Universal Health Coverage Reforms Research Articles

Coordinating external assistance forUHC: Pakistan's early experience ofthe SDG3 GAP.

Pakistan is a lower middle-income setting. External assistance for health and development partners play an important role in health sector development. The federal system and health care delivery as a devolved provincial subject warrant regular and effective coordination among federating units and partners. Pakistan was selected as a priority country in 2019 for the implementation of the Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP). Given the ongoing universal health coverage (UHC) reforms, the country prioritized two SDG3 GAP accelerators, related to primary health care (PHC) and sustainable financing for health (SFH). Eight partner agencies representing PHC and SFH accelerators jointly planned and conducted a 'PHC for UHC mission' to Pakistan in 2021. This mission paved the way for setting up an SDG3 GAP Coordination Committee and a 'PHC Service Delivery and Financing working group', which have been regularly coming together through in-person and virtual meetings; the latter was relatively uncommon previously and this new way of working provided a chance to build rapport, share workplans, identify duplications in technical assistance and jointly gauge governments' priorities. This has shifted the focus of reforms deliberations from 'what' to 'how', enabling joint strategic planning and implementation. The joint work by SDG3 GAP partners with the Ministry of National Health Services Regulation & Coordination linked discussions on health financing and service delivery reforms for the first time, and has contributed to advocacy, analysis, strategic policy dialogue, institutional strengthening and implementation of UHC reforms, with a focus on PHC. Even though joint work by SDG3 GAP partners undoubtedly shows the potential for better alignment and collaboration, translation of the commitment to better collaboration into concrete impact has been the result of committed and engaged staff members, rather than institutionalized change, which will require strong incentives for collaboration.

Implementing Health Policy in Nigeria: The Basic Health Care Provision Fund as a Catalyst for Achieving Universal Health Coverage?

ABSTRACTIn 2014, Nigeria adopted a new law for its healthcare system, which mandated the establishment of a novel health‐financing mechanism, the Basic Health Care Provision Fund (BHCPF). The BHCPF was created to provide sustainable funding with a view to fast‐tracking Universal Health Coverage (UHC) and improving health outcomes in Nigeria. This article places Nigeria's UHC reform process in the broader context of social policy implementation in Africa to illustrate the extent to which interactions between different agents, contextual factors such as Nigeria's federal character, as well as changing conceptualizations of social policy at a global level, shape views on how best to implement UHC. The article is based on the careful examination of three different versions of implementation guidelines for the BHCPF combined with qualitative data collected during fieldwork. It argues that there is a discrepancy between the Nigerian government rhetoric of putting into place a system that improves access to healthcare and the actual practice of implementing UHC via the BHCPF. In reality, a range of controversies surround the ongoing operationalization of the BHCPF, contributing to the perpetuation of a social policy environment that allows poor health outcomes and significant health inequities in Nigeria to persist.

Piercing the veil on the functioning and effectiveness of district health system governance structures: perspectives from a South African province

BackgroundLeadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the proposed National Health Insurance (NHI) system, which underscores the importance of primary health care, delivered through the district health system (DHS). Consequently, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province (GP), and the perceptions of council members on the functioning and effectiveness of these structures.MethodsThis was a mixed-methods, cross-sectional study in GP’s five districts. The population of interest was members of existing governance structures who completed an electronic-self-administered questionnaire (SAQ). Using a seven-point Likert scale, the SAQ focuses on members’ perceptions on the functioning and effectiveness of the governance structures. In-depth interviews with the chairpersons of the DHCs and its technical committees complemented the survey. STATA® 13 and thematic analysis were used to analyze the survey data and interviews respectively.ResultsOnly three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD = 0.7) and 4.8. (SD = 0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities.ConclusionIn light of South Africa’s move toward NHI, strengthening DHS governance is imperative. The governance gaps identified need to be addressed to ensure support for the implementation of UHC reforms.

The genesis ofthe PM-JAY health insurance scheme inIndia: technical andpolitical elements influencing a national reform towards universal health coverage.

