This study assessed the level of optimization of turnaround time (TAT) among the Tuberculosis Directly Observed Treatment Short-Course (TB DOTS) team and explored the treatment-compliance experiences of confirmed pulmonary tuberculosis (PTB) patients in the Rural Health Unit of Sagñay, Camarines Sur. A concurrent parallel mixed-methods design was employed. Quantitative survey data were obtained from 40 confirmed PTB patients, eight of whom were purposively selected for semi-structured interviews, while six TB DOTS team members participated in a focus group discussion. Quantitative data were summarized using weighted and average means, whereas interview and focus-group data were examined through content and thematic analysis and integrated with the quantitative findings. The TB DOTS team demonstrated a very high overall level of TAT optimization (M = 4.29), with screening (M = 4.24), diagnostics (M = 4.27), treatment initiation (M = 4.31), and follow-up (M = 4.36) all rated very high. Important service gaps nevertheless emerged in timely communication of diagnostic results (M = 2.63, Moderate), treatment initiation within five working days of sputum collection (M = 3.85, High), and attendance at scheduled follow-up visits (M = 3.65, High). Patients described symptom recognition, transportation and financial barriers, prolonged waiting for diagnostic results, treatment side effects, and family or healthcare-worker support as central to adherence. Staff identified awareness, knowledge of diagnostic TAT, and appropriate communication as facilitators, while distance and limited schedules, insufficient staffing, and inadequate budget were hindering factors. These findings informed the proposed REACH TB Project, a patient-centered program designed to strengthen decentralized specimen transport, community outreach, adherence support, and sustainable financing. The study concludes that RHU-Sagñay has a strongly functioning TB DOTS system, but targeted improvements in result communication, logistical access, staffing, and follow-up are needed to make timely TB care more consistent and sustainable.
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.
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.
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
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.
BACKGROUND: There are substantial issues with the quality of care (QoC) received by persons living with chronic conditions, particularly in low- and middle-income countries (LMICs). One possible channel to improve QoC is through financing, specifically purchasing arrangements for health services. This has been actively explored in high-income country settings, generating a growing body of scientific knowledge. OBJECTIVE: To understand the potential and the constraints of using purchasing arrangements as a way to improve QoC for chronic conditions in resource-constrained settings. METHODS: A Delphi survey was conducted with 49 international participants with content expertise in chronic care management, health financing, or both, and context expertise in resource-constrained settings including in Small Island Developing States or Fragile and Conflict-Affected States, to assess the possible contribution of purchasing arrangements to QoC for chronic conditions with respect to specific types of care providers (e.g. patients and relatives, community health workers, public health centres), decentralized coordination bodies and purchasing agencies in such settings. RESULTS: There was a high level of consensus among the Delphi panel in favour of considering purchasing arrangements as one of the levers to improve QoC for people living with chronic conditions. Specific directions for action were identified along with their caveats. CONCLUSIONS: The challenge of improving the quality of chronic care in resource-constrained settings is extensive and requires immediate attention. Leveraging purchasing arrangements is one promising channel to strengthen quality chronic care in such settings.
Peter Haastrup, Anne MĂžller, Jette Kolding Kristensen, Linda Huibers
Denmark is known for its good population health, largely attributable to its effective healthcare system. This analysis of the Danish primary healthcare system with focus on general practice describes the system's overall structure, function, and financing. Further, it reviews some of the recent developments in organization and decentralization from secondary to primary care. Finally, we discuss some of the key challenges that primary care faces and potential areas for improvement to ensure a sustainable Danish healthcare system of high quality.
Brittany Hagedorn, Jeremy Cooper, Benjamin Loevinsohn, Valentina Martufi
BACKGROUND: To improve service delivery of Nigeria's primary health care (PHC) system, the government tested two approaches for facility-level financing: performance-based financing (PBF) and decentralized facility financing (DFF). Facilities also had increased autonomy, supervision, and community oversight. We examine how the intervention approach and funding level affected breadth of services and structural quality. METHODS: We use health facility surveys previously collected in 2014 and 2017, covering three years of implementation, in which districts were randomly assigned PBF or DFF and compared to matched districts in control states. We use log-linear regressions and non-parametric statistics to estimate the effect size of the financing approach and level of funding per capita. RESULTS: Service availability was highest in PBF facilities, while DFF also outperformed control on most measures. Results showed that structural readiness and service offerings both increased with more funding, especially under DFF. DFF and PBF facilities were better equipped to provide services that they claimed to offer, which was not the case for controls. Overall, PBF outperformed DFF, partially explained by funding levels. The rate of offering complimentary services followed a pattern of easiest-to-hardest to deliver. CONCLUSION: PBF and DFF both improved the breadth and structural quality of services, although DFF performance was more sensitive to funding levels. Improvements were observed at relatively low levels of funding, but larger investments were associated with better performance. Most DFF facilities exceeded the performance of higher-funded controls, implying that funding was more valuable in the context of autonomy, increased supervision, and community oversight.
Ahmad Shirjang, Leila Doshmangir, Mohammad Bazyar, Vladimir Sergeevich Gordeev
BACKGROUND: Demographic transitions, societal changes, and evolving population health needs are placing increasing pressure on healthcare systems, necessitating ongoing reforms. Primary health care (PHC) is a foundational component of Universal Health Coverage (UHC) and sustainable health systems. Many countries have undertaken PHC reforms aimed at improving population health. This review explores the objectives, implementation mechanisms, challenges, and outcomes of these reforms. METHODS: We conducted a systematic review of studies sourced from five databases (PubMed, Scopus, Proquest, Embase, and Science Direct), applying the World Health Organization's Health Systems Framework for deductive content analysis. The PRISMA guidelines were followed to ensure transparency and rigour in summarizing the published literature. RESULTS: A total of 147 types of interventions were identified, with most targeting service delivery and financing. Key reform objectives included expanding access to care, improving financing and payment systems, scaling up family physician programmes, increasing government health expenditure, leveraging private sector capacities, and strengthening the PHC workforce. These interventions resulted in expanded public health coverage, enhanced access to PHC, increased utilization of services among low-income populations, broader social insurance coverage, and improved service quality, contributing to better community health outcomes. CONCLUSION: The success of PHC reforms depends on their alignment with political, social, and cultural contexts, as well as consideration of the social determinants of health. Strong governmental support, managerial stability, decentralization, and regional capacity building are essential for sustainable implementation. Reforms should be gradual, supported by accurate forecasting, adequate and sustainable resources, and evidence-based strategies, drawing on international experiences.
