There is need for intensive capacity development to ensure that the human resources function is... more There is need for intensive capacity development to ensure that the human resources function is carried out by individuals with the right competencies. Policies should be monitored and evaluated and the findings from such processes should be made available to a wide audience rather than to a select few.
Most countries face challenges attracting and retaining health staff in remote areas but this is ... more Most countries face challenges attracting and retaining health staff in remote areas but this is especially acute in fragile and shock-prone contexts, like Guinea, where imbalances in staffing are high and financial and governance arrangements to address rural shortfalls are weak. The objective of this study was to understand how health staff could be better motivated to work and remain in rural, under-served areas in Guinea. In order to inform the policy dialogue on strengthening human resources for health, we conducted three nationally representative cross-sectional surveys, adapted from tools used in other fragile contexts. We found that the locational job preferences of health workers in Guinea are particularly influenced by opportunities for training, working conditions, and housing. Most staff are satisfied with their work and with supervision, however, financial aspects and working conditions are considered least satisfactory, and worrying findings include the high proportion...
L'Organisation Mondiale de la Sante (OMS) estime que 536.000 femmes meurent chaque annee de p... more L'Organisation Mondiale de la Sante (OMS) estime que 536.000 femmes meurent chaque annee de problemes lies a la grossesse, et que la quasitotalite de ces deces surviennent dans les pays en developpement (OMS 2007). Au Niger, le risque de mortalite maternelle est estime a un sur sept au cours de la vie d’une femme (OMS 2007). Dans les pays moins developpes, 18% des deces de femmes sont attribuables a la maternite (World Bank 1993). On estime que trois quarts de ces deces pourraient etre evites si les structures de soins de sante primaires (centres de sante et hopitaux) proposaient un paquet de soins maternels de base. Cependant, a ce jour, relativement peu de progres ont ete faits. Une etude recente de l’evolution de la mortalite maternelle entre 1990 et 2005 montre une diminution significative de 2,5% par an au niveau mondial, mais sans diminution significative en Afrique sub-saharienne, ou elle ne diminue que de 1,8%, passant de 921 pour 100.000 naissances vivantes en 1990 a 90...
Background As performance-based financing (PBF) is increasingly implemented across sub-Saharan Af... more Background As performance-based financing (PBF) is increasingly implemented across sub-Saharan Africa, some authors have suggested that it could be a 'stepping stone' for health-system strengthening and broad health-financing reforms. However, so far, few studies have looked at whether and how PBF is aligned to and integrated with national health-financing strategies, particularly in fragile and conflict-affected settings. Objective This study attempts to address the existing research gap by exploring the role of PBF with reference to: (1) user fees/exemption policies and (2) basic packages of health services and benefit packages in the Central African Republic, Democratic Republic of Congo and Nigeria. Methods The comparative case study is based on document review, key informant interviews and focus-group discussions with stakeholders at national and subnational levels. Results The findings highlight different experiences in terms of PBF's integration. Although (formal or informal) fee exemption or reduction practices exist in all settings, their implementation is not uniform and they are often introduced by external programmes, including PBF, in an uncoordinated and vertical fashion. Additionally, the degree to which PBF indicators lists are aligned to the national basic packages of health services varies across cases, and is influenced by factors such as funders' priorities and budgetary concerns. Conclusions Overall, we find that where national leadership is stronger, PBF is better integrated and more in line with the health-financing regulations and, during phases of acute crisis, can provide structure and organisation to the system. Where governmental stewardship is weaker, PBF may result in another parallel programme, potentially increasing fragmentation in health financing and inequalities between areas supported by different donors.
Background Results-Based Financing (RBF) has proliferated in the health sectors of low and middle... more Background Results-Based Financing (RBF) has proliferated in the health sectors of low and middle income countries, especially those which are fragile or conflict-affected, and has been presented by some as a way of reforming and strengthening strategic purchasing. However, few if any studies have empirically and systematically examined how RBF impacts on health care purchasing. This article examines this question in the context of Zimbabwe’s national RBF programme. Methods The article is based on a documentary review, including 60 documents from 2008 to 2018, and 40 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in Zimbabwe. Interviews and analysis of both datasets followed an existing framework for strategic purchasing, adapted to reflect changes over. Results We find that some functions, such as assessing service infrastructure gaps, are unaffected by RBF, while others, such as mobilising resources, are partially...
This study has been prepared within the UNU-WIDER project on 'Extractives for development (E4D)',... more This study has been prepared within the UNU-WIDER project on 'Extractives for development (E4D)', which is part of a larger project on 'Macro-economic management (M-EM)'.