Many countries are using health insurance to advance progress towards universal health coverage (UHC). India launched the Pradhan Mantri Jan Arogya Yojana (PM-JAY) health insurance scheme in 2018. We examine the political economy context around PM-JAY policy formulation, by examining the perspectives of policy stakeholders shaping decisions around the reform. More specifically, we focus on early policy design at the central (national) level. We use a framework on the politics of UHC reform proposed by Fox and Reich (The politics of universal health coverage in low- and middle-income countries: A framework for evaluation and action. J. Health Polit. Policy Law 2015;40:1023-1060), to categorize the reform into phases and examine the interactions between actors, institutions, interests, ideas and ideology which shaped reform decisions. We interviewed 15 respondents in Delhi between February and April 2019, who were either closely associated with the reform process or subject experts. The ruling centre-right government introduced PM-JAY shortly before national elections, drawing upon policy legacies from prior and state insurance schemes. Empowered policy entrepreneurs within the government focused discourse around ideas of UHC and strategic purchasing, and engaged in institution building leading to the creation of the National Health Authority and State Health Agencies through policy directives, thereby expanding state infrastructural and institutional power for insurance implementation. Indian state inputs were incorporated in scheme design features like mode of implementation, benefit package and provider network, while features like the coverage amount, portability of benefits and branding strategy were more centrally driven. These balanced negotiations opened up political space for a cohesive, central narrative of the reform and facilitated adoption. Our analysis shows that the PM-JAY reform focused on bureaucratic rather than ideological elements and that technical compromises and adjustments accommodating the interests of states enabled the political success of policy formulation. Appreciating these politics, power and structural issues shaping PM-JAY institutional design will be important to understand how PM-JAY is implemented and how it advances UHC in India.

A discourse and content analysis of representation in the mainstream media of the South African National Health Insurance policy from 2011 to 2019

BackgroundMedia is a crucial factor in shaping public opinion and setting policy agendas. There is limited research on the role of media in health policy processes in low- and middle-income countries. This study profiles South Africa as a case example, currently in the process of implementing a major health policy reform, National Health Insurance (NHI).MethodsA descriptive, mixed methods study was conducted in five sequential phases. Evidence was gathered through a scoping review of secondary literature; discourse analysis of global policy documents on universal health coverage and South African NHI policy documents; and a content and discourse analysis of South African print and online media texts focused on NHI. Representations within media were analysed and dominant discourses that might influence the policy process were identified.ResultsDiscourses of ‘health as a global public good’ and ‘neoliberalism’ were identified in global and national policy documents. Similar neoliberal discourse was identified within SA media. Unique discourses were identified within SA media relating to biopolitics and corruption. Media representations revealed political and ideological contestation which was not as present in the global and national policy documents. Media representations did not mirror the lived reality of most of the South African population. The discourses identified influence the policy process and hinder public participation in these processes. They reinforce social hierarchy and power structures in South Africa, and might reinforce current inequalities in the health system, with negative repercussions for access to health care.ConclusionsThere is a need to understand mainstream media as part of a people-centred health system, particularly in the context of universal health coverage reforms such as NHI. Harmful media representations should be counter-acted. This requires the formation of collaborative and sustainable networks of policy actors to develop strategies on how to leverage media within health policy to support policy processes, build public trust and social cohesion, and ultimately decrease inequalities and increase access to health care. Research should be undertaken to explore media in other diverse formats and languages, and in other contexts, particularly low- and middle-income countries, to further understand media’s role in health policy processes.

A new universalism? Universal health coverage and debates about rights, solidarity and inequality in Kenya.