Ermyas Birru, Melino Ndayizigiye, George Wanje, Tholoana A. Marole · 14 authors
BACKGROUND: Lesotho experienced high rates of maternal (566/100,000 live births) and under-five mortality (72.9/1000 live births). A 2013 national assessment found centralized healthcare management in Ministry of Health led to fragmented, ineffective district health team management. Launched in 2014 through collaboration between the Ministry of Health and Partners In Health, Lesotho's Primary Health Care Reform (LPHCR) aimed to improve service quality and quantity by decentralizing healthcare management to the district level. We conducted a qualitative study to explore health workers' perceptions regarding the effectiveness of LPHCR in enhancing the primary health care system. METHODS: We conducted 21 semi-structured key informant interviews (KII) with healthcare workers and Ministry of Health officials purposively sampled from various levels of Lesotho's health system, including the central Ministry of Health, district health management teams, health centers, and community health worker programs in four pilot districts of the LPHCR initiative. The World Health Organization's health systems building blocks framework was used to guide data collection and analysis. Interviews assessed health care workers' perspectives on the impact of the LPHCR initiative on the six-health system building blocks: service delivery, health information systems, access to essential medicines, health workforce, financing, and leadership/governance. Data were analyzed using directed content analysis. RESULTS: Participants described benefits of decentralization, including improved efficiency in service delivery, enhanced accountability and responsiveness, increased community participation, improved data availability, and better resource allocation. Participants highlighted how the reform resulted in more efficient procurement and distribution processes and increased recognition and status in part due to the empowerment of district health management teams. However, participants also identified limited decentralization of financial decision-making and encountered barriers to successful implementation, such as staff shortages, inadequate management of the village health worker program, and a lack of clear communication regarding autonomy in utilizing and mobilizing donor funds. CONCLUSION: Our study findings indicate that the implementation of decentralized primary health care management in Lesotho was associated a positive impact on health system building blocks related to primary health care. However, it is crucial to address the implementation challenges identified by healthcare workers to optimize the benefits of decentralized healthcare management.
While the importance of primary health care (PHC) as a foundation for a strong healthcare system is widely accepted, the policies needed to achieve it remain deeply controversial. Some proponents call for a greater role for market and user choice in expanding and strengthening PHC, whereas others recommend a greater role for the government in directing its development. The objective of this paper is to assess these arguments by comparing the experience of China and Thailand in strengthening PHC. We find that tight government steering of the healthcare system in Thailand has produced better integration and eventually outcomes than the more decentralized and competitive system in China. The Chinese governmentâs massive administrative and fiscal efforts to strengthen PHC have been undermined by systemic barriers in the wider health system, notably fee-for-service and out-of-pocket financing that distort the incentives of healthcare providers. A key conclusion to emerge from the analysis is that central stewardship and steering accompanied by appropriate incentives to promote integration are critical to building effective primary health care.
Task shifting refers to the strategic redistribution and decentralization of health care tasks from one group to another(including lay workers), the latter usually deemed as having lesser training and qualifications, and is an approach that isutilized to address the shortage and imbalance of the health workforce within a certain geographic area, thereby ensuring apopulationâs access to care.1 Task shifting can involve extending the role of a particular group (enhancement), exchanging workbetween groups (substitution/delegation), or creation of new jobs (innovation).2 While the primary conceptualization of taskshifting is from professional to lay health workers, it must be stated that task shifting can also involve shifting of tasks fromprofessionals to patients; from health workers to technology; and between different types of health workers.2 Task shifting hasbeen implemented in a variety of settings and for different programs/conditions, such as HIV/AIDS treatment3, cancer care4,mental health5, ultrasonography for antenatal care6, surgical care7, and non-communicable disease management8, similar to thecontext of the report by Tamayo and Reyes9 in this issue of Acta Medica Philippina. In addition to bridging the health humanresources gap, it has been proposed that task shifting may address health equity by broadening access to essential health services,contribute to enhancing the quality of care that is aligned with the changing societal needs, and yield cost savings particularlyfor the delivery of routine activities.10,11 Despite its widespread application, touted benefits, and the seeming preference of many organizations to use task shiftinga default solution to the health workforce challenge, three things must be pointed out. First, task shifting should be properly seen as a temporary solution to the health workforce challenge confronting countriesand health systems.12,13 Better and more comprehensive planning and management of human resources for health at the systemlevel is needed so that we can address the underlying problems that resulted to the implementation of task shifting in the firstplace â shortage, maldistribution, skill-mix balance, and sub-optimal working conditions that are, in turn, driven, by both healthsystem and contextual factors.14 Second, in situations where task shifting is perceived to be the better policy alternative, the program should be implementedin an ethical manner, considering respect for persons (i.e., free and informed decision making to take part in task shifting,recognition of recipients of tasks as critical contributors to the health program), justice (i.e., adequate guidance and supervision,fair remuneration, minimization of undue burden), beneficence (i.e., promoting health and welfare of workers, minimizingharm to workers and communities), proportionality (i.e., assignment of workload and responsibility commensurate to skillsand resources available), and cultural humility (i.e., cultural competency and humility on the part of dominant institutions),especially when the recipient of tasks are volunteer community health workers.15 Lastly, task shifting should be implemented as a comprehensive package of interventions, rather than a single activity.At the outset, the necessary conditions and important considerations for launching a task shifting program should be present,as outlined in the Concepts and Opportunities to Advance Task Shifting and Task Sharing (COATS) Framework.16 The keyelements for successful implementation (i.e., collaboration and coordinated care, financing, patient preference, shared decisionmaking,provider empowerment, training and competency, clear process outcomes, and supportive organizational system) oftask shifting should also be present.17 Recommendations on how and when to adopt task shifting as a strategy have also beenpublished by various organizations such as the World Health Organization1 and the World Medical Association18. The success of a task shifting strategy will require, among others, that health workers be actively engaged in the process,ensuring that the planned task shifting is aligned with their personal values, and creating an enabling environment19 that willallow them to carry out their tasks effectively, efficiently, and in a safe manner. In short, one of the requirements is that, aspointed out in the paper by Tamayo and Reyes9, stakeholders find task shifting an acceptable strategy.
