Sub-Saharan Africa has fewer medical workers per capita than any region of the world, and that shortage has been highlighted consistently as a critical constraint to improving health outcomes in the region. This paper draws on newly available, systematic, comparable data from ten countries in the region to explore the dimensions of this shortage. We find wide variation in human resources performance metrics, both within and across countries. Many facilities are barely staffed, and effective staffing levels fall further when adjusted for health worker absences. However, caseloads-while also varying widely within and across countries-are also low in many settings, suggesting that even within countries, deployment rather than shortages, together with barriers to demand, may be the principal challenges. Beyond raw numbers, we observe significant proportions of health workers with very low levels of clinical knowledge on standard maternal and child health conditions. This work demonstrates that countries may need to invest broadly in health workforce deployment, improvements in capacity and performance of the health workforce, and on addressing demand constraints, rather than focusing narrowly on increases in staffing numbers.

The design of complex health systems interventions, such as pay for performance (P4P), can be critical to determining such programmes' success. In P4P programmes, the design of financial incentives is crucial in shaping how these programmes work. However, the design of such schemes is usually homogenous across providers within a given scheme. Consequently, there is a limited understanding of the strengths and weaknesses of P4P design elements from the implementers' perspective. This study takes advantage of the unique context of Brazil, where municipalities adapted the federal incentive design, resulting in variations in incentive design across municipalities. The study aims to understand why municipalities in Brazil chose certain P4P design features, the associated challenges, and the local adaptations made to address problems in scheme design. This study was a multiple-case study design relying on qualitative data from twenty municipalities from two states in northeastern Brazil. We conducted two key informant interviews with municipal-level stakeholders and focus group discussions with primary care providers. We also reviewed municipal PMAQ laws in each municipality. We found substantial variation in the design choices made by municipalities regarding 'who was incentivised', the 'payment size' and 'frequency'. Design choices affected relationships within municipalities and within teams. Challenges were chiefly associated with fairness relating to 'who received the incentive', 'what is incentivised', and the 'incentive size'. Adaptations were made to improve fairness, mostly in response to pressure from the healthcare workers. The significant variation in design choices across municipalities and providers' response to them highlights the importance of considering local context in the design and implementation of P4P schemes and ensuring flexibility to accommodate local preferences and emerging needs. Attention is needed to ensure the choice of 'who is incentivised' and the 'size of incentives' are inclusive and fair, and the allocation and 'use of funds' are transparent.

Pay-for-performance (P4P) schemes have been shown to have mixed effects on health care outcomes. A challenge in interpreting this evidence is that P4P is often considered a homogenous intervention, when in practice schemes vary widely in their design. Our study contributes to this literature by providing a detailed depiction of incentive design across municipalities within a national P4P scheme in Brazil (PMAQ) and exploring the association of alternative design typologies with the performance of primary health /care providers. We carried out a nation-wide survey of municipal health managers to characterize the scheme design, based on the size of the bonus, the providers incentivized, and the frequency of payment. Using OLS regressions and controlling for municipality characteristics, we examined whether each design feature was associated with better family health team performance. To capture potential interactions between design features, we used cluster analysis to group municipalities into five design typologies and then examined associations with quality of care. A majority of the municipalities included in our study used some of the PMAQ funds to provide bonuses to family health team workers, while the remaining municipalities spent the funds in the traditional way using input-based budgets. Frequent bonus payments (monthly) and higher size bonus allocations (share of 20-80%) were strongly associated with better team performance, while who within a team was eligible to receive bonuses did not in isolation appear to influence performance. The cluster analysis showed what combinations of design features were associated with better performance. The PMAQ score in the 'large bonus/many workers/high-frequency' cluster was 8.44 points higher than the 'no bonus' cluster, equivalent to a difference of 21.7% in the mean PMAQ score. Evidence from our study shows how design features can potentially influence health provider performance, informing the design of more effective P4P schemes.