The rise of universal health coverage (UHC) as a global policy endorsed in the Sustainable Development Goals (SGDs) appears to signal new directions in global health as it introduces a progressive language of inclusion, solidarity and social justice and advocates the right of 'everyone' to access the healthcare they need 'without financial hardship'. Since 2018 the Kenyan government has attempted to widen access to healthcare by experimenting with free health care services and expanding health insurance coverage. Such progressive moves are, however, layered onto histories of healthcare, citizenship and state responsibility that in Kenya have been dominated by forms of exclusion, differentiation, a politics of patronage, and class inequality, all of which work against universal access. In this paper, we follow recent attempts to increase access to healthcare, paying particular attention to how a language of rights and inclusion circulated among "ordinary citizens" as well as among the health workers and government officials tasked with implementing reforms. Despite being clothed in a language of universalism, solidarity and inclusion, Kenya's UHC reforms feed into an already fragmented and struggling healthcare system, reinforcing differentiated, limited and uneven access to healthcare services and reproducing inequity and exclusions. In this context, reforms for universal health coverage that promise a form of substantial citizenship are in tension with Kenyans' experiences of accessing healthcare. We explore how, amid vocal concerns about healthcare costs and state neglect, the promises and expectations surrounding universal health coverage reforms shaped the claims people made to accessing care. While our informants were cynical about these promises, they were also hopeful. The language of universality and inclusion drew people's attention to entrenched forms of inequality and difference, the limits of solidarity and the gaps between promises and realities, but it also generated expectations and a sense of new possibilities.

Zdravstveni kadrovi i reforma primarne zdravstvene zaštite u Crnoj Gori

Introduction: Universal health coverage reform activities in primary health care in Montenegro were conducted in the period between 2004 and 2012, with the aim of increasing the efficiency of the health care system by ensuring rational use and availability of resources. Aim: The purpose of this study is to describe the health personnel during and after the reform activities in Montenegro. Materials and methods: We adapted the four-dimensional World Health Organization framework to examine availability, accessibility, acceptability and quality of the health personnel in public primary health care facilities, in Montenegro, during and after the reform. Availability, accessibility, acceptability and quality of health personnel were examined using a defined set of proxies. In addition, the latest available data on density rates of health personnel were presented, in order to examine the sustainability of the implemented reforms. The data used included primary health care information system data, data published by the Institute of Public Health of Montenegro, as well as data from a number of official and expert reports by relevant experts and institutions. Results: The total number of physicians employed in primary health care was reduced during the reform by 5%, while the number of nurses was decreased by 35%. At the same time, the number of GPs (chosen doctors for adults) increased, which improved their availability (54.4 in 2015 vs. 36.3 in 2004, per 100,000). Accessibility showed great variations among municipalities. The utilization of health care services, at the national level, increased by 25% in adult health care services. The reduction of the number of nurses was tailored to meet set norms in health care services for adults, women, and children. Reform activities improved the professional competencies of primary health care teams. Conclusion: Primary health care reform improved the availability and accessibility of health personnel and implemented activities that improved their acceptability and quality. It is recommended to establish a permanent body which would continuously monitor the functioning of the primary health care (PHC) system, as well as the changes that occur in PHC, thus ensuring that reform results are maintained and further improved.

Radiothérapie et lutte contre les cancers : défis de maintenance de l’unique accélérateur linéaire à l’Hôpital du Mali

Cancer incidence and mortality rates are increasing in West Africa. Cancer is a recent discipline in Mali and the means available to treat patients are insufficient. Mali has only one radiotherapy machine for the country and its malfunctions are regularly reported in the media. In order to understand the recurrent dissatisfactions linked to access to radiotherapy in Mali, we retraced the history of this machine and described its functioning. Based on semi-directive interviews with patients’ associations and health professionals involved in cancer care in Bamako, we describe how radiotherapy in Mali reveals global health issues through the intervention of numerous international cooperations. In addition, based on data collection from medical registers and institutional reports, we report that the average time to get a radiotherapy appointment is 3 to 6 months in Mali, but also that the radiotherapy machine has experienced 198 breakdowns between April 3, 2014 and September 24, 2021, which represents more than 54 weeks of cumulative downtime. Radiotherapy is a crucial element in the treatment of cancer and the lack of access to this treatment worsens the vital diagnosis of patients. While the Malian government is committed to universal health coverage reforms, strengthening cancer treatment facilities should also be considered a public health priority for Mali.

