Universal Health Coverage in Francophone Sub-Saharan Africa: Assessment of Global Health Experts' Confidence in Policy Options.

Many countries rely on standard recipes for accelerating progress toward universal health coverage (UHC). With limited generalizable empirical evidence, expert confidence and consensus plays a major role in shaping country policy choices. This article presents an exploratory attempt conducted between April and September 2016 to measure confidence and consensus among a panel of global health experts in terms of the effectiveness and feasibility of a number of policy options commonly proposed for achieving UHC in low- and middle-income countries, such as fee exemptions for certain groups of people, ring-fenced domestic health budgets, and public-private partnerships.

Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality.

This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care.

Improvement of maternal and newborn health through midwifery.

In the concluding paper of this Series about midwifery, we look at the policy implications from the framework for quality maternal and newborn care, the potential effect of life-saving interventions that fall within the scope of practice of midwives, and the historic sequence of health system changes that made a reduction in maternal mortality possible in countries that have expanded their midwifery workforce. Achievement of better health outcomes for women and newborn infants is possible, but needs improvements in the quality of reproductive, maternal, and newborn care, alongside necessary increases in universal coverage. In this report, we propose three priority research areas and outline how national investment in midwives and in their work environment, education, regulation, and management can improve quality of care.

Perceptions of the usefulness of external support to immunization coverage in Guinea-Bissau: a Delphi analysis of the GAVI-Alliance cash-based support.

Introduction: Although many countries have improved vaccination coverage in recent years, some, including Guinea-Bissau, failed to meet expected targets. This paper tries to understand the main barriers to better vaccination coverage in the context of the GAVI-Alliance (The Global Alliance for Vaccines and Immunisation) cash-based support provided to Guinea-Bissau.

Methods: The analysis is based on a document analysis and a three round Delphi study with a final consensus meeting.

The role of hospitals within the framework of the renewed primary health care (PHC) strategy.

This article summarizes a presentation made at the IHF Leadership Summit held in Chicago, USA in June 2010, by Denis Porignon from the World Health Organization (WHO) and Reynaldo Holder from the Pan American Health Organization (PAHO/WHO). It focuses on the role of hospitals within the framework of the renewed PHC strategy.

The response to flexibility: country intervention choices in the first four rounds of the GAVI Health Systems Strengthening applications.

Since December 2005 the GAVI Alliance (GAVI) Health Systems Strengthening (HSS) window has offered predictable funding to developing countries, based on a combined population and economic formula. This is intended to assist them to address system constraints to improved immunization coverage and health care delivery, needed to meet the Millennium Development Goals. The application process invites countries to prioritize specific system constraints not adequately addressed by other donors, and allows them to allocate their eligible funds accordingly.

The contribution of primary care to health and health systems in low- and middle-income countries: a critical review of major primary care initiatives.

It has been 30 years since the Declaration of Alma Ata. During that time, primary care has been the central strategy for expanding health services in many low- and middle-income countries. The recent global calls to redouble support for primary care highlighted it as a pathway to reaching the health Millennium Development Goals.

Linking programmes and systems: lessons from the GAVI Health Systems Strengthening window.

Objectives: To analyse the first four rounds of country applications to the GAVI Alliance Health Systems Strengthening (GAVI-HSS) funding window; to provide valuable insight into how countries prioritize, articulate and propose solutions for health system constraints through the GAVI-HSS application process and to examine the extent to which this process embodies alignment and harmonization, Principles of the Paris Declaration.

Methods: The study applied multiple criteria to analyse 48 funding applications from 40 countries, submitted in the first four rounds, focusing on the country analysis of health systems constraints, coordination mechanisms, alignment with national and sector planning processes, inclusiveness of the planning processes and stakeholder engagement.

Results: The applications showed diversity in the health systems constraints identified and the activities proposed.

A case study of team work and performance-linked payment of family physicians in Portugal.

In Portugal, the design and the implementation of models of primary care teams has a history of 30 years. The evolution observed is from individual medical work, in Health Centres, supported on an ad hoc basis by other health professionals, to health centres integrating a diversity of formal working groups, including primary care/family health teams called "Family Health Units" (FHU). This evolution included the creation and gradual affirmation of the speciality of family medicine and the experimentation with different models of primary health care provision: voluntary primary care health teams without financial incentives (Alfa project), voluntary primary care health teams with a performance-related-remuneration system and the current phase of scaling up FHU.

Going to scale with professional skilled care.