Health insurance coverage and the risk protection it provides may improve enrollees' subjective well-being (SWB), as demonstrated for example by Oregon Medicaid's randomized expansion significantly improving enrollees' mental health and happiness. Yet little evidence from low- and middle-incomen countries documents the link between insurance coverage and SWB. We analyze individual-level data on a large natural experiment in China: the integration of the rural and urban resident health insurance programs. This reform, expanded nationally since 2016, is recognized as a vital step toward attaining the goal of providing affordable and equitable basic healthcare in China, because integration raises the level of healthcare coverage for rural residents to that enjoyed by their urban counterparts. This study is the first to investigate the impact of urban-rural health insurance integration on the SWB of the Chinese population. Analyzing 2011-2018 data from the China Health and Retirement Longitudinal Study in a difference-in-difference (DID) framework with variation in the treatment timing, we find that the integration policy significantly improved the life satisfaction of rural residents, especially among low-income and elderly individuals. The positive impact of the integration on SWB appears to stem from the improvement of rural residents' mental health (decrease in depressive symptoms) and associated increases in some health behaviors, as well as a mild increase in outpatient care utilization and financial risk protection. There was no discernible impact of the integration on SWB among urban residents, suggesting that the reform reduced inequality in healthcare access and health outcomes for poorer rural residents without negative spillovers on their urban counterparts.

Unfair knowledge practices easily beset our efforts to achieve health equity within and between countries. Enacted by people from a distance and from a position of power ('the centre') on behalf of and alongside people with less power ('the periphery'), these unfair practices have generated a complex literature of complaints across various axes of inequity. We identified a sample of this literature from 12 journals, and systematised it using the realist approach to explanation. We framed the outcome to be explained as 'manifestations of unfair knowledge practices'; their generative mechanisms as 'the reasoning of individuals or rationale of institutions'; and context that enable them as 'conditions that give knowledge practices their structure'. We identified four categories of unfair knowledge practices, each triggered by three mechanisms: 1. credibility deficit related to pose (mechanisms: 'the periphery's cultural knowledge, technical knowledge, and 'articulation' of knowledge do not matter); 2. credibility deficit related to gaze (mechanisms: 'the centre's learning needs, knowledge platforms, and scholarly standards must drive collective knowledge-making'); 3.interpretive marginalisation related to pose (mechanisms: 'the periphery's sensemaking of partnerships, problems, and social reality do not matter'); and 4. interpretive marginalisation related to gaze (mechanisms: 'the centre's learning needs, social sensitivities and status-preservation must drive collective sensemaking'). Together, six mutually overlapping, reinforcing and dependent categories of context influence all 12 mechanisms: mislabelling (the periphery as inferior); miseducation (on structural origins of disadvantage); under-representation (of the periphery on knowledge platforms); compounded spoils (enjoyed by the centre); under-governance (in making, changing, monitoring, enforcing, and applying rules for fair engagement); and colonial mentality (of/at the periphery). These context-mechanism-outcome links can inform efforts to redress unfair knowledge practices; investigations of unfair knowledge practices across disciplines and axes of inequity; and ethics guidelines for health system research and practice when working at a social or physical distance.

Patient and Public Participation (PPP) is key to improving health systems. Yet, studies have shown that PPP implementations across many countries have been largely tokenistic. Particularly, in Ghana, whilst PPP is prioritised in national health policies and legislation, there appears to be little research focused on understanding PPP's role in health system improvement. The aim of this study, therefore, is to examine how PPP is working across the Ghanaian health system levels, as well as to understand the perspectives and experiences of participants on how PPP contributes to health system improvement. The qualitative study was undertaken in six communities in three districts in the Ashanti region of Ghana. Data were collected from semi-structured individual interviews. The selection of participants was purposive, based on their PPP-related roles. As a result, findings of this study may not reflect the experiences of others who are not directly involved in PPP initiatives. Thirty-five participants, mainly health service users and health professionals, were interviewed. Data were transcribed and analysed descriptively using Braun and Clarke's 2006 thematic analysis approach. Overall, participants noted PPP implementation was largely limited at higher health system levels (i.e. national, regional and district levels), but was functioning at the community level. PPP also improved access to health services, responsiveness to patient needs, community-health worker relationships, health-seeking behaviours, empowered healthcare users, and improved health outcomes. The study, therefore, recommended the need to undertake PPP across all levels of the health system to maximise PPP's role in health system improvement. Finally, the study suggested prioritising PPP, especially for resource-poor countries to complement government's efforts in improving accessibility of healthcare services to many communities and also provide a more patient-centred healthcare system responsive to patients' and public needs.