A Review of Recent Developments and Future Challenges in the Implementation of Universal Health Coverage Policy Framework in Some Countries

Global attention has recently converged on the need for countries to achieve universal health coverage (UHC), which aims to guarantee that all persons are able to access needed and effective healthcare without facing financial ruin by using services. In the attempt to move towards UHC, several low- and middle-income countries are developing more sustainable revenue sources, expanding pooling arrangements and employing more efficient and sustainable purchasing strategies. Their experiences represent a growing evidence of the application of mandatory (social), private and community-based health insurance in low- and middle-income countries and their potential contribution to UHC. UHC reforms are an inherently political process, and public health advocates will need to do more to promote not only the health benefits of public health interventions but also the economic and political benefits too. Crucially, as UHC continues to be championed and rolled out globally, all people working in global health need to reinforce the importance of including the full scope of public health in health system reforms; only then can the full potential of UHC be realized—a true reduction in health inequities. However, implementation of a UHC is not an easy phenomenon, rather it needs proper design of a good health insurance system by integrating both the public and private health care providers. The influence of good governance and a sustainable health financing system is fundamental to establish UHC in the developing countries. This review Paper encompasses recent developments and future challenges in the implementation of Universal Health Coverage Policy framework in some countries.

Public financing for primary health care is the key to universal health coverage and strengthening health security

Public financing for primary health care is the key to universal health coverage and strengthening health security

Does the implementation of UHC reforms foster greater equality in health spending? Evidence from a benefit incidence analysis in Burkina Faso

IntroductionBurkina Faso is one among many countries in sub-Saharan Africa having invested in Universal Health Coverage (UHC) policies, with a number of studies have evaluated their impacts and equity impacts....

Using social network analysis to examine inter-governmental relations in the implementation of the Ideal Clinic Realisation and Maintenance programme in two South African provinces.

BackgroundWithin the context of universal health coverage (UHC), South Africa has embarked on a series of health sector reforms. The implementation of the Ideal Clinic Realisation and Maintenance (ICRM) programme is a major UHC reform. Cooperative governance is enshrined in South Africa’s Constitution, with health a concurrent competency of national and provincial government. Hence, effective inter-governmental relations (IGR) are essential for the ICRM programme implementation.AimThe aim of the study was to measure the cohesion of IGR, specifically consultation, support and information sharing, across national, provincial and local government health departments in the ICRM programme implementation.Materials and methodsUsing Provan and Milward’s theory on network effectiveness, this study was a whole network design social network analysis (SNA). The study was conducted in two districts in Gauteng (GP) and Mpumalanga (MP) provinces of South Africa. Following informed consent, we used both an interview schedule and a network matrix to collect the social network data from health policy actors in national, provincial and local government. We used UCINET version 6.619 to analyse the SNA data for the overall network cohesion and cohesion within and between the government spheres.ResultsThe social network analysis revealed non-cohesive relationships between the different spheres of government. In both provinces, there was poor consultation in the ICRM programme implementation, illustrated by the low densities of seeking advice (GP = 15.6%; MP = 24.4%) and providing advice (GP = 14.1%; MP = 25.1%). The most cohesive relationships existed within the National Department of Health (density = 66.7%), suggesting that national policy actors sought advice from one another, rather than from the provincial health departments. A density of 2.1% in GP, and 12.5% in MP illustrated the latter.ConclusionThe non-cohesive relationships amongst policy actors across government spheres should be addressed in order to realise the benefits of cooperative governance in implementing the ICRM programme.

Three Decades of Healthcare System Reform in Iran from the Perspective of Universal Health Coverage: A Macro-Qualitative Study.