Because most women prefer professionally provided maternity care when they have access to it, and since the needed clinical interventions are well known, we discuss in their paper what is needed to move forward from apparent global stagnation in provision and use of maternal health care where maternal mortality is high. The main obstacles to the expansion of care are the dire scarcity of skilled providers and health-system infrastructure, substandard quality of care, and women's reluctance to use maternity care where there are high costs and poorly attuned services. To increase the supply of professional skilled birthing care, strategic decisions must be made in three areas: training, deployment, and retention of health workers.

Is motivation enough? Responsiveness, patient-centredness, medicalization and cost in family practice and conventional care settings in Thailand.

Background: In Thailand, family practice was developed primarily through a small number of self-styled family practitioners, who were dedicated to this professional field without having benefited from formal training in the specific techniques of family practice. In the context of a predominantly hospital-based health care system, much depends on their personal motivation and commitment to this area of medicine. The purpose of this paper is to compare the responsiveness, degree of patient-centredness, adequacy of therapeutic decisions and the cost of care in 37 such self-styled family practices, i.

Monitoring the referral system through benchmarking in rural Niger: an evaluation of the functional relation between health centres and the district hospital.

Background: The main objective of this study is to establish a benchmark for referral rates in rural Niger so as to allow interpretation of routine referral data to assess the performance of the referral system in Niger.

Methods: Strict and controlled application of existing clinical decision trees in a sample of rural health centres allowed the estimation of the corresponding need for and characteristics of curative referrals in rural Niger. Compliance of referral was monitored as well.

Choosing between public and private or between hospital and primary care: responsiveness, patient-centredness and prescribing patterns in outpatient consultations in Bangkok.

Objective: To document differences in provider behaviour between private and public providers in hospital outpatient departments, health centres and clinics in Bangkok, Thailand.

Method: Analysis of the characteristics of 211 taped consultations with simulated patients.

Results: Private hospitals and clinics were significantly more responsive.

Unaffordable or cost-effective?: introducing an emergency referral system in rural Niger.

Objectives: An important investment was made in two health districts in Niger to organize an emergency referral system. This study estimates its impact and cost-effectiveness in relation with external determinants.

Methods: After installing a solar radio network in the health centres, emergency calls and related data were monitored over 7 years and investment and recurrent costs for the system were estimated.

Dual practice in the health sector: review of the evidence.

This paper reports on income generation practices among civil servants in the health sector, with a particular emphasis on dual practice. It first approaches the subject of public-private overlap. Thereafter it focuses on coping strategies in general and then on dual practice in particular.

Pilfering for survival: how health workers use access to drugs as a coping strategy.

BACKGROUND: Coping strategies have, in some countries, become so prevalent that it has been widely assumed that the very notion of civil services ethos has completely - and possibly irreversibly - disappeared. This paper describes the importance and the nature of pilfering of drugs by health staff in Mozambique and Cape Verde, as perceived by health professionals from these countries. Their opinions provide pointers as to how to tackle these problems.

The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger.

BACKGROUND: For a health district to function referral from health centres to district hospitals is critical. In many developing countries referral systems perform well below expectations. Niger is not an exception in this matter.

Strengthening health services to control epidemics: empirical evidence from Guinea on its cost-effectiveness.

Objective: To assess the cost-effectiveness of control measures implemented against epidemics in Guinea, West Africa.

Methods: We collected all routine data available on incidence, mortality, control measures implemented and their cost during epidemics of cholera, measles and meningococcal meningitis in 1993-95. Then we estimated for one prefecture the effectiveness and cost-effectiveness of epidemic control measures for three scenarios: (i) 'natural' situation, (ii) 'routine' health services and (iii) 'intervention'.

Skilled attendants for pregnancy, childbirth and postnatal care.

This paper sets out the rationale for ensuring that all pregnant women have access to skilled health care practitioners during pregnancy and childbirth. It describes why increasing access to a skilled attendant, especially at birth, is not only based on legitimate demand and clinical common sense, but is also cost-effective and feasible in resource-poor countries. Skilled attendants need to be supported by a health system providing a legal and policy infrastructure, an effective referral system and the supplies that are necessary for effective care.

When staff is underpaid: dealing with the individual coping strategies of health personnel.

Health sector workers respond to inadequate salaries and working conditions by developing various individual "coping strategies"--some, but not all, of which are of a predatory nature. The paper reviews what is known about these practices and their potential consequences (competition for time, brain drain and conflicts of interest). By and large, governments have rarely been proactive in dealing with such problems, mainly because of their reluctance to address the issue openly.