BACKGROUND The Durban University of Technology (DUT) Faculty of Health Sciences (FHS) in KwaZulu-Natal, South Africa, is embarking on a project to implement a Decentralized Clinical Training Program (DCTP). The DUT FHS DCTP project is being conducted in response to the growing demands of students requiring clinical service placements as part of work-integrated learning. The project is also geared toward responding to existing gaps in current practices related to the implementation of a DCTP, which has mainly been through traditional universities providing training to medical, optometry, occupational therapy, and physiotherapy students. In South Africa, a DCTP is yet to be implemented within the context of a university of technology; it is yet to be implemented within health science faculties that offer undergraduate health science programs in mainstream biomedicine and alternative and complementary disciplines. OBJECTIVE We aim to design, pilot, and establish an effective DCTP at the DUT FHS in KwaZulu-Natal, South Africa. METHODS Participatory action research comprising various designsânamely, appreciative inquiry, qualitative case study design, phenomenography, and descriptive qualitative study designâwill be used to conduct the study. Data will be collected using individual interviews, focus group discussions, nominal group technique, consensus methodology, and narrative inquiry. Study participants will include various internal and external stakeholders of the DUT, namely, academic staff; students; key informants from universities currently using successfully established DCTPs; academic support staff; staff working in human resources, finance, procurement, and accounting; and experts in other disciplines such as engineering and information systems. Overall, 4 undergraduate health science programsânamely, Radiography, Medical Orthotics and Prosthetics, Clinical Technology, and Emergency Medical Care and Rescueâwill be part of the projectâs pilot phase. Findings from the projectâs pilot phase will be used to inform scale-up in the other undergraduate programs in the DUT FHS. The project is being implemented as part of the universityâs strategic objective of devising innovative curricula and pedagogical practices to improve the mastery, skill set, and competence of health science graduates. RESULTS The study has currently commenced with the situational analysis, consisting of engagement with external stakeholders implementing DCTPs. The data to be generated from the completion of the situational analysis are anticipated to be published in 2024. CONCLUSIONS This project is envisioned to facilitate collaboration among the universities of technology, traditional universities, Ministry of Health, and private sector for clinical placement of undergraduate health science students in health establishments that are away from the university, thereby exposing them to real-life experiences related to health care. This will facilitate authentic learning experiences that will contribute to improved competencies of graduates in relation to the health needs of society and the multiple realities of the South African health system. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/52243
OBJECTIVES: The study applies the principal-agent approach to explore providers' experiences before and after the introduction of performance-based financing (PBF) in Cameroon, challenges and facilitators in the implementation process, and mechanisms in place to ensure sustainability. METHODS: The study was an in-depth qualitative study whose goal was to provide multiple descriptions of experiences and insights from a principal-agent analysis perspective. Purposive sampling was used to identify the key characteristics of the participants relevant to the study. A snowballing technique was used to further identify eligible participants. Only healthcare providers who were exposed to the previous system and could reflect on and provide meaningful data that captured the everyday experiences before and after the implementation of PBF were included. Data were collected from three districts in the Southwest region of Cameroon from May 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. RESULTS: A total of 17 interviews and 3 focus group discussions (24 participants) were conducted with healthcare providers and key stakeholders involved in PBF. The respondents described a range of changes that they had experienced since the introduction of PBF. Each of these changes was categorized as either positive or negative. Positive changes were framed into 14 dominant categories: motivation, negotiations, innovation, resource allocation, autonomy, decentralization, transparency, improved quality of care, separation of function, performance, equity considerations, opportunity to recruit, participation in decision-making, and improved access to and utilization of maternal health services. The main challenges (negative experiences) reported were framed into nine categories: management of change, retention issues, conflict of interest, poor understanding of the PBF concept, resistance to change, verification challenges, delays in payment of PBF incentives, data entry and documentation, and challenges in meeting the equity considerations of the poor and vulnerable. Despite the challenges, providers preferred the decentralized approach to the centralized system. CONCLUSION: PBF is a national strategy for achieving universal health coverage in Cameroon, and the experiences of providers provide a vital guide to refine national policy. The introduction of PBF has provided positive changes to providers' quality of care when compared to the previous system. Addressing the delays in PBF payments will help to overcome the challenges to implementation and provide opportunities for health facilities to be more efficient and improve their performance. Despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal).
Madhulika Khanna, Benjamin Loevinsohn, Elina Pradhan, Opeyemi Fadeyibi · 10 authors
BACKGROUND: Health system financing presents a challenge in many developing countries. We assessed two reform packages, performance-based financing (PBF) and direct facility financing (DFF), against each other and business-as-usual for maternal and child healthcare (MCH) provision in Nigeria. METHODS: We sampled 571 facilities (269 in PBF; 302 in DFF) in 52 districts randomly assigned to PBF or DFF, and 215 facilities in 25 observable-matched control districts. PBF facilities received $2 ($1 for operating grants plus $1 for bonuses) for every $1 received by DFF facilities (operating grants alone). Both received autonomy, supervision, and enhanced community engagement, isolating the impact of additional performance-linked facility and health worker payments. Facilities and households with recent pregnancies in facility catchments were surveyed at baseline (2014) and endline (2017). Outcomes were Penta3 immunization, institutional deliveries, modern contraceptive prevalence rate (mCPR), four-plus antenatal care (ANC) visits, insecticide-treated mosquito net (ITN) use by under-fives, and directly observed quality of care (QOC). We estimated difference-in-differences with state fixed effects and clustered standard errors. RESULTS: PBF increased institutional deliveries by 10% points over DFF and 7% over business-as-usual (p<0.01). PBF and DFF were more effective than business-as-usual for Penta3 (p<0.05 and p<0.01, respectively); PBF also for mCPR (p<0.05). Twenty-one of 26 QOC indicators improved in both PBF and DFF relative to business-as-usual (p<0.05). However, except for deliveries, PBF was as or less effective than DFF: Penta3 immunization and ITN use were each 6% less than DFF (p<0.1 for both) and QOC gains were also comparable. Utilization gains come from the middle of the rural wealth distribution (p<0.05). CONCLUSIONS: Our findings show that both PBF and DFF represent significant improvements over business-as-usual for service provision and quality of care. However, except for institutional delivery, PBF and DFF do not differ from each other despite PBF disbursing $2 for every dollar disbursed by DFF. These findings highlight the importance of direct facility financing and decentralization in improving PHC and suggest potential complementarities between the two approaches in strengthening MCH service delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT03890653 ; May 8, 2017. Retrospectively registered.
