Health systems and reform最新文献

{"title":"Public Financial Management: A Pathway to Universal Health Coverage in Low-and-Middle Income Countries.","authors":"Hélène Barroy, Pierre Yameogo, Mark Blecher, Martin Sabignoso, Moritz Piatti, Joseph Kutzin","doi":"10.1080/23288604.2024.2368051","DOIUrl":"10.1080/23288604.2024.2368051","url":null,"abstract":"","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2368051"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142803737","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Does Provider Autonomy Work Well in Tanzania? Perspectives of Primary Care Facilities on Budget Execution under Direct Facility Financing and Factors Affecting Provider Autonomy in Singida Region.","authors":"Peter Binyaruka, John Maiba, Dastan Mshana, Agnes Gatome-Munyua, Gemini Mtei","doi":"10.1080/23288604.2024.2432043","DOIUrl":"https://doi.org/10.1080/23288604.2024.2432043","url":null,"abstract":"<p><p>Primary care facilities' autonomy and the factors that influence it are understudied. Direct facility financing (DFF) is gaining popularity in low- and middle-income countries as a modality to finance primary care facilities. Tanzania has introduced DFF with the objectives of streamlining resource allocation, fostering fiscal decentralization, and granting autonomy to health facilities for enhanced service readiness and responsiveness. This study aims to contribute evidence on primary care facilities' autonomy to execute DFF funds and the factors influencing this autonomy.Qualitative interviews and group discussions were conducted with health workers, managers, and community representatives from two councils to understand their perceptions of the autonomy of primary care facilities under DFF and remaining bottlenecks to effective budget execution. Data were analyzed using thematic content analysis to explore factors that influence facility autonomy to execute DFF funds.Primary care facilities are well informed on financial management and have adequate autonomy to execute DFF funds. However, several factors constrain their autonomy, including delays in funds disbursement, complex procurement and approval processes, rigid spending caps, restrictions on reallocations, and weaknesses in financial management capacity.DFF is a promising modality for health financing that supports health system goals. However, various challenges continue to hinder the autonomy of frontline service providers to fully execute DFF funds. To improve DFF budget execution, policy makers in Tanzania and elsewhere should consider reforms to better align public financial management and health financing.</p>","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2432043"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142803734","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Examining the Implementation Experience of the Universal Health Coverage Pilot in Kenya.","authors":"Lizah Nyawira, Yvonne Machira, Kenneth Munge, Jane Chuma, Edwine Barasa","doi":"10.1080/23288604.2024.2418808","DOIUrl":"https://doi.org/10.1080/23288604.2024.2418808","url":null,"abstract":"<p><p>The Kenyan government implemented a Universal Health Coverage (UHC) pilot project in four (out of 47) counties in 2019 to address supply-side gaps and remove user fees at county referral hospitals. The objective of this study was to examine the UHC pilot implementation experience using a mixed-methods cross-sectional study in the four UHC pilot counties (Isiolo, Kisumu, Machakos, and Nyeri). We conducted exit interviews (<i>n</i> = 316) with health facility clients, in-depth interviews (<i>n</i> = 134) with national and county-level health sector stakeholders, focus group discussions (<i>n</i> = 22) with community members, and document reviews. We used a thematic analysis approach to analyze the qualitative data and descriptive analysis for the quantitative data. The UHC pilot resulted in increased utilization of healthcare services due to removal of user fees at the point of care and increased availability of essential health commodities. Design and implementation challenges included: a lack of clarity about the relationship between the UHC pilot and existing health financing arrangements, a poorly defined benefit package, funding flow challenges, limited healthcare provider autonomy, and inadequate health facility infrastructure. There were also persistent challenges with the procurement and supply of healthcare commodities and with accountability mechanisms between the Ministry of Health and county health departments. The study underscores the need for whole-system approaches to healthcare reform in order to ensure that the capacity to implement reforms is strengthened, and to align new reforms with existing system features.</p>","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2418808"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142677966","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Health Reforms in Pursuit of Universal Health Coverage: Lessons from Kenyan Bureaucrats.","authors":"Wangari Ng'ang'a, Mercy Mwangangi, Agnes Gatome-Munyua","doi":"10.1080/23288604.2024.2406037","DOIUrl":"10.1080/23288604.2024.2406037","url":null,"abstract":"<p><p>In this commentary, two members of the technical teams that led Kenyan health reforms reflect on progress made in the country's journey toward universal health coverage during President Uhuru Kenyatta's second term (2017 to 2022). The authors discuss how key decisions were made while balancing multiple considerations such as: maintaining the technical fidelity of the reforms to achieve objectives, accounting for the context of previous reforms, and making necessary trade-offs between technical and political pressures. They share three lessons, contextualized with African proverbs, for others implementing health reforms. First: \"The person who does not seize today's opportunity will also be unable to seize tomorrow's opportunity\"-that is, act quickly when opportunities arise. Second: \"The person who cannot dance will say, 'The drum is bad!'\" This implies that naysayers, especially those who are not part of technical teams, may not understand the reasons behind certain decisions or trade-offs. Reformers must balance different needs, including responding to varied opinions, taking urgent action, generating timely results, making technically sound decisions, and getting the design right. And third: \"A bird that flies from the ground onto an anthill does not know that it is still on the ground.