The International Journal of Health Planning and Management, 2019
Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because... more Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability (effects being sustained over time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness). We also argue that agreeing a framework for design and evaluation of HSS is urgent. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spillover effects and their contribution to meeting overarching health system process goals. We make some initial suggestions about such goals, to reflect the features that characterise a "strong health system." We highlight that current findings on "what works" are just indicative, given the limitations
Background: Since 2000, results based financing (RBF) has proliferated in health sectors in Afric... more Background: Since 2000, results based financing (RBF) has proliferated in health sectors in Africa in particular, including in fragile and conflict affected settings (FCAS) and there is a growing but still contested literature about its relevance and effectiveness. Less examined are the political economy factors behind the adoption of the RBF policy, as well as the shifts in influence and resources which RBF may bring about. In this article, we examine these two topics, focusing on Zimbabwe, which has rolled out RBF nationwide in the health system since 2011, with external support. Methods: The study uses an adapted political economy framework, integrating data from 40 semi-structured interviews with local, national and international experts in 2018 and thematic analysis of 60 policy documents covering the decade between 2008 and 2018. Results: Our findings highlight the role of donors in initiating the RBF policy, but also how the Zimbabwe health system was able to adapt the model to suit its particular circumstancesseeking to maintain a systemic approach, and avoiding fragmentation. Although Zimbabwe was highly resource dependent after the political-economic crisis of the 2000s, it retained managerial and professional capacity, which distinguishes it from many other FCAS settings. This active adaptation has engendered national ownership over time, despite initial resistance to the RBF model and despite the complexity of RBF, which creates dependence on external technical support. Adoption was also aided by ideological retro-fitting into an earlier government performance management policy. The main beneficiaries of RBF were frontline providers, who gained small but critical additional resources, but subject to high degrees of control and sanctions. Conclusions: This study highlights resource-seeking motivations for adopting RBF in some low and middle income settings, especially fragile ones, but also the potential for local health system actors to shape and adapt RBF to suit their needs in some circumstances. This means less structural disruption in the health system and it increases the likelihood of an integrated approach and sustainability. We highlight the mix of autonomy and control which RBF can bring for frontline providers and argue for clearer understanding of the role that RBF commonly plays in these settings.
Over the last few years, there has been growing attention to health systems research in fragile a... more Over the last few years, there has been growing attention to health systems research in fragile and conflictaffected setting (FCAS) from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the ongoing gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.
Background: Results-Based Financing (RBF) has proliferated in health sectors of low and middle in... more Background: Results-Based Financing (RBF) has proliferated in health sectors of low and middle income countries, especially fragile and conflict-affected ones, and has been presented as a way of reforming and strengthening strategic purchasing. However, few studies have empirically examined how RBF impacts on health care purchasing in these settings. This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings: Uganda, Zimbabwe and the Democratic Republic of Congo (DRC) over the past decade. Methods: The article is based on a documentary review, including 110 documents from 2004 to 2018, and 98 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in the selected districts of the three countries. Interviews and analysis followed an adapted framework for strategic purchasing, which was also used to compare across the case studies. Results: Across the cases, at the government level, we find little change to the accountability of purchasers, but RBF does mobilise additional resources to support entitlements. In relation to the population, RBF appears to bring in improvements in specifying and informing about entitlements for some services. However, the engagement and consultation with the population on their needs was found to be limited. In relation to providers, RBF did not impact in any major way on provider accreditation and selection, or on treatment guidelines. However, it did introduce a more contractual relationship for some providers and bring about (at least partial) improvements in provider payment systems, data quality, increased financial autonomy for primary providers and enforcing equitable strategies. More generally, RBF has been a source of much-needed revenue at primary care level in under-funded health systems. The contextparticularly the degree of stability and authority of government-, the design of the RBF programme and the potential for effective integration of RBF in existing systems and its stage of development were key factors behind differences observed. Conclusions: Our evidence suggests that expectations of RBF as an instrument of systemic reform should be nuanced, while focusing instead on expanding the key areas of potential gain and ensuring better integration and institutionalisation, towards which two of the three case study countries are working.