The coronavirus disease 2019 (COVID-19) pandemic, with its overlapping public health and economic emergencies, is a global reminder of the importance of addressing social and environmental determinants of health and inequality, and investing in health systems oriented towards primary care, all of which are components of a primary health care (PHC) approach. PHC â the importance of which was famously articulated in the Declaration of Alma-Ata in 1978 and reaffirmed at the 2018 Astana Conference â is recognized as one of the best ways of promoting population health and well-being.[1,2,3] PHC is âa whole-of-society approach to health that aims to ensure the highest possible level of health and well-being and their equitable distribution by focusing on peopleâs needs and preferences (as individuals, families, and communities) as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to peopleâs everyday environmentâ.[4] It promotes a focus on health systems oriented towards primary care, which have been shown to strengthen appropriateness, access, quality and efficiency of care, through their defining focus on people and the delivery of integrated preventive, curative and public health services.[5] However, the efficacy and impact of such primary care is understood to be intrinsically linked to, and embedded within, a broader context that is inclusive of participatory and responsive financing and governance structures, and policies and actions in non-health sectors.[6] In 2020, with the aim of supporting countries to operationalize PHC, the World Health Organization (WHO) launched its Operational framework for primary health care: transforming vision into action.[7] Showcasing evidence-based strategic and operational levers, the framework highlights the need for a whole-of-society approach. Of note, the frameworkâs emphasis â on more and better multisectoral action, empowerment of people and communities, and the urgency of strengthening primary care as the âservice frontâ[6] and programmatic engine of universal health coverage[2] â overlaps considerably with issues highlighted by the COVID-19 pandemic. In the WHO South-East Asia Region, Member States have articulated a high-level commitment to the vision of PHC as one means by which to improve health and well- being. Even before the COVID-19 pandemic, an estimated 60 million people annually in the region experienced poverty because of out-of-pocket spending on health care. Regionally, various initiatives are seeking to both build primary care capacity and implement policies and strategies that reflect a multisectoral approach. As observed in the WHO Regional Directorâs message accompanying this special issue, since 2014, achieving universal health coverage has been one of the flagship priorities across the South-East Asia Region, with service coverage improving from an average of 47% a decade ago to more than 61% in 2020. However, many challenges remain; the COVID-19 pandemic has provided opportunities for innovation and adaptation but has also presented new problems or compounded problems in relation to Member Statesâ efforts to operationalize PHC. In this supplement, South-East Asia Region authors and others reflect on the challenges and lessons learned regarding PHC during the first 12 months of the COVID-19 pandemic, highlighting among other things examples of the rapid review and extension of health workforce capability; the expedited introduction of technological solutions to maintain and strengthen health care access; and newly decentralized governance arrangements designed to enable the integration of public health functions into front-line services.[8,9] Addressing the critical issue of access to essential services, for example, Reddy et al.[10] present findings from the analysis of routine facility data in Indiaâs Telangana state, which show a positive association between a highly decentralized model of hypertension care that brings follow-up services and medicines closer to communities and indicators of service uptake and hypertension outcomes. Although identifying some decreases in service access during the pandemic-induced lockdown, the same study suggests a potentially protective effect on access to and use of hypertension follow-up services in populations covered by decentralized services compared with those covered by non-decentralized services. Zangmo et al.[11] similarly describe various adaptations to traditional models of antenatal care employed to ensure continuity of this vital service in country settings experiencing widespread social and economic lockdowns. Bezbaruah et al.[12] and Zakoji and Sundararaman[13] observe the critical importance of integrating emergency response capabilities and functions with routine community engagement and health workforce functions in support of effective and sustained emergency response measures that can be led by local stakeholders and are trusted by local populations. Bahl[14] et al. describe how, despite the reduction in immunization services and surveillance for vaccine-preventable diseases across the South-East Asia Region early in the pandemic, rapid adaptation of guidelines and action plans meant that, in most countries, immunization coverage recovered during JulyâSeptember 2020 to levels seen during the corresponding months in 2019. In fact, this was observed in Bangladesh, as reported by Wangmo et al.,[15] where the rate of fully immunized children fell by 46% between January and April 2020 but recovered to 100% by June 2020. The benefits of long-term community engagement (a key pillar of comprehensive PHC), including through investment in community health workers, is evident in several contributions (Bezbaruah et al.,[12] Zakoji and Sundararaman,[13] Reddy et al.[10]). These contributions provide further evidence of the critical role of primary care services not only in ensuring access to essential health care during public health emergencies but also in providing a platform for long-term and sustained efforts to strengthen national and subnational health systems through community engagement.[3] Even with examples of innovation and adaptation, multiple challenges to progressing PHC in the South-East Asia Region remain, particularly in the new context of the COVID-19 crisis. Zapata et al.[16] and Tangcharoensathien[17] note that, despite several decades of investment by Member States in human resources for health, huge health workforce challenges remain, with only two countries currently meeting the revised WHO threshold of 44.5 health workers per 10 000 population. The pandemic has highlighted the need to prioritize locally appropriate actions in the delivery of primary care, yet health budgets are overstretched and, as Kwon[18] points out, health governance and financing systems are too often unresponsive in the face of shifting health needs. Tandon et al.[19] observe that, in many South-East Asia Region countries, low levels of public spending on health and tied donor funding inhibit investment in primary care or the types of multisectoral action needed to realize PHC. Alongside the political economy of pharmaceutical research, development and sales, such budget constraints can influence the availability of medicines, which, despite the remarkable efforts behind the COVAX initiative, will affect the ability of different countries to access and roll out COVID-19 vaccines. Reflecting on a long-standing challenge, Khan et al.[20] observe how, despite mixed health systems being the norm in the region, attention to, and investment in, effective regulatory mechanisms to ensure the quality and affordability of nongovernment (private for-profit and not-for-profit) services remain weak. Reflecting on issues of health governance, Tangcharoensathien[17] and Guisset et al.[21] observe how, often, decisions about health service type and availability are driven by siloed governance and financing systems that are distant, if not disconnected, from the realities of both patients and frontline providers. Looking at the intersection of such governance and regulatory issues, Rajbhandary et al.[22] describe the need for urgent investment to strengthen health information systems in the South-East Asia Region, noting the growing capacity for the collection and collation of health information within regional Member States but also the still underdeveloped capacity for analysing and utilizing these data at subnational and particularly facility levels, where it is arguably most needed. Walcott and Akinola[23] reflect on the power of digital technologies, including data capture from rapidly expanding telemedicine applications, to inform on better targeted interventions and advance the universal health care agenda. Wangmo et al. present data illustrating the positive role that health information systems, and especially the collection and use of routine data, have played in Bangladesh, to help identify and inform the government response, down to the health facility level, on early reductions in coverage of essential services during the first months of the COVID-19 pandemic. Providing an important synthesis of many of these issues, Peiris et al.[24] review the literature to highlight how, even when accounting for some welcome pandemic-related health service adaptations, country-level attention to strategic functions that would strengthen underlying health systems in support of PHC remains generally weak. Challenges include many of the strategic areas identified in WHOâs operational framework, such as leadership, governance and policy, funding and allocation of resources, and engagement of communities and other stakeholders.[7] Around the globe, the COVID-19 pandemic has laid bare the devastating impact of both structural inequities and suboptimally designed health systems. The pandemic has highlighted the pressing need to move away from brittle, uncoordinated and disease-specific responses and to reorient health systems towards a PHC approach. âBuilding back betterâ in the South-East Asia Region and beyond means taking stock of current weaknesses in often fragmented health systems and service functions and making changes to improve responsiveness, resilience and the capability to deliver better and more equitable health outcomes. This collection speaks to emerging insights and opportunities created by the willingness to adapt in the context of the COVID-19 pandemic but also to an urgent need to pay more attention to and invest more in PHC, before the health and economic impacts of the pandemic slow or reverse the progress made in recent decades. We hope that this collection serves to reinforce the need for enacted commitment to the vision of health for all, through investment in well-aligned governance, financing and structural reforms.