\" This proverb reminds us to not mistake short-term gains for the achievement of long-term goals. Kenya continues to enjoy unprecedented political will to pursue health reforms. For other reformers lucky enough to have political support, the final advice to the technical teams in the driver's seat is to design for delivery … and then start!</p>","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2406037"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143442665","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Objective-Oriented Health Systems Reform.","authors":"Joseph Kutzin, Susan P Sparkes, Alexandra J Earle, Agnes Gatome-Munyua, Nirmala Ravishankar","doi":"10.1080/23288604.2024.2428415","DOIUrl":"10.1080/23288604.2024.2428415","url":null,"abstract":"<p><p>This paper emphasizes the importance of orienting health system reforms to address underlying system-level performance problems. Too often in practice, the objective-orientation that is stressed in health system frameworks gets lost in relation to policies or schemes that are promoted without plausible linkages to the actual objectives of the reforms. The objective-orientation can also get subsumed by political agendas that are disconnected, or can even detract from, people's health needs. There are three core attributes to objective-oriented health system reform: (i) problem-oriented; (ii) consistent (extent to which reforms are connected to the problems they are meant to address and reflect lessons from global and national experience); and (iii) continuously evaluated. Country experiences reviewed in the paper, and presented in this special issue, illustrate how taking an objective-orientation led reformers to alter the details of implementation. Continuous learning also informed adaptations needed to strategically sequence and link reforms with objectives. An objective-oriented approach enables reformers to: (i) seize windows of opportunity; (ii) find room to maneuver under the label of the reform; (iii) integrate applied research into reform implementation; and (iv) skillfully interpret political statements to align with technical best practices. The approach and attributes laid out in this paper put forward considerations for policy makers as they design, implement, evaluate, and adapt policies to feasibly improve health system performance. They also, importantly, help guard against a rush toward policies or schemes that may sound good in speeches or declarations but do not have a plausible link to objectives.</p>","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2428415"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142735204","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Strengthening the Resilience of Objective-Oriented Health System Reforms. Analysis of the Left-Turn in the Health Reform Proposals in Mexico (2019) and Colombia (2023).","authors":"Laura Flamand, Octavio Gómez-Dantés, Natalia Losada-Trujillo, Diana Pinto, Edson Serván-Mori, Diego Cerecero-García, Thomas Hone, Sumit Mazumdar","doi":"10.1080/23288604.2025.2461096","DOIUrl":"10.1080/23288604.2025.2461096","url":null,"abstract":"<p><p>This article explores the political and institutional factors that led two leftist governments to propose sweeping, rather than incremental, changes to earlier objective-oriented health systems reforms. One is the government of Mexico led by President Andrés Manuel López Obrador, who in 2019 proposed to replace reforms approved in 2003. His proposal was passed by Congress and implemented. The other is the government of President Gustavo Petro in Colombia, who in 2023 recommended the replacement of the health reform implemented in Colombia since 1993. His proposal was rejected by Congress. Drawing on historical institutionalism, we analyzed the interactions among actors and institutions that shaped their reform proposals, focusing on policy feedback effects and veto points. We examined news articles, government and policy documents, electoral results, presidential approval ratings, and legislative voting records. We also conducted in-depth interviews with key actors about the factors behind the need for reform, the policy proposals, and the public and legislative debates. In both countries, we found that a combination of policy feedback effects (political ideology beliefs, and policy legacies that shape public perceptions and expectations) and veto points (the perceived strength of the president vis-à-vis reform opponents) help explain the decisions to propose such significant changes to the health care systems. Based on these findings, we offer initial recommendations for safeguarding objective-oriented health system reforms in lower-middle and upper-middle-income countries facing stark political change, especially in polarized contexts. Objective-oriented health system reforms should be evidence-based and supported by long-term financing, delivery, management, and evaluation plans. For long-term resilience, they also need multiple networks to secure them, including citizens well informed about their benefits, health workers with a sense of ownership, and legal protections.