Background: Performance based financing (PBF) has been increasingly implemented across low and mi... more Background: Performance based financing (PBF) has been increasingly implemented across low and middleincome countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme. However, the literature has been surprisingly thin in the discussion of how PBF has been adapted to different contexts, and in turn how different contexts may influence PBF. With case studies from three humanitarian settings (northern Nigeria, Central African Republic and South Kivu in the Democratic Republic of Congo), we examine why and how PBF has emerged and has been adapted to those unsettled and dynamic contexts, what the opportunities and challenges have been, and what lessons can be drawn. Methods: Our comparative case study is based on data collected from a document review, 35 key informant interviews and 16 focus group discussions with stakeholders at national and subnational level in the three settings. Data were analysed in order to describe and compare each setting in terms of underlying fragility features and their implications for the health system, and to look at how PBF has been adopted, implemented and iteratively adapted to respond to acute crisis, deal with other humanitarian actors and involve local communities. Results: Our analysis reveals that the challenging environments required a high degree of PBF adaptation and innovation, at times contravening the so-called 'PBF principles' that have become codified. We develop an analytical framework to highlight the key nodes where adaptations happen, the contextual drivers of adaptation, and the organisational elements that facilitate adaptation and may sustain PBF programmes. Conclusions: Our study points to the importance of pragmatic adaptation in PBF design and implementation to reflect the contextual specificities, and identifies elements (such as, organisational flexibility, local staff and knowledge, and embedded long-term partners) that could facilitate adaptations and innovations. These findings and framework are useful to spark a reflection among PBF donors and implementers on the relevance of incorporating, reinforcing and building on those elements when designing and implementing PBF programmes.
Performance-based financing (PBF) schemes have been expanding rapidly across low and middle incom... more Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in...
Background: Few studies look at policy making in the health sector in the aftermath of a conflict... more Background: Few studies look at policy making in the health sector in the aftermath of a conflict or crisis and even fewer specifically focus on Human Resources for Health, which is a critical domain for health sector performance. The main objective of the article is to shed light on the patterns and drivers of post-conflict policy-making. In particular, we explore whether the post-conflict period offers increased chances for the opening of 'windows for opportunity' for change and reform and the potential to reset health systems. Methods: This article uses a comparative policy analysis framework. It is based on qualitative data, collected using three main tools-stakeholder mapping, key informant interviews and document reviews-in Uganda, Sierra Leone, Cambodia and Zimbabwe. Results: We found that HRH challenges were widely shared across the four cases in the post-conflict period but that the policy trajectories were differentdriven by the nature of the conflicts but also the wider context. Our findings suggest that there is no formula for whether or when a 'window of opportunity' will arise which allows health systems to be reset. Problems are well understood in all four cases but core issuessuch as adequate pay, effective distribution and HRH managementare to a greater or lesser degree unresolved. These problems are not confined to post-conflict settings, but underlying challenges to addressing themincluding fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutionsare liable to be even more acute in these settings. The role of the MoH emerged as weaker than expected, while the shift from donor dependence was clearly not linear and can take a considerable time. Conclusions: Windows of opportunity for change and reform can occur but are by no means guaranteed by a crisisrather they depend on a constellation of leadership, financing, and capacity. Recognition of urgency is certainly a facilitator but not sufficient alone. Post-conflict environments face particularly severe challenges to evidence-based policy making and policy implementation, which also constrain their ability to effectively use the windows which are presented.
P a g e two years), which are respected; preferential training access for those who are working i... more P a g e two years), which are respected; preferential training access for those who are working in rural areas; and provision of housing close to facilities (especially for female staff, for security reasons) 3. Routes into the medical profession for those of low income should be encouraged as it is likely that these staff, especially if mid-level, will more easily be retained in rural areas. 4. The development of a career structure with options for progression in pay and responsibility for CHOs should be developed (e.g. through the Scheme of Service which is currently being developed for for Health Workers in Sierra Leone). 5. The PBF scheme should be reformed so that payments are regular (monthly, rather than quarterly), paid on time, and transparent. It was clear that as well as the financial top-up, health workers appreciated getting feedback on their work in the form of an appraisal system, and a way of providing this in a supportive way should be built into the PBF process. 6. The issue of controlling political interference is more delicate but could be addressed through the new Health Service Commission as well as through organisational culture changes of a broader nature. 7. The RAA should be reviewed to establish the additional costs of living and working in rural areas. It is not just a motivation scheme but also needs to cover the extra costs which health workers face. Greater involvement in its design would also ensure that health workers understand how it is meant to operate. 'From the way I saw how the nurses were all well dressed at that time, the doctors were working efficiently…….. '(Female, Koinadugu, IDI-9) 'I loved it. When I was younger I used to admire the young nurses in our chiefdom headquarter town, the way they dress, the way they walk, they way they talk, so I said if I could be a nurse it will be better for me'.(Female, Koinadugu, IDI-8) '………right there I started to admire medical personnels….. ' (Male, Koinadugu, IDI-11) Subjects taken at secondary level Another factor that influenced the decision to become a health worker was the subjects studied at O Level in secondary school. In general having done science subjects at O Level predisposed individuals to join the medical profession. 'I studied the sciences; I thought that was a very good opportunity for me to do so, that is how I came into health. I came to that school and upon my graduation I gain acceptance into the Ministry' (Male Kenema, IDI-5) Table 6: Distribution of initial training location showing ownership Location of initial training Number of respondents Ownership National School of Nursing-Freetown 13 Public Paramedical School-Bo 6 Public
