Assessing Root Causes and Solutions to Address Cross-Programmatic Inefficiencies in a Subnational Health System: A Case Study of Anambra State, Nigeria.

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.

Cross-Programmatic Efficiency: The System is Greater Than the Sum of Its Programs.

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.

Objective-Oriented Health Systems Reform.

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.

Using a Small Lever to Achieve Big Outcomes in a Devolved Health System: 20 Years of Programa Sumar in Argentina.

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.

Managing transitions from external assistance: cross-national learning about sustaining effective coverage.

The often-prominent role of external assistance in health financing in low- and middle-income countries raises the question of how such resources can enable the sustained or even expanded coverage of key health services and initiatives even after donor funding is no longer available. In response to this question, this paper analyses the process and outcomes of donor transitions in health-where countries or regions within countries are no longer eligible to receive grants or concessional loans from external sources based on eligibility criteria or change in donor policy. The comparative analysis of multiple donor transitions in four countries-China, Georgia, Sri Lanka and Uganda-identifies 16 factors related to policy actors, policy process, the content of donor-funded initiatives and the broader political-economic context that were associated with sustained coverage of previously donor supported interventions.

Normalizing the political economy of improving health.

Problem: Political economy factors are important in determining the adoption and implementation of health policies. Yet these factors are often overlooked in the development of policies that have the potential to influence health.

Approach: Political economy analysis provides a way to take into consideration political and social realities, whether at the community, subnational, national, regional or global levels.

Will the Quest for UHC be Derailed?

COVID-19 has shocked all countries' economic and health systems. The combined direct health impact and the current macro-fiscal picture present real and present risks to health financing that facilitate progress toward universal health coverage (UHC). This paper lays out the health financing mechanisms through which the UHC objectives of service coverage and financial protection may be impacted.

Financing Common Goods for Health: A Country Agenda.

Collective financing, in the form of either public domestic revenues or pooled donor funding, at the country level is necessary to finance common goods for health, which are population-based functions or interventions that contribute to health and have the characteristics of public goods. Financing of common goods for health is an important part of policy efforts to move towards Universal Health Coverage (UHC). This paper builds from country experiences and budget documents to provide an evidence-based argument about how government and donor financing can be reorganized to enable more efficient delivery of common goods for health.

Political Economy Analysis for Health Financing Reform.

Health financing reform is an inherently political process that alters the distribution of entitlements, responsibilities and resources across the health sector and beyond. As a result, changes in health financing policy affect a range of stakeholders and institutions in ways that can create political obstacles and tensions. As countries pursue health financing policies that support progress towards Universal Health Coverage, the analysis and management of these political concerns must be incorporated in reform processes.

The impact of the Family Medicine Model on patient satisfaction in Turkey: Panel analysis with province fixed effects.

Background: In this study, we aim to establish the impact of the introduction of the Family Medicine Model patient satisfaction in the Turkish health system.

Methods: We use data on data 69,028 primary health care (PHC) patients over the period 2010-2012. We estimate the impact of the Family Medicine Model in panel regressions with province fixed effects, exploiting the sequential introduction of this health systems transformation across Turkey's 81 provinces.

Can Low- and Middle-Income Countries Increase Domestic Fiscal Space for Health: A Mixed-Methods Approach to Assess Possible Sources of Expansion.

There has not been a systematic effort to synthesize findings of domestic fiscal space for health (DFSH) assessments, despite the existence of a commonly applied conceptual framework. To fill this gap and provide support to policy makers designing health financing policies toward universal health coverage (UHC), this study uses both qualitative and quantitative methods to assess the scope of possible sources of DFSH in low- and middle-income countries (LMICs). First, the findings of 28 studies assessing DFSH in LMICs were reviewed.

PEPFAR Investments In Governance And Health Systems Were One-Fifth Of Countries' Budgeted Funds, 2004-14.

Launched in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) is the largest disease-focused assistance program in the world. We analyzed PEPFAR budgets for governance and systems for the period 2004-14 to ascertain whether PEPFAR's stated emphasis on strengthening health systems has been manifested financially. The main outcome variable in our analysis, the first of its kind using these data, was the share of PEPFAR's total annual budget for a country that was designated for governance and systems.

Political Strategies for Health Reform in Turkey: Extending Veto Point Theory.

-This qualitative case study uses primary interview data to investigate the political processes of how Turkey established a unified and universal health coverage system. The goal of providing health coverage to all citizens through a unified system has been adopted by many low- and middle-income countries, but few have achieved it; Turkey is a notable exception. We use institutional veto point theory to identify four institutional obstacles to a unified and universal coverage system in Turkey between 2003 and 2008: (1) the Ministry of Finance and Treasury, (2) the Ministry of Labor and Social Security, (3) the Office of the President, and (4) the Constitutional Court.

Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening.

Background: Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), yet few studies have examined their effects on health systems.

Objective: To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the largest investor in HRH outside national governments.

Methods: We used mixed research methodology to analyse budget allocations and expenditures for HRH, including training, for 138 countries receiving money from the Global Fund during funding rounds 1-7.

Health workforce skill mix and task shifting in low income countries: a review of recent evidence.

Background: Health workforce needs-based shortages and skill mix imbalances are significant health workforce challenges. Task shifting, defined as delegating tasks to existing or new cadres with either less training or narrowly tailored training, is a potential strategy to address these challenges. This study uses an economics perspective to review the skill mix literature to determine its strength of the evidence, identify gaps in the evidence, and to propose a research agenda.