</p>","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2461096"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143257512","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Objective-Oriented Health Systems Reform: Implications for Moving Towards Universal Health Coverage.","authors":"Agnes Gatome-Munyua, Susan P Sparkes, Alexandra J Earle, Joseph Kutzin, Nirmala Ravishankar","doi":"10.1080/23288604.2024.2440214","DOIUrl":"10.1080/23288604.2024.2440214","url":null,"abstract":"","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2440214"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142959809","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rwanda's Single Project Implementation Unit: An Effective Donor Coordination Platform in the Journey to Achieving Universal Health Coverage.","authors":"Parfait Uwaliraye, Valencia Lyle, James Mwanza, Gilbert Biraro","doi":"10.1080/23288604.2024.2403527","DOIUrl":"https://doi.org/10.1080/23288604.2024.2403527","url":null,"abstract":"<p><p>Following the devastating 1994 Genocide, the Government of Rwanda and its citizens have worked relentlessly to rebuild the country and reassemble a strong health system. Immediately after the genocide, global development partners sought to swiftly provide aid and support to the country to address urgent health system needs. However, inadequate coordination of the influx of aid resulted in duplicated efforts and inefficient health sector management. In 1998, the Central Public Investments and External Finance Bureau undertook the monitoring and evaluation of donor-funded projects and management of the Public Investment Program. However, the Bureau had limited time, resources, and health system expertise, impeding its efforts to effectively coordinate development partners. To address these inefficiencies, the Rwandan government next adopted a Sector-Wide Approach to coordinate the support of development partners at the sector level. Again, this coordination approach did not adequately consider the health sector's needs. In 2011, the Single Project Implementation Unit (SPIU) structure was created to coordinate national- and district-level government sectoral initiatives, including ensuring that intended populations were included in planning and decision-making processes. In the health sector, this included a focus on the overall goal of achieving universal health coverage. The health sector SPIU has aided Rwanda in addressing systemic financing issues at all health system levels. Challenges remain; in particular, the SPIU has struggled to align some development partners with the Government's planning calendar to maximize efficiency. It also needs to optimize the use of technology in the health sector to ensure timely decision making.</p>","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2403527"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142634141","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Policy Options for Contributory Health Insurance Schemes in Low and Lower-Middle Income Countries to Enable Progress Towards Universal Health Coverage.","authors":"Agnes Gatome-Munyua, Joseph Kutzin, Cheryl Cashin","doi":"10.1080/23288604.2025.2449905","DOIUrl":"10.1080/23288604.2025.2449905","url":null,"abstract":"<p><p>The promise of contributory health insurance to generate additional, self-sustaining funding for the health sector has not been achieved in many low- and lower-middle-income countries. Instead, contributory health insurance has been found to exacerbate inequities in access to health care because entitlements are linked to contributions. For these countries with contributory health insurance schemes, with separate institutional arrangements for revenue collection and purchasing, that operate alongside budget-funded and other health financing schemes, it is usually not politically or technically feasible to reverse or eliminate these arrangements even when they fragment the health system. We propose three complementary policy options for countries in this difficult position to enable progress towards UHC: (1) Merge existing schemes into a single scheme (or fewer schemes) to consolidate pooling and purchasing functions. (2) Build on what they have by: reducing reliance on contributions by increasing budget transfers; using existing revenue collection mechanisms to allow the insurance agency to focus on the purchasing function; and strengthening insurance agencies' operational capacity for purchasing. (3) Reframe the insurance agency's role within the overall health system, rather than treating it as a distinct system by: unifying data collection and analysis for all patient visits irrespective of scheme membership, and universalizing core benefits across the population. We urge countries to review the patchwork of schemes and avoid worsening fragmentation that compromises health system performance. Countries can then create a strategy to expand coverage more equitably in a sequential manner, while consolidating institutional capacity for purchasing and unifying data systems.</p>","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2449905"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143029997","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Applied Political Analysis for Health System Reform.","authors":"Michael R Reich, Paola Abril Campos Rivera","doi":"10.1080/23288604.2024.2430284","DOIUrl":"https://doi.org/10.1080/23288604.2024.2430284","url":null,"abstract":"<p><p>Understanding and managing the political context of health policies is crucial to improving the chances of effectively designing, adopting, and implementing health policies and reforms that can achieve their intended objectives. This article focuses on applied political analysis as an approach to assist policymakers and public health professionals in improving political feasibility for policies and reforms. The article draws on our experience in doing applied political analysis and in advising and teaching others how to do applied political analysis. We describe the role of applied political analysis at six stages of the policy cycle (problem definition, diagnosis, policy development, political decision, implementation, and evaluation). We then present four steps for doing applied political analysis, using a concrete example at each step: 1) agree on the objectives and methods of analysis, 2) conduct a stakeholder analysis, 3) design a set of political strategies, and 4) assess the impact of the strategies on policitcal feasibility of the desired change. Political landscapes can change suddenly in unexpected ways. Doing applied political analysis, however, can increase the likelihood that the proposed policy changes will be adopted and achieve the desired outcomes in implementation. Repeating the analysis over time as the policy process unfolds and keeping track of stakeholders and strategies can increase the chances that health reform teams successfully manage the politics of policy change.</p>","PeriodicalId":73218,"journal":{"name":"Health systems and reform","volume":"10 3","pages":"2430284"},"PeriodicalIF":0.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142787708","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}