Background: Burkina Faso, like many low and middle income countries, has been taking a range of a... more Background: Burkina Faso, like many low and middle income countries, has been taking a range of actions to address its poor maternal and neonatal health indicators. In 2006 the government introduced an innovative national subsidy scheme for deliveries and emergency obstetric care in public facilities. This article reports on a complex evaluation of this policy, carried out 5 years after its introduction, which examined its effects on utilisation, quality of care, equity and the health system as a whole, as well as its cost and sustainability. Methods: The evaluation was carried out in six purposively selected districts, as well as at national level, using a case study approach. Data sources included: national and district routine and survey data, household interviews with women who had recently given birth, data extraction from hospital and medical records, and key informant and health worker interviews. Results: The underlying secular trend of a 1 % annual increase in the facility-based delivery rate (1988-2010) was augmented by an additional 4 % annual increase from 2007 onwards (after the policy was introduced), especially in rural areas and amongst women from poor households. The absence of baseline quality of care data made it difficult to assess the impact of the policy on quality of care, but hospitals with the best level of implementation of the subsidy offered higher quality of care (as measured by health care near-misses), so there is no evidence of a negative impact on quality (as is often feared). Similarly, there is little evidence of unintended negative effects on untargeted services. Household payments for facility-based deliveries have reduced significantly, compared with payments before the policy, and the policy as a whole is affordable, costing about 2 % of total public health expenditure. Concerns include that the amounts paid by households are higher than the rates set by the policy, and also that 7 % of households still say that they cannot afford to pay. Wealthier women have higher utilisation of services, as before, and the policy of fully exempting indigents is not being put into practice. Conclusions: These findings highlight the importance of maintaining the subsidy policy, given the evidence of positive outcomes, but they also point out areas where attention is needed to ensure the poor and most vulnerable population benefit fully from the policy.
Background: Sierra Leone has faced a shortage and maldistribution of staff in its post-conflict p... more Background: Sierra Leone has faced a shortage and maldistribution of staff in its post-conflict period. This long-standing challenge is now exacerbated by the systemic shock and damage wrought by Ebola. This study aimed to investigate the importance of different motivation factors in rural areas in Sierra Leone and thus to contribute to better decisions on financial and non-financial incentive packages, here and in similar contexts. Methods: This article is based on participatory life histories, conducted in 2013 with 23 health workers (doctors, nurses, midwives and Community Health Officers) in four regions of Sierra Leone who had worked in the sector since 2000. Although the interviews covered a wide range of themes, here we present findings on motivating and demotivating factors for staff, especially those in rural areas, based on thematic analysis of transcripts. Results: Rural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities, etc.). Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive. Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected. By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general. Conclusions: This study provides important policy-focused insights into motivation of health workers and can contribute towards building a resilient and responsive health system, incorporating the priorities and needs of health workers. Their voices and experiences should be taken into account as the post-Ebola landscape is shaped.
background The Free Deliveries and Caesarean Policy (FDCP) entitles all women in Morocco to deliv... more background The Free Deliveries and Caesarean Policy (FDCP) entitles all women in Morocco to deliver free of charge within public hospitals. This study assesses the policy's effectiveness by analysing household expenditures related to childbirth, by delivery type and quintile. methods Structured exit survey of 973 women in six provinces at five provincial hospitals, two regional hospitals, two university hospitals and three primary health centres with maternity units. results Households reported spending a median of US$ 59 in total for costs inside and outside of hospitals. Women requiring caesareans payed more than women with uncomplicated deliveries (P < 0.0001). The median cost was US$45 for a uncomplicated delivery, US$50 for a complicated delivery and US$65 for a caesarean section. The prescription given upon exiting the hospital comprised 62% of the total costs. Eighty-eight per cent of women from the poorest quintiles faced catastrophic expenditures. The women's perception of their hospital stay and the FDCP policy was overwhelmingly positive, but differences were noted at the various sites. conclusion The policy has been largely but not fully effective in removing financial barriers for delivery care in Morocco. More progress should also be made on increasing awareness of the policy and on easing the financial burden, which is still borne by households with lower incomes.
There is need for intensive capacity development to ensure that the human resources function is... more There is need for intensive capacity development to ensure that the human resources function is carried out by individuals with the right competencies. Policies should be monitored and evaluated and the findings from such processes should be made available to a wide audience rather than to a select few.
