ABSTRACT Previous studies have shown that facility autonomy, especially control over budget allocation, and management practices can have a modest positive effect on health facility performance, but the evidence is limited and often qualitative. Data from the evaluation of the Nigeria States Health Investment Project (NSHIP), a study that examined the effects of direct facility and performance-based financing, offers a novel opportunity to quantitatively examine these relationships in the context of a lower middle-income country. We utilize non-parametric statistics and regression methods to test the hypothesis that autonomy, supervision, and management affected facility performance. Results show that facilities with greater autonomy, more budget control, and better management practices generally outperform their peers on a range of facility readiness and service delivery measures. For example, regressions show that facilities with high autonomy held an additional 2.1 outreach sessions per month and facilities with a business plan offered 1.8 additional outreach services (p < 0.05). Supervision practices, including visit frequency and a quantitative checklist, are associated with 26% higher productivity and up to a 29% increase in equipment availability (p < 0.05). Sensitivity analyses validated that results are robust. We conclude that facility-level autonomy and especially budget control can improve primary healthcare facility readiness and service availability. Further, management practices that are reinforced through supportive supervision and routine monitoring can maximize the benefits that accrue from even small amounts of incremental financing. This shows that these policies and practices can contribute critically to efficiently achieving the goals of universal healthcare policies in the context of limited resources.

ABSTRACT The Universal Health Care (UHC) Act in the Philippines aims to provide equitable access to quality and affordable health care. However, its implementation is hampered by significant financing and resource constraints. This study explores these challenges from the perspectives of various stakeholders, aiming to inform policy and improve the execution of the UHC Act. In this qualitative study, we conducted 17 focus group discussions and 19 key informant interviews between September 2023 and May 2024. Participants included national and local policymakers, public and private healthcare providers, and patients. The data were analyzed using the WHO’s health system financing framework, focusing on revenue raising, pooling, and purchasing. The findings reveal critical issues across all financing functions. Revenue-raising is undermined by a lack of funding for local government units and challenges in PhilHealth premium collection from the informal sector. In terms of pooling, the Special Health Fund is hindered by the absence of clear guidelines and delays in fund transfers. Purchasing is plagued by bureaucratic procurement processes, shortages of suppliers, and significant delays and issues in PhilHealth reimbursements. The optimal implementation of the UHC Act in the Philippines is impeded by interrelated financing and resource challenges. Addressing these challenges requires comprehensive reforms, including strengthening local health system integration, finalizing guidelines for local governments, and reforming procurement and PhilHealth’s payment systems.

ABSTRACT Ethnic inequities in the receipt of medicines are influenced by a range of factors including inequities in the social determinants of health, barriers to accessing health care, and differences in quality of care. Policy decisions about medicines funding and eligibility play an important role in contributing to equity in access and equity in outcomes. This policy report analyzes the 2021 policy decision in Aotearoa New Zealand to use ethnicity as an explicit eligibility criterion for access to publicly funded sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists for type 2 diabetes. Advocacy for this policy decision was driven by Indigenous health experts, based on strong evidence of persisting ethnic inequities in diabetes prevalence, access to treatment, and outcomes. The impact this policy has had so far on inequities in receipt of diabetes treatment indicates that using explicit ethnicity-based eligibility criteria may help overcome some barriers to access to diabetes care, even in universal health care systems.

ABSTRACT Diabetes and other chronic NCDs pose a major public health threat in Ghana, and where health systems are less developed and there are numerous competing societal priorities. This qualitative study examines the barriers hindering domestic financing and prioritization of diabetes and other NCDs in Ghana. The study applied Kingdon’s multiple stream framework using document reviews and face-to-face interviews with 29 key informants/stakeholders in the diabetes or NCD landscape in Ghana. Data from the document review and key informant interviews were thematically analyzed. The study revealed that at the problem stream level, diabetes and other NCDs are not yet sufficiently perceived by the general population and policy makers as major societal issues. Donors are also focusing on different health priorities. On the policy solution stream, many solutions are being initiated and developed by a rich array of policy entrepreneurs. The recent introduction of an excise tax bill on sugar-sweetened, alcoholic beverages and tobacco products suggests positive developments in the politics stream. The health financing system is advanced institutionally, and the country could rapidly convert a higher prioritization of diabetes into resource allocation if the macro-fiscal context permits it. The study concludes that applying Kingdon’s framework provides a nuanced understanding of the barriers, enablers, and opportunities for prioritizing NCDs in Ghana, and finds that policy prioritization will require political commitment from the upper echelon of government. Higher public awareness on the determinants and costs of NCDs would contribute to broad citizen support and the sustainability of the political commitment across successive governments.

ABSTRACT Following the global health challenge of Ebola, the World Health Organization (WHO) developed a new approach to prioritizing health policy actions when both markets and government fail. The new approach, Common Goods for Health (CGH), is applied in this paper to identify priority actions to tackle failures in addressing the increasing prevalence of type 2 diabetes globally. National governments could realistically implement these actions to efficiently and equitably reduce the prevalence of type 2 diabetes, a non-communicable disease that is growing in every region of the world. The paper identifies three broad categories of CGH actions: (i) earlier risk identification; (ii) better communication for behavior change; and (iii) reforming tax/subsidy policies on food.