Ătienne V Langlois, Andrew McKenzie, Helen Schneider, Jeffrey W. Mecaskey
Primary health care offers a cost-effective route to achieving universal health coverage (UHC). However, primary health-care systems are weak in many low- and middle-income countries and often fail to provide comprehensive, people-centred, integrated care. We analysed the primary health-care systems in 20 low- and middle-income countries using a semi-grounded approach. Options for strengthening primary health-care systems were identified by thematic content analysis. We found that: (i) despite the growing burden of noncommunicable disease, many low- and middle-income countries lacked funds for preventive services; (ii) community health workers were often under-resourced, poorly supported and lacked training; (iii) out-of-pocket expenditure exceeded 40% of total health expenditure in half the countries studied, which affected equity; and (iv) health insurance schemes were hampered by the fragmentation of public and private systems, underfunding, corruption and poor engagement of informal workers. In 14 countries, the private sector was largely unregulated. Moreover, community engagement in primary health care was weak in countries where services were largely privatized. In some countries, decentralization led to the fragmentation of primary health care. Performance improved when financial incentives were linked to regulation and quality improvement, and community involvement was strong. Policy-making should be supported by adequate resources for primary health-care implementation and government spending on primary health care should be increased by at least 1% of gross domestic product. Devising equity-enhancing financing schemes and improving the accountability of primary health-care management is also needed. Support from primary health-care systems is critical for progress towards UHC in the decade to 2030.
Abstract Introduction Chronic diseases form the largest burden of disease in European countries. Redesign of health systems towards chronic integrated care is needed, with more collaboration between first and second line, between medical and social services and support to prevention and self-management. What are the levers for change in such health systems? This study addresses this knowledge gap, through a policy analysis of barriers and facilitators for change towards chronic integrated care. Methods 26 central level stakeholders were selected, based upon their influence in regulation and policy, financing, health care provision and community representation. Semi-structured face-to-face interviews were held covering assessment of past and current policies and implementation, barriers and opportunities for change. Results Reforms have taken place, such as the stimulation of local initiatives for chronic integrated care projects and the set-up of local care councils. Most stakeholders assessed the current Belgium's implementation of integrated care as low, despite a growing awareness for the need for change. A context factor often mentioned to constrain implementation was a state reform which led to a partial decentralization, fragmentation of decision power and a division of healthcare competences between federal and federated levels. Other barriers were the current financing system, the lack of investments in new models of care and the vested interests of providers. Discussion This analysis shows that chronic care reform in Belgium is constrained by partial decentralization of primary health care, and by the financing system and vested interests. It points to the need for coordination of health policy making and implementation. Disentangling the levels of decision-making and the financial leverage at these levels gives insights for change and change management, for the Belgium health system and other countries with a strong decentralized system. Key messages The current Belgiumâs implementation of integrated care was assessed as low, due to different contexts factors such as division of health care competencies between different governmental levels. In a country as Belgium with a strong decentralized health care system coordination of health policy making and implementation is key in order to scale up integrated care for chronic diseases.
To say that we live in turbulent times is a massive understatement. COVID-19 ruthlessly exposes the fault lines of health services and systems, and the responses put in place to prevent its spread or mitigate its effects may affect people more than the actual infection. The outbreak in Wuhan quickly grew to a pandemic that has affected countries and regions all over the world in many, and as of yet, little understood ways. This is a global infectious disease outbreak of a scale not seen since the Spanish Flu. For many countries, it is an extreme stress test of the health system and of society at large. All over the world, people, patients, providers, health service managers, health and other sectoral policymakers and politicians, are dealing with high levels of uncertainty and severe challenges to the resilience of their systems. The governance not only of health, at national and global levels, but also of trade, communication and globalization itself is under scrutiny. The virus exposes, yet again, the structural determinants that lead to health inequalities (Shadmi et al., 2020), including racism and colonial legacies. Many see this as a key moment of reckoning, nationally and globally: the pandemic and its responses have precipitated unprecedented economic, social and health crises that may shape the decades ahead. At the same time, the role of health systems in responding to COVID-19 and the need to (re-)invest in these systems through the state offers transformative opportunities. In the light of this, we outline how health policy and systems research (HPSR) can both address current short-term challenges, and support the system transformations needed to strengthen people-centred and equitable health systems over the long term. The HPSR community has responded to the COVID-19 pandemic quickly, following the wave of publications on epidemiological and clinical aspects of the disease. Initial studies have included those describing the capacity of hospitals, intensive care units and first line health services required to respond to the disease, and those reporting specific experiences at community and local levels, including the denial of care and the inequitable effects of disease control measures. Many commentaries and calls for action have been published (COVID-19 Clinical Research Coalition, 2020; English et al., 2020; Shamasunder et al., 2020). Inevitably, however, due to the acute nature of the crisis, few papers have yet focused on how health systems are coping with or adapting to the pandemic, or how health policy-making and decision-making has (or has not) changed in this time of crisis. Yet, there is an urgent need to develop a structured research agenda to inform health policy and system responses to COVID-19 that can move us beyond the current crisis, and into the future. This commentary makes proposals towards such an agenda. In line with the audience of Health Policy and Planning, we specifically focus on low- and middle-income country (LMIC) HPSR needs, drawing on our collective experience as a group of HPS researchers based around the world. The Health System Research and Health Policy Processes section editors initiated the process and purposefully sought inputs from HPS researchers in a range of LMICs . The process was also supported by both the Alliance for Health Policy and Systems Research and Health System Global. We organized an online consultation process, whereby the first authors invited the co-authors to identify research priorities, questions and themes. In a second round, these were compiled and categorized in themes and sent out for further comment. In a final round, the issues and questions within each theme were examined and gaps and overlaps eliminated. We consider, first, key dimensions of the overall approach of HPSR to frame the further work needed, and second, in an annex, we suggest an initial categorization and listing of possible research topics. We present these ideas to prompt wider reflectionâand we conclude by proposing ways of engaging further with these ideas, acknowledging the fast-changing nature of the pandemic and the need to review research priorities regularly. We start by reviewing how the defining features of HPSR, including the systems approach, multi-disciplinarity and the emphasis on policy and power may be applied to the pandemic. One defining feature of HPSR is its systems approach. This frames COVID-19 and the responses to it in a criticalâanalytical perspective, zooming out from specific experiences to seek the root causes of the differential impact of the pandemic across individuals and population groups as a function of societyâs power structures and dominant culturesâas reflected in their social, political