Most countries face challenges attracting and retaining health staff in remote areas but this is ... more Most countries face challenges attracting and retaining health staff in remote areas but this is especially acute in fragile and shock-prone contexts, like Guinea, where imbalances in staffing are high and financial and governance arrangements to address rural shortfalls are weak. The objective of this study was to understand how health staff could be better motivated to work and remain in rural, under-served areas in Guinea. In order to inform the policy dialogue on strengthening human resources for health, we conducted three nationally representative cross-sectional surveys, adapted from tools used in other fragile contexts. We found that the locational job preferences of health workers in Guinea are particularly influenced by opportunities for training, working conditions, and housing. Most staff are satisfied with their work and with supervision, however, financial aspects and working conditions are considered least satisfactory, and worrying findings include the high proportion...
L'Organisation Mondiale de la Sante (OMS) estime que 536.000 femmes meurent chaque annee de p... more L'Organisation Mondiale de la Sante (OMS) estime que 536.000 femmes meurent chaque annee de problemes lies a la grossesse, et que la quasitotalite de ces deces surviennent dans les pays en developpement (OMS 2007). Au Niger, le risque de mortalite maternelle est estime a un sur sept au cours de la vie d’une femme (OMS 2007). Dans les pays moins developpes, 18% des deces de femmes sont attribuables a la maternite (World Bank 1993). On estime que trois quarts de ces deces pourraient etre evites si les structures de soins de sante primaires (centres de sante et hopitaux) proposaient un paquet de soins maternels de base. Cependant, a ce jour, relativement peu de progres ont ete faits. Une etude recente de l’evolution de la mortalite maternelle entre 1990 et 2005 montre une diminution significative de 2,5% par an au niveau mondial, mais sans diminution significative en Afrique sub-saharienne, ou elle ne diminue que de 1,8%, passant de 921 pour 100.000 naissances vivantes en 1990 a 90...
Background As performance-based financing (PBF) is increasingly implemented across sub-Saharan Af... more Background As performance-based financing (PBF) is increasingly implemented across sub-Saharan Africa, some authors have suggested that it could be a 'stepping stone' for health-system strengthening and broad health-financing reforms. However, so far, few studies have looked at whether and how PBF is aligned to and integrated with national health-financing strategies, particularly in fragile and conflict-affected settings. Objective This study attempts to address the existing research gap by exploring the role of PBF with reference to: (1) user fees/exemption policies and (2) basic packages of health services and benefit packages in the Central African Republic, Democratic Republic of Congo and Nigeria. Methods The comparative case study is based on document review, key informant interviews and focus-group discussions with stakeholders at national and subnational levels. Results The findings highlight different experiences in terms of PBF's integration. Although (formal or informal) fee exemption or reduction practices exist in all settings, their implementation is not uniform and they are often introduced by external programmes, including PBF, in an uncoordinated and vertical fashion. Additionally, the degree to which PBF indicators lists are aligned to the national basic packages of health services varies across cases, and is influenced by factors such as funders' priorities and budgetary concerns. Conclusions Overall, we find that where national leadership is stronger, PBF is better integrated and more in line with the health-financing regulations and, during phases of acute crisis, can provide structure and organisation to the system. Where governmental stewardship is weaker, PBF may result in another parallel programme, potentially increasing fragmentation in health financing and inequalities between areas supported by different donors.
Background Results-Based Financing (RBF) has proliferated in the health sectors of low and middle... more Background Results-Based Financing (RBF) has proliferated in the health sectors of low and middle income countries, especially those which are fragile or conflict-affected, and has been presented by some as a way of reforming and strengthening strategic purchasing. However, few if any studies have empirically and systematically examined how RBF impacts on health care purchasing. This article examines this question in the context of Zimbabwe’s national RBF programme. Methods The article is based on a documentary review, including 60 documents from 2008 to 2018, and 40 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in Zimbabwe. Interviews and analysis of both datasets followed an existing framework for strategic purchasing, adapted to reflect changes over. Results We find that some functions, such as assessing service infrastructure gaps, are unaffected by RBF, while others, such as mobilising resources, are partially...
This study has been prepared within the UNU-WIDER project on 'Extractives for development (E4D)',... more This study has been prepared within the UNU-WIDER project on 'Extractives for development (E4D)', which is part of a larger project on 'Macro-economic management (M-EM)'.
