental health financing remains centralized, hospital-focused, and misaligned with population needs. Institutional inertia, weak coordination, and delayed implementation of the Act have constrained equitable scale-up. Activating the Mental Health Fund and integrating mental health into national financing mechanisms are urgently required to prevent deepening inequities.
Nepal’s health policy landscape has shifted from a centralized, curative model to a more preventive, equitable, and decentralized system. Since the first National Health Policy in 1991, subsequent reforms in 1997, 2014, and 2019 have aimed to expand access, strengthen institutional capacity, and align the health sector with global commitments such as the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC). The National Health Policy 2019 (NHP 2019) represents the most recent and comprehensive effort to advance Primary Health Care (PHC) within a federal governance structure and further reinforce these national and global priorities. This review critically examines NHP 2019 through document analysis of government policies, implementation reports, and peer-reviewed literature; comparative policy review against earlier national policies and regional standards; and evaluation using the WHO health system building blocks framework. NHP 2019 strengthens PHC by expanding health insurance, integrating federal-provincial-local roles, and promoting digital health and essential public health services. Implementation evidence shows progress in decentralization and community-level service delivery. However, major gaps persist, including inequitable financing, rural workforce shortages, weak health information systems, inadequate coordination across government tiers, and limited inclusion of marginalized groups and traditional health practices. NHP 2019 is conceptually strong but faces operational challenges. Its success depends on sustained financing, evidence-driven governance, improved intergovernmental coordination, and equitable workforce and resource allocation. Strengthening monitoring systems and integrating community and traditional health practices are critical for achieving the policy’s vision of healthier and more informed citizens and for guiding decision-makers in advancing PHC-oriented reforms.
Ashar Prima, Dewi Gayatri, Yati Afiyanti, Christantie Effendy
Background: Indonesia faces a growing double burden of non-communicable diseases, particularly cancer. The latest data from the Global Cancer Observatory (Globocan) indicates over 408,661 new cases and 242,099 cancer-related deaths in 2022, with a projected 63% increase in the case burden between 2025 and 2040 without strategic intervention. Although a new legal framework through Health Law No. 17 of 2023 and the Minister of Health Decree (KMK) No. HK.01.07/MENKES/2180/2023 has mandated palliative care as an integral component of health services, its implementation still faces significant systemic barriers. Policy and Implications: This policy brief analyzes the disconnection between the policy mandate and on-the-ground reality, identifying critical gaps in accessibility, healthcare workforce capacity particularly among nursesand financing mechanisms through the National Health Insurance (JKN) program. The failure to effectively integrate palliative care not only causes unnecessary suffering for millions of patients but also burdens the health system with inefficient costs and suboptimal end-of-life care, reflected in the high "financial toxicity" experienced by patients. Recommendations: We recommend a four-pillar strategy: (1) Formalize and standardize palliative services within the JKN benefits package with a clear financing model to address regulatory ambiguity; (2) Develop a national competency-based palliative education and training strategy for all health workers, with a focus on empowering nurses in primary care; (3) Implement a decentralized and tiered palliative care delivery model centered on Community Health Centers (Puskesmas) to ensure equitable access; and (4) Launch a national public education campaign to destigmatize palliative care and increase awareness. Conclusion: The integration of palliative care is not merely an option but a strategic and ethical imperative for achieving Universal Health Coverage (UHC) in Indonesia. It is a cost-effective investment to improve patients' quality of life, support families, and ensure the sustainability of the national health system in facing future non-communicable disease challenges.
Open access
Healthcare Systems and Reforms
Palliative Care and End-of-Life Issues
Health Systems, Economic Evaluations, Quality of Life
Purpose This study analyzes Georgia’s healthcare transformation from 1991 through both historical policy evolution and the WHO Health Systems Framework, evaluating how reforms prioritized or neglected system components while projecting 2030 outcomes. Design/methodology/approach We analyzed 26 peer-reviewed studies, WHO reports and Georgian government records, categorizing reforms by WHO component and assessing their cumulative impact on equity and efficiency. Findings Georgia’s journey reveals three distinct phases: post-Soviet collapse (1991–2006), market-driven reforms (2007–2012) and universal coverage expansion (2013–present). While financing and service delivery improved (OOP payments reduced from 74.7 to 57%), chronic workforce shortages (1:1 nurse–doctor ratio) and governance gaps persist. The 2030 strategy represents the first holistic attempt to address all WHO components simultaneously. Practical implications Policymakers must balance historical lessons (e.g. corruption risks in decentralization) with WHO-aligned investments, particularly in workforce training and digital infrastructure, to achieve 2030 goals. Originality/value This is the first study to combine historical policy analysis with WHO framework application for Georgia, revealing how reform sequencing explains current strengths (90% coverage) and weaknesses (rural disparities).
