Health systems and reform最新文献

Cross-programmatic inefficiencies are duplications or misalignments that arise from undue fragmentation of health systems by vertical health programs. Identifying and addressing the root causes of cross-programmatic inefficiencies in a health system can ensure more efficient use of resources to make progress toward Universal Health Coverage. This paper examines the root causes of cross-programmatic inefficiencies related to governance and financing in the state health system of Anambra in southeast Nigeria. Data were collected from 38 in-depth interviews and four focus group discussions and analyzed thematically. The governance- and finance-related cross-programmatic inefficiencies identified were duplicative and misaligned roles within and between state and federal agencies, functions, and activities within and across health programs; misaligned donor priorities with that of the state; and poor formulation and implementation of the approved annual state health budget. The root causes of governance and financing cross-programmatic inefficiencies included weak policy development, communication, and enforcement; excessive influence of external donors and the federal government; weak accountability mechanisms affecting program coordination and service delivery; and a disharmony between state priorities and objectives with planning, budgeting, and execution of the budget. Addressing the root causes of cross-programmatic inefficiencies has the potential to significantly improve the overall efficiency and performance of the health system to contribute to improved health outcomes in Anambra state. This approach can serve as a model for other states and regions facing similar challenges.

The Philippine Universal Health Care (UHC) law enacted in 2019 aimed to address entrenched health system challenges to achieving equitable access to quality health care. This commentary discusses the progress in its implementation to meet its objectives. Some of these health system challenges include overlapping financing roles; weak incentives for integrating health services across local government units (LGUs), the inclusion of the private sector in networks of care, and fragmented primary health care services. The UHC law introduced reforms to transform the Philippine Health Insurance Corporation (PhilHealth) into a strategic purchaser of health services, expand population coverage, and prioritize comprehensive outpatient and primary care services. Furthermore, the law mandated bolstering subnational health financing through a Special Health Fund (SHF) intended to encourage LGUs to integrate into provincial or city health systems. Pilots of the SHF highlighted opportunities and challenges in pooling, prioritizing, and redistributing resources if local health systems are capacitated. Despite facing implementation challenges, including changing priorities, politics, and lack of resources, the Philippines' experience emphasizes the importance of adaptive leadership, sustained commitment, and effective stakeholder engagement to ensure that these health financing reforms remain objective-oriented. Maximizing the UHC law's potential going forward requires addressing ongoing challenges: sustained resource generation, ensuring effective coverage of the poor, and capacitating local health systems. The journey of the Philippines toward UHC offers valuable insights for global health reformers, underscoring the need for adaptive approaches and active political engagement to sustain and achieve progress toward universal and equitable health care access.

Health programs play important roles in health systems, contributing to the development of best practices, guidelines, awareness, and advocacy for specific services, populations, or conditions. However, a person's health is not defined by single conditions or interventions and therefore cannot be fully catered to by only one program. Additionally, the Universal Health Coverage (UHC) index has stagnated in recent years, even for programmatic outcomes heavily supported by external assistance, raising concerns about the efficiency and sustainability of many programs and their objectives. The World Health Organization's cross-programmatic efficiency analysis (CPEA) approach provides a way to assess programs with a system-wide perspective. CPEA is an approach for analyzing programs based on health system functions and considers how the entire system, including programs, aligns to meet objectives. It focuses on identifying areas of duplication or misalignment as targets for reforms. This policy report summarizes findings from CPEA analyses conducted by six countries (Bhutan, Ghana, Kenya, South Africa, Sri Lanka, and Tanzania) between 2017 and 2021. The cases demonstrate the extent and areas of duplication across programs, including information systems, health workforce, and supply chains. Duplications and misalignments in the generation of human and physical resources (subsequently referred to as "inputs") are often driven by how health programs are financed and governed. These inefficiencies directly impact how people receive health services. Comparing CPEA findings from multiple countries demonstrates that using the whole health system as the unit of analysis is critical when seeking to increase system efficiency and align available resources to meet UHC objectives.

Incremental health system transformations towards universal health coverage run the risk of losing sight of the overarching objectives and can lose momentum in the implementation process. Argentina's Programa Sumar is a program born out of response to both urgent and long-standing health challenges. Starting with a relatively small share of the government's budget for health, the Program over the last 20 years has gradually expanded in pursuit of increasing access to quality health care, fostering coherence through policy alignment and coordination in a highly decentralized system, and achieving its performance objectives through conditional transfers linked to results. This commentary reflects on how Programa Sumar created and has sustained its approach to health system transformation and provides four lessons: 1) distribute leadership across levels of government to enhance autonomy, collaboration, and implementation; 2) expand gradually, with a clear long-term vision - Programa Sumar took an incremental approach to expansion in terms of regions, populations, services, and management capacities; 3) ensure evolution through solid and flexible design - the Program needed both the flexibility to adapt strategies to various challenges and a constancy of purpose; and 4) compromise to make progress. The Argentine experience with Programa Sumar shows that strengthening a scheme does not have to mean adopting a fragmented approach. Instead, by implementing Programa Sumar thoughtfully and collaboratively, the reform has developed a solid foundation with the flexibility to adapt across geographies and time, creating the necessary conditions for expansion to and greater coherence across the entire system.

Health financing fragmentation poses a challenge to reforms intended to address system-wide objectives vis-à-vis universal health coverage (UHC). India's experience with publicly subsidized health insurance schemes (PSHIs), such as Rashtriya Swasthya Bima Yojana (RSBY) and its state adaptations, testify to the challenges inherent in effecting objective-oriented health systems reforms, particularly owing to wide variation in programmatic and operational design. Recent efforts to defragment PSHIs under the aegis of a new government initiative called Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) using, inter alia, a unified information and communication technology (ICT) interface provide important policy lessons. This paper presents a theory of change for the role that ICT systems can play in promoting the objectives of UHC and highlights the early effects of ICT reforms in India on UHC. Holistic and defragmented ICT systems have a positive effect on the processes and operations of government health programs, according to the literature reviewed. Streamlined ICT systems promote equity through the introduction of portability modules, which increase access to services and facilitate stronger transparency and accountability measures by using big data and machine learning for fraud detection. Although reliability issues persist on certain fronts, India's experience with homegrown, incremental reforms to defragment ICT systems for health financing have proven of paramount importance for progressing toward UHC.

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.

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 (n = 316) with health facility clients, in-depth interviews (n = 134) with national and county-level health sector stakeholders, focus group discussions (n = 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.

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.