and economic position, and their race, gender, caste, class and more. Groups that become vulnerable due to systemic and structural inequities include those living in informal settlements in cities or in geographically isolated areas, informal workers, migrant and refugee communities, people without citizenship rights, sex workers, single-women households, LGBTQI+ communities and indigenous peoples. The systems lens equips HPS researchers to understand how, for such groups, health system fault lines interact with the histories of discrimination and disenfranchisement that underpin other determinants of vulnerability, risks and infection. Some people have already faced worse effects from COVID-19 responses than from (the possibility of) infection itself, due to social exclusion, racism and human rights abuse. Meanwhile, privilege and social networks have largely allowed wealthy elites to avoid the negative social and economic effects of lockdowns, deepening inequalities. Health systems have, in turn, generally been poorly equipped to respond fast enough either to the medical and psychological demands of the pandemic or to the wider public and social action needed to address multiple disadvantage and vulnerability. HPSR is well placed to contribute in understanding the layered causes and effects of the pandemic on people and systems. Identifying how health system gaps and weaknesses interact with the root causes of vulnerability to COVID-19 is a vital responsibility that HPSR needs to shoulderânot only as an obligation of itself (referring to HPSRâs social justice agenda), but also as an opportunity to strengthen health systems in more just and inclusive ways than before. The multi-disciplinary approach of HPSR will be key to this task because of the complex nature of health and its determinants, as well as of health policies and health systems. This multi-disciplinary approach supports consideration of how agents and systems interact and of the inter-connections among the systems relevant to health. These include community, workplace and government systems; health and other government sectors; local, national and global systems and markets, corporate actors and the private sector in its full heterogeneity. HPSR can assist in distinguishing COVID-19-related challenges that are simple problems, from those that are better considered as complex problems and that demand appropriate context-sensitive response strategies. It can also nurture and sustain the systemic responses to COVID-19 and its impacts that are vital for the long-term. It supports a system-based approach in anticipating the collateral effects of policies aimed at responding to the pandemic, generating ideas about how mitigate the damages and optimize the gains. The pandemic specifically demands recognition of the interactions of human, animal and ecological systems. The spill-over of the virus from animal to human reservoirs inevitably calls for a critical exploration of how humans continue to interfere with fragile equilibria in the natural world through urbanization, deforestation and more. Beyond âone healthâ research, attention should be paid to the dominant economic growth paradigm on health, development, trade, society and the natural world and the role of populist and isolationist ideologies in framing the response. Another defining feature of HPSR is its focus on policy, policy-making and how health systems are nested in and influenced by power dynamics and political forces, histories and cultures: the âpâ in HPSR. This is another vital lens for research in the time of COVID-19. It supports inquiry into governance, decision-making and health policy responses in times of crisis, as well as how both to inform and strengthen system change. It encourages consideration of the values driving decision-making and the ethical demands of leadership. In addition, this lens underpins investigation of the political economy of the pandemic response and whether and how health systems and political action align to address the structural determinants of ill health and inequity which COVID-19 exposes. It can expose the lack of accountability towards some marginalized groups and the focus on politically important constituencies, the lack of stewardship/leadership at multiple levels and how efforts towards decentralizing and commercializing health system responsibilities lead to fragmented health systems. It could focus on new forms of sub-national and national governance arrangements and investigate how that deepens community-level and inter-sectoral action for health and societal development. The pandemic forces us to consider governance not only at national level, but also at global level: Should we redefine global health? How can we promote better global leadership to coordinate and enforce efforts across countries, including the need for consideration of global public goods and global health ethics? Drawing on well-established bodies of knowledge and evidence from other disciplines (e.g. political science, policy studies, public administration, sociology, complexity theory, critical studies), HPSR can make major contributions to learning how better to deal with pandemics. But HPSR must also do more than help systems absorb future shocks. It must help establish the foundations of more just, equitable and better health systemsâhealth systems that demonstrate resilience through their capacity to be transformative as they respond to shock and stress. Crucial in this effort will be research around how health systems can be transformed for the better during or in the wake of the pandemic. This includes work around adaptive governance as well as on other fundamental system driversâsuch as the health workforce, and information and financing systems. Prioritizing among research topics is not straightforward. Such prioritization must, first, be informed by the views of vulnerable groups, community groups, health system decision-makers and health policymakers in the broadest sense and be situated in specific settings. Below, we discuss a few waypoints that may help in thinking about HPSR priorities in relation to COVID-19. As Marquette (2020) has argued for social science more generally, more immediate needs for research are likely to include understanding the root causes of vulnerability to support response activities and limit their negative effects. However, she notes that even mid- to longer-term research to understand secondary effects and long-term impacts and recovery must start now, accompanied by political analysis, and this will be needed to sustain recovery and support the emergence of new and better systems. Critical to this work will be revealing opportunity, agency and resilience, even in the midst of multi-layered challenges. For HPSR, we can also be guided by our understanding of people-centred health systems. This points, e.g. to the importance of understanding community-level COVID-19 experiences, including the experience of marginalized groups, and considering how system software (including power, trust and values) interacts with other system changes to influence the impacts of COVID-19; examining how health systems and COVID-19 responses may exclude people on the basis of their gender, race, income and other characteristics, and how histories of colonialism and racism underpin such exclusion; analysing the power and influence of ideas and framing, and the role of communication in decision-making at every level; and finally, purposefully considering the political economy influences driving COVID-19 and responses to it . Our research must offer new ideas for future health systemsâbuilding evidence around new ways of organizing, new ways of caring, new strategies of health development. In responding to COVID-19 and offering new ideas for future health systems, the HPSR community must also consider how to go about doing research. Issues to be reflected upon include the distribution of power within HPSR communities, the balance between global concerns and priorities on one hand and context-sensitivity on the other hand, the challenge of researching what is essentially a fast moving target, the practical problems induced by the control measures (such as social distancing) when collecting data, and finally the issue of research governance. Power-balancing strategies must be reflected in how the research is doneâconsidering, e.g. with whom and how we collaborate, and what forms of knowledge are valued and enhanced through this work. Research responding to COVID-19 must also be relevant to the contexts in which it is located, and acknowledge the imperatives of this moment. In the short term, then, it must be conducted quickly to address immediate needs, and be fed-back into decision-making rapidly. Innovative knowledge translation efforts and new models of collaborations between research, policymaking and stakeholder organizations are of special interest. Being systematic and rigorous will always be important, but we must