Community-facility linkage interventions are gaining popularity as a way to improve community health in low-income settings. Their aim is to create/strengthen a relationship between community members and local healthcare providers. Representatives from both groups can address health issues together, overcome trust problems, potentially leading to participants' empowerment to be responsible for their own health. This can be achieved via different approaches. We conducted a systematic literature review to explore how this type of intervention has been implemented in rural and low or lower-middle income countries, its various features and how/if it has helped to improve child health in these settings. Publications from three electronic databases (Web of Science, PubMed, Embase) up to 03/02/2022 were screened, with 14 papers meeting the inclusion criteria (rural setting in low/lower-middle income countries, presence of a community-facility linkage component, outcomes of interest related to under-five children's health, peer-reviewed articles containing original data written in English). We used Rosato's integrated conceptual framework for community participation to assess the transformative and community empowering capacities of the interventions, and realist principles to synthesize the outcomes. The results of this analysis highlight which conditions can lead to success of this type of intervention: active inclusion of hard-to-reach groups, involvement of community members in implementation's decisions, activities tailored to the actual needs of interventions' contexts, and usage of mixed methods for a comprehensive evaluation. These lessons informed the design of a community-facility linkage intervention and offer a framework to inform the development of monitor and evaluation plans for future implementations.

The prevalence of common perinatal mental disorders in Vietnam ranges from 16.9% to 39.9%, and substantial treatment gaps have been identified at all levels. This paper explores constraints to the integration of maternal and mental health services at the primary healthcare level and the implications for the health system's responsiveness to the needs and expectations of pregnant women with mental health conditions in Vietnam. As part of the RESPONSE project, a three-phased realist evaluation study, we present Phase One findings which employed systematic and scoping literature reviews, and qualitative data collection (focus groups and interviews) with key health system actors, in Bac Giang province, Vietnam, to understand the barriers to maternal mental healthcare provision, utilisation, and integration strategies. A four-level framing of the barriers to integrating perinatal mental health services in Vietnam was used in reporting findings, which comprised individual, socio-cultural, organisational, and structural levels. At the socio-cultural and structural levels, these barriers included: cultural beliefs about the holistic notion of physical and mental health, stigma towards mental health, biomedical approach to healthcare services, absence of comprehensive mental health policy, and a lack of mental health workforce. At the organisational level, there was absence of clinical guidelines on the integration of mental health in routine antenatal visits, a shortage of staff, and poor health facilities. Finally, at the provider level, a lack of knowledge and training on mental health was identified. The integration of mental health into routine antenatal visits at the primary care level has the potential help to reduce stigma towards mental health and improve health system responsiveness by providing services closer to the local level, offering prompt attention, better choice of services, and better communication while ensuring privacy and confidentiality of services. This can improve the demand for mental health services and help reduce the delay of care-seeking.

Providers have intended and unintended responses to payment reforms, such as China's new case-based payment system, i.e. Diagnosis-Intervention Packet (DIP) under global budget, that classified patients based on the combination of principal diagnosis and procedures. Our study explores the impact of DIP payment reform on hospital selection of patients undergoing total hip/knee arthroplasty (THA/TKA) or with arteriosclerotic heart disease (AHD) from July 2017 to June 2021 in a large city. We used a difference-in-differences approach to compare the changes in patient age, severity reflected by the Charlson Comorbidity Index (CCI), and a measure of treatment intensity [relative weight (RW)] in hospitals that were and were not subject to DIP incentives before and after the DIP payment reform in July 2019. Compared with non-DIP pilot hospitals, trends in patient age after the DIP reform were similar for DIP and non-DIP hospitals for both conditions, while differences in patient severity grew because severity in DIP hospitals increased more for THA/TKA (P = 0.036) or dropped in non-DIP hospitals for AHD (P = 0.011) following DIP reform. Treatment intensity (measured via RWs) for AHD patients in DIP hospitals increased 5.5% (P = 0.015) more than in non-DIP hospitals after payment reform, but treatment intensity trends were similar for THA/TKA patients in DIP and non-DIP hospitals. When the DIP payment reform in China was introduced just prior to the pandemic, hospitals subject to this reform responded by admitting sicker patients and providing more treatment intensity to their AHD patients. Policymakers need to balance between cost containment and the unintended consequences of prospective payment systems, and the DIP payment could also be a new alternative payment system for other countries.