Background: Decentralization in health systems enhances responsiveness and equity but is often accompanied by uneven implementation and resource disparities. Greece' health system has undergone successive phases of decentralization, culminating in a transformation in 2015 when regional health authorities (RHAs) assumed operational responsibility for public primary healthcare (PHC). This study presents the first comprehensive assessment of this transition, examining funding adequacy and resource allocation across RHAs. Methods: Financial and operational analyses were performed to assess disparities among RHAs and between RHAs and hospitals. Data were drawn from publicly available sources, including financial statements, reports from the Ministry of Health, and national statistics. The analysis examined patient visits, staffing levels, infrastructure, funding, labor productivity, and efficiency across health regions. Results: Between 2018 and 2023, patient visits declined at most RHAs. Staffing composition shifted toward nursing personnel, while medical staff numbers declined. Substantial intraregional and interregional disparities were observed in service utilization, staffing, infrastructure, funding, labor productivity, and efficiency. Hospitals continued to absorb a large share of PHC demand and funding, whereas RHA units held markedly fewer assets and received lower financial support. Funding imbalances among RHAs were evident, and the overall negative return on assets indicated systemic underfunding of public PHC. Conclusion: The ongoing decentralization of Greece's health system faces structural challenges, including overlapping territorial jurisdictions and uneven, occasionally insufficient, resource allocation. These challenges hinder progress toward health equity. Policy interventions should prioritize evidence-based resource allocation, standardized financing frameworks, and strengthened PHC integration to promote equitable and sustainable healthcare delivery under decentralized governance.
Abstract Stronger health systems are better equipped to withstand shocks and continue providing quality services as response measures are implemented. We conducted a systematic review to synthesize the understanding of the concept of health system resilience from various stakeholders in Africa, focusing on definitions and attributes of a resilient health system. We conducted a search for peer-reviewed articles and grey literature, filtered for Africa, from 1980 to 2023, using the SPIDER framework. We searched four databases: PubMed, the Bielefeld Academic Search Engine, the Cumulative Index to Nursing and Allied Health Literature, and Scopus, and reviewed the websites of the World Health Organization, Africa CDC, and Ministries of Health of African countries. Articles were selected based on set inclusion and exclusion criteria. Qualitative articles were appraised using the Critical Appraisal Skills Programme, and mixed-methods articles using the Mixed Methods Appraisal Tool. We mapped the distribution of included articles by country studied; categorized the articles based on reported shock, health system building block described; and identified the definition of health system resilience, and its attributes in each article. The search yielded 4,306 relevant records, fifty-five of which were included in the study. Studies were found from 48 of the 54 African countries. Up to 75% of the articles focused on COVID-19; others were on Ebola Virus Disease, cholera, and meningitis. Service delivery and health workforce were the most frequently studied health system building blocks. In defining or describing health system resilience, the adaptive capacity (39, 65%) was most frequently mentioned, followed by absorptive capacity (17, 28%), preparedness (3, 5%), and recovery (1, 2%). Identified attributes of a resilient health system were: community engagement and involvement; leadership and governance; collaborations and partnerships; human resources for health; health education and promotion; health information systems; health service delivery; decentralization and local governance; health infrastructure and logistics; preparedness; learning and adaptation; and innovation and financing. Our review reports four core capacities that define a resilient health system: preparedness, absorptive capacity, adaptive capacity, and recovery. Essential attributes encompass community engagement, health education and promotion, leadership and governance, surveillance and laboratory capacity, innovation, service delivery, and adaptability.
Decentralization has emerged as a prominent strategy for health sector reform in low- and middle-income countries (LMICs), aiming to enhance service quality, efficiency, equity, and responsiveness. This study systematically reviews literature published between 2021 and 2025 to explore the role of decentralized health systems in shaping healthcare service quality across LMICs. Using PRISMA 2020 guidelines, 20 eligible studies were identified and analyzed from databases including PubMed, Scopus, Web of Science, and Google Scholar. Thematic synthesis of findings reveals mixed outcomes: while decentralization improves local responsiveness, enhances community engagement, and strengthens health system performance in some settings, it also exacerbates disparities in others due to uneven institutional capacity, limited fiscal resources, and fragmented coordination. Key performance areas identified include human resource deployment, financing, access to services, and equity in service delivery. The study emphasizes the significance of local capacity-building, efficient resource allocation, and integrated planning in attaining sustainable and equitable healthcare improvements within decentralized systems. This review provides practical insights for policymakers aiming to align decentralization strategies with health equity and service quality objectives.
Khanh Phuong Nguyen, The Due Ong, Xinyu Zhang, Tra My · 6 authors
Ensuring sufficient financial resources for improving effective and efficient procurement of vaccines was highlighted by the Immunization Agenda 2030, which is particularly challenging for middle-income countries (MICs) that are ineligible for support from Gavi, the Vaccine Alliance. In response to the broader decentralization of the governance system and decreased international development aid, the central government of Vietnam decentralized the responsibility of financing the Expanded Program on Immunization (EPI) to provincial governments in 2023 but rapidly reversed it considering its following negative consequences, for example, severe vaccine stockouts and the largest decline in childhood immunization coverage in over 20 years. This paper analyzed the consequences closely linked to decentralization in Vietnam, the underlying reasons, and lessons for other MICs. To avoid recurrence, MICs should ensure the primary role of the central government in EPI financing and management, improve the local management capacity, and allocate more resources toward less-developed areas to narrow the intra-country disparities.