The International Journal of Health Planning and Management, 2019
Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because... more Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability (effects being sustained over time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness). We also argue that agreeing a framework for design and evaluation of HSS is urgent. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spillover effects and their contribution to meeting overarching health system process goals. We make some initial suggestions about such goals, to reflect the features that characterise a "strong health system." We highlight that current findings on "what works" are just indicative, given the limitations
Background: Since 2000, results based financing (RBF) has proliferated in health sectors in Afric... more Background: Since 2000, results based financing (RBF) has proliferated in health sectors in Africa in particular, including in fragile and conflict affected settings (FCAS) and there is a growing but still contested literature about its relevance and effectiveness. Less examined are the political economy factors behind the adoption of the RBF policy, as well as the shifts in influence and resources which RBF may bring about. In this article, we examine these two topics, focusing on Zimbabwe, which has rolled out RBF nationwide in the health system since 2011, with external support. Methods: The study uses an adapted political economy framework, integrating data from 40 semi-structured interviews with local, national and international experts in 2018 and thematic analysis of 60 policy documents covering the decade between 2008 and 2018. Results: Our findings highlight the role of donors in initiating the RBF policy, but also how the Zimbabwe health system was able to adapt the model to suit its particular circumstancesseeking to maintain a systemic approach, and avoiding fragmentation. Although Zimbabwe was highly resource dependent after the political-economic crisis of the 2000s, it retained managerial and professional capacity, which distinguishes it from many other FCAS settings. This active adaptation has engendered national ownership over time, despite initial resistance to the RBF model and despite the complexity of RBF, which creates dependence on external technical support. Adoption was also aided by ideological retro-fitting into an earlier government performance management policy. The main beneficiaries of RBF were frontline providers, who gained small but critical additional resources, but subject to high degrees of control and sanctions. Conclusions: This study highlights resource-seeking motivations for adopting RBF in some low and middle income settings, especially fragile ones, but also the potential for local health system actors to shape and adapt RBF to suit their needs in some circumstances. This means less structural disruption in the health system and it increases the likelihood of an integrated approach and sustainability. We highlight the mix of autonomy and control which RBF can bring for frontline providers and argue for clearer understanding of the role that RBF commonly plays in these settings.
Over the last few years, there has been growing attention to health systems research in fragile a... more Over the last few years, there has been growing attention to health systems research in fragile and conflictaffected setting (FCAS) from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the ongoing gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.
Background: Results-Based Financing (RBF) has proliferated in health sectors of low and middle in... more Background: Results-Based Financing (RBF) has proliferated in health sectors of low and middle income countries, especially fragile and conflict-affected ones, and has been presented as a way of reforming and strengthening strategic purchasing. However, few studies have empirically examined how RBF impacts on health care purchasing in these settings. This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings: Uganda, Zimbabwe and the Democratic Republic of Congo (DRC) over the past decade. Methods: The article is based on a documentary review, including 110 documents from 2004 to 2018, and 98 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in the selected districts of the three countries. Interviews and analysis followed an adapted framework for strategic purchasing, which was also used to compare across the case studies. Results: Across the cases, at the government level, we find little change to the accountability of purchasers, but RBF does mobilise additional resources to support entitlements. In relation to the population, RBF appears to bring in improvements in specifying and informing about entitlements for some services. However, the engagement and consultation with the population on their needs was found to be limited. In relation to providers, RBF did not impact in any major way on provider accreditation and selection, or on treatment guidelines. However, it did introduce a more contractual relationship for some providers and bring about (at least partial) improvements in provider payment systems, data quality, increased financial autonomy for primary providers and enforcing equitable strategies. More generally, RBF has been a source of much-needed revenue at primary care level in under-funded health systems. The contextparticularly the degree of stability and authority of government-, the design of the RBF programme and the potential for effective integration of RBF in existing systems and its stage of development were key factors behind differences observed. Conclusions: Our evidence suggests that expectations of RBF as an instrument of systemic reform should be nuanced, while focusing instead on expanding the key areas of potential gain and ensuring better integration and institutionalisation, towards which two of the three case study countries are working.
Background: Performance based financing (PBF) has been increasingly implemented across low and mi... more Background: Performance based financing (PBF) has been increasingly implemented across low and middleincome countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme. However, the literature has been surprisingly thin in the discussion of how PBF has been adapted to different contexts, and in turn how different contexts may influence PBF. With case studies from three humanitarian settings (northern Nigeria, Central African Republic and South Kivu in the Democratic Republic of Congo), we examine why and how PBF has emerged and has been adapted to those unsettled and dynamic contexts, what the opportunities and challenges have been, and what lessons can be drawn. Methods: Our comparative case study is based on data collected from a document review, 35 key informant interviews and 16 focus group discussions with stakeholders at national and subnational level in the three settings. Data were analysed in order to describe and compare each setting in terms of underlying fragility features and their implications for the health system, and to look at how PBF has been adopted, implemented and iteratively adapted to respond to acute crisis, deal with other humanitarian actors and involve local communities. Results: Our analysis reveals that the challenging environments required a high degree of PBF adaptation and innovation, at times contravening the so-called 'PBF principles' that have become codified. We develop an analytical framework to highlight the key nodes where adaptations happen, the contextual drivers of adaptation, and the organisational elements that facilitate adaptation and may sustain PBF programmes. Conclusions: Our study points to the importance of pragmatic adaptation in PBF design and implementation to reflect the contextual specificities, and identifies elements (such as, organisational flexibility, local staff and knowledge, and embedded long-term partners) that could facilitate adaptations and innovations. These findings and framework are useful to spark a reflection among PBF donors and implementers on the relevance of incorporating, reinforcing and building on those elements when designing and implementing PBF programmes.