capture current experience even as we also develop longer-term research activities. To support such HPSR can on and new ways of doing research. These include research et al., action research et al., action learning 2020), research and policy and All multiple forms of knowledge and for researchers to through with in the response in ways of that for HPSR to help shape the world COVID-19. At the same time, in the response to COVID-19 it always important to consider the ethical dimensions and of ethical and In the we will also need to about research and that can be to and vulnerable groups by online and online from experiences, as they their is and social could be a relevant research forms offer other new ways of and such experience et al., other an online of and studies could be to support the HPSR of secondary and simple work can also important, immediate about social and among other evidence drawing on both and and is into the and process research will be important to out the of is also needed both to understand the current experience and from experience and work can offer into the experience of groups and into responses to inform future action 2020). The of will support understanding of system sub-national or can e.g. on critical governance influences over of experience will also always be important to understand the layered vulnerability of people and systems, and the agency and to and must become a of HPSR et al., it is critical to and research governance at all levels to important, research that supports social justice is possible and is and to identify and limit research. We must also and how research governance and the research that is are by COVID-19 and responses to the research of and is for it is of this will not only work but also papers by and by At another level, how can we contribute to global health for whom in the current research on COVID-19 challenges HPS researchers to and in research that to new health systems for the future. HPSR that current needs and experiences will offer important and both about how COVID-19 impacts on our and about the responses to the pandemic. It can help how these responses and or new for just health systems. The HPSR in LMICs must support in the place and capacity for and nationally research, with appropriate Health and research in LMICs must as needed, be to do Research for must also include communities, patients, providers, health service and health and other policy in to society and HPSR must be an as it is for global health more and these are in that the current a new COVID-19 has just been for the on Health Systems Research the of the HPSR are within its theme of health systems for better health and social and for of the political social, economic and forces and and social In the annex, we also present a of HPSR themes and topics the of importance we have already These range from studies the differential impact on people, disadvantage and to those focused on the impacts on health systems, including studies on governance and system of health system towards better and just health systems. 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Introduction Argentina is the third most populated country in South America with an estimated population of 44,494,502. Despite having an area of 2,780,400 km2 (eighth largest in the world), 90% of the population resides in urban areas, with the majority concentrated in and around Buenos Aires. Life expectancy is 79.7 years in women and 73.6 years in men, with cardiovascular disease as the leading cause of mortality. Argentina spends approximately 10% of its gross domestic product on health care (1). There are 3.94 physicians and 4.5 hospital beds per 1000 inhabitants in Argentina (2). The physician-patient ratio is similar to that of Australia, Italy, Spain, and Switzerland, and is double than Brazil and almost four times than Chile and Peru. Argentina has a multitiered, decentralized health care system that is plagued by fragmented management and financing. There are national, provincial, and municipal governmentâsponsored health care insurances, which together with union-sponsored insurances, provide health care coverage to nearly 22 million people. An additional approximately 10% of the population has private health insurance, leaving nearly 36% of the population without health care coverage or the financial means to pay for private insurance. These individuals are cared for at cost-free public hospitals and community facilities (1,2). The first hemodialysis (HD) treatment in Argentina dates back to 1955. Five years later in 1960, the Argentine Society of Nephrology was founded (3). Epidemiology The incidence and prevalence of CKD and ESKD have been growing steadily, most likely because of increasing rates of diabetes and obesity as well as an aging population. Indeed, CKD is now the seventh leading cause of mortality in Argentina, and CKD-related deaths have increased by 15% between 2007 and 2017 (4). The National Transplantation Institute (INCUCAI) supports a National Dialysis and Transplant Registry (5,6). Patient reporting is obligatory; therefore, national data are valid and representative. Reporting is the responsibility of the dialysis center director, and it is provided online. Patient identity is preserved by data security systems. The annual incidence of ESKD is 160 patients per million population, with diabetes and hypertension as the most common etiologies (Table 1). At the end of 2018, there were 29,929 patients with ESKD on chronic dialysis, representing a prevalence rate of 673 patients per million population (Figure 1) (5,6). Of these, approximately 93.5% are on in-center HD, 6.5% on peritoneal dialysis (PD), and none are on home HD. Of the patients on HD, 70% receive dialysis via an arteriovenous fistula, 15% receive dialysis via an arteriovenous graft, and 15% receive dialysis via central venous catheters. First year and annual mortality rates on dialysis are 18% and 16.4%, respectively (Table 1), with cardiovascular cause being the most common (6). Annual mortality rate has been above 16% for the last 4 years (Figure 2). RRT in Argentina has incidence and prevalence rates above the mean for Latin America, most likely because dialysis and transplant are readily available in the country (Table 2). Nevertheless, PD is relatively less used compared with the rest of Latin America (7â9). Table 1. - Characteristics of patients on dialysis in Argentina Characteristic Value Country population 44,494,502 Patients on hemodialysis 29,929 Patients on peritoneal dialysis 1945 Patients with functioning kidney transplant 11,486 Prevalence of hepatitis B, % 0.2 Prevalence of hepatitis C, % 1 Prevalence of HIV, % 0.8 Prevalence of diabetes, % 28 Membrane dialyzer (reuse), synthetic/substituted cellulose/cellulose, % 83/14/4 Type of vascular access, native AVF/prosthetic AVF/catheter 70/15/15 Prevalence of patients with ESA, % 87 No. of hemodialysis centers 597 Hospital-based dialysis units, % 25 Nonprofit dialysis units, % 11 No. of peritoneal dialysis centers 79 Dialysis covered by insurance, % 100 Out-of-pocket expenses, % 0 Dialysis unit staffing, nurses/technicians, % 95/5 Payment per hemodialysis session, USD 55 Patient-nurse ratio in hemodialysis units, adult/pediatric 4â5/2â3 Average length of dialysis session, h 4 Minimum patient evaluation by physician per mo 4 No. of transplant centers 55 Adjusted annual mortality dialysis rate, % 16.48 Etiology of ESKD, % Diabetes 36.5 Nephroangiosclerosis 20 Unknown cause 17 GN 9 Myeloma and amyloidosis 1 Obstructive uropathy 6 Polycystic kidney disease, adult type 5 Epidemic uremic hemolytic syndrome 0.5 Other 5 Cause of death, % Cardiovascular 50 Infection 25 Neoplasia 6 Other 19 Source: Argentinean Registry of Dialysis and Transplantation (5,6). AVF, arteriovenous fistula; ESA, erythropoiesis-stimulating agents; USD, United States dollars. Figure 1.: Annual prevalence of dialysis patients ( 5 , 6 ).Figure 2.: Annual dialysis mortality rate . Rate is expressed in deaths per 100 patients at risk with 95% confidence interval bars. Source: Argentinean Registry of Dialysis and Transplantation (5,6). Table 2. - Comparison of RRT between Argentina and Latin America Argentina Latin America Prevalence of patients with ESKD under RRT (dialysis and transplant) a 976 805 Dialysis incidence rate a 160 154 Kidney transplant rate a 30 21 Patients on peritoneal dialysis, % 6.5 11.5 Nephrologist a 30 18 aRates are expressed per million population. Source: Latin American Registry of Dialysis and Transplantation (7). Structural Organization and Logistics of Dialysis Argentina has dialysis units in both hospital and private settings. There are a total number of 597 dialysis centers in the country. Eleven percent (68 centers) of these centers are government owned, 377 (63%) are independent dialysis centers, and the rest (152 centers; 26%) are owned by foreign dialysis companies. One hundred eighty-seven dialysis units are in the province of Buenos Aires, and the rest