ABSTRACT Non-communicable diseases (NCDs) represent the largest burden of disease, even in low–and middle-income countries (LMICs). The long latency period, chronicity, and common environmental, behavioral and genetic etiologies of NCDs—as shown through the example of Type 2 diabetes mellitus (T2DM)—expose health system failures to undertake multi-sectoral public health actions, address early detection, and provide integrated care. Development assistance for health (DAH), with its focus on donor priorities, often exacerbates such health system challenges. DAH has mainly focused on infectious diseases along with conditions related to reproductive health. Some programs show how DAH could help LMICs reorient health systems by focusing on neglected areas like economic and social policies, along with environmental and behavioral drivers of diseases like T2DM. Furthermore, in an era of declining resources for DAH, external support needs to be catalytic, supporting reforms more than financing services. Orienting limited DAH to address NCDs could support the necessary transformation of service organization, financial allocation criteria, data generation and use, health promotion, and training of care providers. DAH could also strengthen the public institutions and policies that prevent NCDs like T2DM through economic policies, environmental regulation, and health promotion interventions that address social and behavioral risk factors. Four broad categories of actions can guide DAH to better orient health systems to address NCDs: “First, do no harm,” help transform health systems, think outside the box, and match tools to needs. Several existing assistance modalities are also presented to show specific ways that this reorientation can be implemented.

ABSTRACT Health systems research as a field has increased its attention to political factors that shape health system development. However, there has been a lack of consensus about which conceptual frameworks and models from the academic discipline of political science are most relevant to the study of health systems. The COVID-19 pandemic underlined the centrality of politics to health, but it also demonstrated the limitations of existing frameworks used to analyze the politics of health. This article reviews the political science literature on the politics of COVID-19, identifies several gaps in the theoretical frameworks used in this work, and draws some conclusions for future work on the politics of pandemics and the politics of health system development writ large.

ABSTRACT This commentary traces the origins of Japan’s special education system and explores the need to equip preschool teachers with the specific knowledge and skills necessary to care for children under the age of six with disabilities during disasters in Japan. Japan’s slow implementation of inclusive education, in which children with and without disabilities are educated together, was noted by the UN Committee on the Rights of Persons with Disabilities in 2022. The Committee also recommended improved care for persons with disabilities in disaster situations and humanitarian emergencies. Historically, Japan has promoted policies that segregate children with disabilities from children without disabilities. Integrated childcare began in the 1970s, but there continues to be a lack of suitable systems and practical guidelines for disaster management in inclusive childcare. The curricula of institutions that train childcare professionals were reviewed. As of April 1, 2023, there were 666 designated childcare teacher training institutions in Japan. Of these, 498 training institutions offered courses to obtain both kindergarten and nursery teaching licenses. Thirty-seven of the institutions were national and public schools, of which the present study included 36 schools whose syllabus was available online and whose course content could be confirmed. Only one school (2.8%) was found to include “disaster and childcare” in its curriculum, and three schools (8.3%) included “safety of children with disabilities” in their curriculum. Specialist disaster preparedness training to enable teachers to care for preschool children with disabilities in the event of a disaster is critical in the context of inclusive childcare.

ABSTRACT Sri Lanka has one of the highest prevalence rates of diabetes, and improving diabetes control is a national priority. The care cascade framework, a tool for evaluating diabetes control and identifying system gaps, has not been assessed nationally in Sri Lanka. This study addresses this gap using data from a nationally representative longitudinal cohort. Using 2018–2019 data from the Sri Lanka Health and Ageing Study (SLHAS), we evaluated the diabetes care cascade, estimating levels of (i) prevalence, (ii) testing, (iii) diagnosis, (iv) awareness, (v) treatment, (vi) medication adherence, and (vii) control. Logistic regression assessed factors associated with step performance, and concentration indices quantified socioeconomic inequalities. Performance was benchmarked against other countries. In 4,827 participants the weighted diabetes prevalence was 23.2%. Of those with diabetes, 86.0% had been tested, 62.3% diagnosed, 58.6% aware, 44.7% treated, and 20.6% (hemoglobin A1c, HbA1c < 8.0%) and 12.4% (HbA1c < 7.0%) controlled. Older adults and those with hypertension achieved higher rates at all steps, while disparities by gender, education, location, and body mass index were minimal. Concentration indices confirmed pro-rich inequity from testing to treatment but revealed no significant inequity in control. Sri Lanka outperforms most low- and middle-income countries (LMICs) in testing, diagnosis, treatment, and disparities in coverage, reflecting underlying system strengths. But only one in five Sri Lankans with diabetes achieve control, with significant losses post-treatment. High diagnosis and treatment rates alone are insufficient; strategy must shift toward understanding the reasons for poor control. and improving treatment outcomes, a lesson with wider relevance.