Performance-based financing (PBF) schemes have been expanding rapidly across low and middle incom... more Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in...
Background: Few studies look at policy making in the health sector in the aftermath of a conflict... more Background: Few studies look at policy making in the health sector in the aftermath of a conflict or crisis and even fewer specifically focus on Human Resources for Health, which is a critical domain for health sector performance. The main objective of the article is to shed light on the patterns and drivers of post-conflict policy-making. In particular, we explore whether the post-conflict period offers increased chances for the opening of 'windows for opportunity' for change and reform and the potential to reset health systems. Methods: This article uses a comparative policy analysis framework. It is based on qualitative data, collected using three main tools-stakeholder mapping, key informant interviews and document reviews-in Uganda, Sierra Leone, Cambodia and Zimbabwe. Results: We found that HRH challenges were widely shared across the four cases in the post-conflict period but that the policy trajectories were differentdriven by the nature of the conflicts but also the wider context. Our findings suggest that there is no formula for whether or when a 'window of opportunity' will arise which allows health systems to be reset. Problems are well understood in all four cases but core issuessuch as adequate pay, effective distribution and HRH managementare to a greater or lesser degree unresolved. These problems are not confined to post-conflict settings, but underlying challenges to addressing themincluding fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutionsare liable to be even more acute in these settings. The role of the MoH emerged as weaker than expected, while the shift from donor dependence was clearly not linear and can take a considerable time. Conclusions: Windows of opportunity for change and reform can occur but are by no means guaranteed by a crisisrather they depend on a constellation of leadership, financing, and capacity. Recognition of urgency is certainly a facilitator but not sufficient alone. Post-conflict environments face particularly severe challenges to evidence-based policy making and policy implementation, which also constrain their ability to effectively use the windows which are presented.
P a g e two years), which are respected; preferential training access for those who are working i... more P a g e two years), which are respected; preferential training access for those who are working in rural areas; and provision of housing close to facilities (especially for female staff, for security reasons) 3. Routes into the medical profession for those of low income should be encouraged as it is likely that these staff, especially if mid-level, will more easily be retained in rural areas. 4. The development of a career structure with options for progression in pay and responsibility for CHOs should be developed (e.g. through the Scheme of Service which is currently being developed for for Health Workers in Sierra Leone). 5. The PBF scheme should be reformed so that payments are regular (monthly, rather than quarterly), paid on time, and transparent. It was clear that as well as the financial top-up, health workers appreciated getting feedback on their work in the form of an appraisal system, and a way of providing this in a supportive way should be built into the PBF process. 6. The issue of controlling political interference is more delicate but could be addressed through the new Health Service Commission as well as through organisational culture changes of a broader nature. 7. The RAA should be reviewed to establish the additional costs of living and working in rural areas. It is not just a motivation scheme but also needs to cover the extra costs which health workers face. Greater involvement in its design would also ensure that health workers understand how it is meant to operate. 'From the way I saw how the nurses were all well dressed at that time, the doctors were working efficiently…….. '(Female, Koinadugu, IDI-9) 'I loved it. When I was younger I used to admire the young nurses in our chiefdom headquarter town, the way they dress, the way they walk, they way they talk, so I said if I could be a nurse it will be better for me'.(Female, Koinadugu, IDI-8) '………right there I started to admire medical personnels….. ' (Male, Koinadugu, IDI-11) Subjects taken at secondary level Another factor that influenced the decision to become a health worker was the subjects studied at O Level in secondary school. In general having done science subjects at O Level predisposed individuals to join the medical profession. 'I studied the sciences; I thought that was a very good opportunity for me to do so, that is how I came into health. I came to that school and upon my graduation I gain acceptance into the Ministry' (Male Kenema, IDI-5) Table 6: Distribution of initial training location showing ownership Location of initial training Number of respondents Ownership National School of Nursing-Freetown 13 Public Paramedical School-Bo 6 Public