are located throughout the rest of the country. Dialysis is covered by patientsâ union health system or health insurance; ultimately, the government pays if the patient does not have insurance. Government coverage is universal if a patient does not have union or health insurance. This includes illegal immigrants, noncitizens, and refugees. Payment for HD and PD is capitated at approximately United States $700 per month or United States $55 per HD session. Physicians across the country are paid by monthly salaries, and some also have private practice. PD solutions are not manufactured in the country and are, therefore, imported. Bundle HD and PD payment includes vascular access, erythropoietin, appropriate vaccination, and transfer to and from the dialysis unit. Monthly reimbursement is irrespective of procedure number. Average HD sessions last for 240 minutes, with 95% of patients receiving three or more dialysis sessions per week (5,6). Online hemodiafiltration has been recorded since 2015. Approximately 20% of HD centers have this technology. Although 70% of patients on incident dialysis start with a temporary catheter as their vascular access, at 6 months into treatment most have permanent vascular access. Seventy percent of prevalent patients have an arteriovenous fistula. Nephrologists insert all temporary catheter access. Permanent HD catheters are placed by nephrologists also but mostly by vascular surgeons. Arteriovenous fistulas are 100% done by vascular surgery. Interventional nephrologists do not perform arteriovenous fistulas. Almost 87% of the patients are on erythropoietin or similar agents, and synthetic HD membranes are most commonly used. (Table 1) (5,6). The advent of technologic advancement, biosecurity implementation, and specific treatment has decreased the prevalence of hepatitis B, hepatitis C, and HIV in the dialysis population (0.2%, 1%, and 0.8%, respectively). Isolation of patients with hepatitis B is mandatory. No formal end-of-life care support programs are available in Argentina. Staffing of Dialysis Units Argentina is third among Latin American countries considering nephrology physicians per million inhabitants (Table 2) (7,8). There is one nephrologist for every 40 patients, and a nephrologist must be present in the dialysis unit at all times. There are approximately 80 renal fellows in training per year. Most patients are seen daily or at least four times a month. In continuous ambulatory peritoneal dialysis, they are seen once a month. Historically, non-nurse technicians accounted for the majority of dialysis personnel, but this has progressively decreased to approximately 5%. Nurses now provide the lionâs share of dialysis care. The main driving force for this change occurred 10 years ago when regulations were changed to increase the number of dialysis nurses taking care of these patients. The nurse to patient ratio is four to five adult patients per nurse in HD units and two to three children per nurse in pediatric units. In PD, the ratio is 20 adult and 15 pediatric patients per nurse (5,6). No formal dialysis nurse certification is in place in the country. Transplantation in Argentina The International Registry of Organ Donation and Transplantation reports that in 2019 there were approximately 1674 kidney transplants (1325 from deceased donors and 349 from living donors) in Argentina. There were 69 simultaneous kidney-pancreas transplants, 19 kidney-liver transplants, and 5 kidney-heart transplants. More men (62%) were transplanted than women. The availability of kidney transplants differs regionally around Argentina, with approximately 6546 patients with ESKD currently on the transplant list waiting for a new kidney. Average waiting time on the transplant list is over 4 years. Swap living kidney transplants have occurred, but there are very few cases (5). Transplantation is regulated by the INCUCAI (5,6). Since 2004, the INCUCAI has supported a National Dialysis and Transplant Registry. Patient reporting is obligatory, and therefore, national data are valid and representative. The INCUCAI in conjunction with the Argentine Society of Nephrology analyzes and reports the data of the National Dialysis and Transplant Registry (5,6). The INCUCAI, the Argentine Society of Nephrology, and the Argentine Transplant Society promote organ donation campaigns regularly. A recent law has declared the general population as presumed donors, and this has increased donation by 20%â25%. There are barriers to donation, but none are due to social or cultural barriers. Some of these barriers include logistics of organ harvesting and transportation in a large country, insufficient organ harvesting teams in some regions, etc. Future Directions and Challenges RRTs are accessible and available in Argentina, and utilization rates are acceptable compared with other countries in the region. It will be challenging to improve what is currently available with limited economic resources. An advanced kidney care program is not available nationwide and needs to be designed and implemented to guarantee early and programmed dialysis initiation and preemptive transplant when possible. PD is underused in Argentina for many reasons: peritoneal solutions are not manufactured in the country and are expensive, and most nephrologists have not been trained in PD because HD has been the predominant form of dialysis historically. Because many patients still begin dialysis without previous planification, the preferred dialysis modality used in urgent situations is HD through temporary catheter access. Training and economic incentives will help develop PD further. Home HD will most likely be set aside for some time. This technology is not available yet, and no reimbursement plans are underway for this dialysis modality. Disclosures G.J. Rosa Diez is employed by Fressenius. The remaining author has nothing to disclose. Funding None.
Zambia has been using output-based approaches for over two decades to finance whole or part of the public health system. Between 1996 and 2006, performance-based contracting (PBC) was implemented countrywide with the Central Board of Health (CBoH) as the provider of health services. This study reviews the association between PBC and equity of access to maternal health services in Zambia between 1996 and 2006. A comprehensive document review was undertaken to evaluate the implementation process, followed by a trend analysis of health expenditure at district level, and a segmented regression analysis of data on antenatal care (ANC) and deliveries at health facilities that was obtained from five demographic and health survey datasets (1992, 1996, 2002, 2007 and 2014). The results show that PBC was anchored by high-level political support, an overarching policy and legal framework, and collective planning and implementation with all key stakeholders. Decentralization of health service provision was also an enabling factor. ANC coverage increased in both the lower and upper wealth quintiles during the PBC era, followed by a declining trend after the PBC era in both quintiles. Further, the percentage of women delivering at health facilities increased during the PBC era, particularly in rural areas and among the poor. The positive trend continued after the PBC era with similar patterns in both lower and upper wealth quintiles. Despite these gains, per capita health expenditure at district level declined during the PBC era, with the situation worsening after the PBC era. The study concludes that a nationwide PBC approach can contribute to improved equity of access to maternal health services and that PBC is a cost-efficient and sustainable policy reform. The study calls for policymakers to comprehensively evaluate the impact of health system reforms before terminating them.
This analysis of the Finnish health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Finland is a welfare state witha high standard of social and living conditions and a low poverty rate. Its health system has a highly decentralized administration, multiple funding sources, and three provision channels for statutory services in first-contact care: the municipal system, the national health insurance system, and occupational health care. The core health system is organized by the municipalities (i.e. local authorities) which are responsible for financing primary and specialized care. Health financing arrangements are fragmented, with municipalities, the health insurance system, employers and households all contributing substantial shares. The health system performs relatively well, as health services are fairly effective, but accessibility may be an issue due to long waiting times and relatively high levels of cost sharing. For over a decade, there has been broad agreement on the need to reform the Finnish health system, but reaching a feasible policy consensus has been challenging.
Healthcare Policy and Management
Primary Care and Health Outcomes
Health Systems, Economic Evaluations, Quality of Life