Background: Burkina Faso, like many low and middle income countries, has been taking a range of a... more Background: Burkina Faso, like many low and middle income countries, has been taking a range of actions to address its poor maternal and neonatal health indicators. In 2006 the government introduced an innovative national subsidy scheme for deliveries and emergency obstetric care in public facilities. This article reports on a complex evaluation of this policy, carried out 5 years after its introduction, which examined its effects on utilisation, quality of care, equity and the health system as a whole, as well as its cost and sustainability. Methods: The evaluation was carried out in six purposively selected districts, as well as at national level, using a case study approach. Data sources included: national and district routine and survey data, household interviews with women who had recently given birth, data extraction from hospital and medical records, and key informant and health worker interviews. Results: The underlying secular trend of a 1 % annual increase in the facility-based delivery rate (1988-2010) was augmented by an additional 4 % annual increase from 2007 onwards (after the policy was introduced), especially in rural areas and amongst women from poor households. The absence of baseline quality of care data made it difficult to assess the impact of the policy on quality of care, but hospitals with the best level of implementation of the subsidy offered higher quality of care (as measured by health care near-misses), so there is no evidence of a negative impact on quality (as is often feared). Similarly, there is little evidence of unintended negative effects on untargeted services. Household payments for facility-based deliveries have reduced significantly, compared with payments before the policy, and the policy as a whole is affordable, costing about 2 % of total public health expenditure. Concerns include that the amounts paid by households are higher than the rates set by the policy, and also that 7 % of households still say that they cannot afford to pay. Wealthier women have higher utilisation of services, as before, and the policy of fully exempting indigents is not being put into practice. Conclusions: These findings highlight the importance of maintaining the subsidy policy, given the evidence of positive outcomes, but they also point out areas where attention is needed to ensure the poor and most vulnerable population benefit fully from the policy.
Background: Sierra Leone has faced a shortage and maldistribution of staff in its post-conflict p... more Background: Sierra Leone has faced a shortage and maldistribution of staff in its post-conflict period. This long-standing challenge is now exacerbated by the systemic shock and damage wrought by Ebola. This study aimed to investigate the importance of different motivation factors in rural areas in Sierra Leone and thus to contribute to better decisions on financial and non-financial incentive packages, here and in similar contexts. Methods: This article is based on participatory life histories, conducted in 2013 with 23 health workers (doctors, nurses, midwives and Community Health Officers) in four regions of Sierra Leone who had worked in the sector since 2000. Although the interviews covered a wide range of themes, here we present findings on motivating and demotivating factors for staff, especially those in rural areas, based on thematic analysis of transcripts. Results: Rural health workers face particular challenges, some of which stem from the difficult terrain, which add to common disadvantages of rural living (poor social amenities, etc.). Poor working conditions, emotional and financial costs of separation from families, limited access to training, longer working hours (due to staff shortages) and the inability to earn from other sources make working in rural areas less attractive. Moreover, rules on rotation which should protect staff from being left too long in rural areas are not reported to be respected. By contrast, poor management had more resonance in urban areas, with reports of poor delegation, favouritism and a lack of autonomy for staff. Tensions within the team over unclear roles and absenteeism are also significant demotivating factors in general. Conclusions: This study provides important policy-focused insights into motivation of health workers and can contribute towards building a resilient and responsive health system, incorporating the priorities and needs of health workers. Their voices and experiences should be taken into account as the post-Ebola landscape is shaped.
background The Free Deliveries and Caesarean Policy (FDCP) entitles all women in Morocco to deliv... more background The Free Deliveries and Caesarean Policy (FDCP) entitles all women in Morocco to deliver free of charge within public hospitals. This study assesses the policy's effectiveness by analysing household expenditures related to childbirth, by delivery type and quintile. methods Structured exit survey of 973 women in six provinces at five provincial hospitals, two regional hospitals, two university hospitals and three primary health centres with maternity units. results Households reported spending a median of US$ 59 in total for costs inside and outside of hospitals. Women requiring caesareans payed more than women with uncomplicated deliveries (P < 0.0001). The median cost was US$45 for a uncomplicated delivery, US$50 for a complicated delivery and US$65 for a caesarean section. The prescription given upon exiting the hospital comprised 62% of the total costs. Eighty-eight per cent of women from the poorest quintiles faced catastrophic expenditures. The women's perception of their hospital stay and the FDCP policy was overwhelmingly positive, but differences were noted at the various sites. conclusion The policy has been largely but not fully effective in removing financial barriers for delivery care in Morocco. More progress should also be made on increasing awareness of the policy and on easing the financial burden, which is still borne by households with lower incomes.
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Papers by Sophie Witter