Background: The healthcare system in Iran has undergone several reforms to achieve the objectives of universal health coverage (UHC). Some reforms have delivered positive benefits, however, still many challenges remain. Hence, the current study assessed the progress and outcomes of these reforms over the past three decades. Methods: The present nationwide macro-qualitative study was conducted in Iran during 2016-2017. Data were collected through 32 in-depth interviews with 30 high-ranking policymakers and healthcare providers at the national and provincial levels to identify their experiences and perceptions of the reforms. The data were analyzed using the constant comparative analysis method. Results: Analysis of the interview data resulted in two main themes, six categories, and 18 sub-categories. The extracted themes were adverse situational context and the chaotic healthcare system. The results showed that the Iranian healthcare system reforms could be characterized as incoherent and passive, and that these were the main reasons for not achieving the objectives of UHC reforms. It was revealed that the implemented reforms lacked a comprehensive approach and at times were counterproductive. Moreover, the situational context adversely hindered the successful implementation of the reforms.Conclusion: Despite many efforts to improve the Iranian healthcare system through reforms, the situational context and organizational factors have prevented achieving the main objectives. Iran’s health policymakers should consider a phased implementation of small-scale reforms based on a comprehensive master plan that takes social, political, and economic factors into account. This approach would minimize potential risks and encourages the cooperation of the main stakeholders.

Unmet need for primary healthcare and associated individual and household-level factors in Kenya: results from a national survey

ObjectiveTo determine the prevalence of unmet need for primary healthcare and associated individual and household-level factors in Kenya.DesignThe data for this study are drawn from the 2016 Kenya Integrated Household...

Politics of success stories in the path towards Universal Health Coverage: The case of Turkey

AbstractMotivationTurkey has been acknowledged as a “successful” example of Universal Health Coverage (UHC) reforms and has recently gained donor “darling status.” While the literature on UHC and health reforms in various countries has increased significantly in recent years, there is still little research on the political dynamics of the rise of UHC in national and global development agendas.PurposeThis study examines the politics of UHC in Turkey’s Health Transformation Program (HTP). It investigates how various policy actors, such as international organizations, policy experts and national political leaders, use UHC framing for different purposes.Approach & MethodsThe article develops an interdisciplinary conceptual framework that combines elements of ideational scholarship and critical policy analysis. The analysis is based on a review of the secondary literature and primary sources. Qualitative content analysis is used to identify major themes and analyse patterns of interactions across the various policy levels.FindingsThe article’s main findings demonstrate the ways in which international actors and national policy‐makers engage in policy work and use their relationships, global policy ideas and experiences to build legitimacy and support for their respective agendas. Reforms in Turkey were proposed and implemented before the rise of UHC in the global agenda, suggesting an ex post facto rebranding of its reforms as UHC. For Turkey’s policy‐makers, rebranding worked to tie their policy solutions, summarized in the HTP, to UHC as a widely accepted cultural symbol. The Ministry of Health’s deliberate strategy to encourage data collection and monitoring was also a key part of its efforts to construct a success narrative in collaboration with global policy actors. For the global‐level advocates of UHC, Turkey provided evidence that UHC works. Before it became a target under the health‐related Social Development Goals (SDGs), advocates needed to demonstrate that they had the right framing and metrics for a UHC agenda. After 2015, successful examples have served as strategic tools for building support and political momentum as the agenda was diffused, and as these diverse agendas and interests overlapped.Policy ImplicationsThis article contributes to the current debates on policy diffusion, translation and implementation of the UHC agenda. It unpacks the use of success stories to navigate the political dynamics among national governments and global policy communities. Success stories, alongside an emphasis on country ownership, may serve to encourage the co‐production of policy across local, national and global levels.

Monitoring Universal Health Coverage reforms in primary health care facilities: Creating a framework, selecting and field-testing indicators in Kerala, India.

In line with the Sustainable Development Goals (SDGs) and the target for achieving Universal Health Coverage (UHC), state level initiatives to promote health with "no-one left behind" are underway in India. In Kerala, reforms under the flagship Aardram mission include upgradation of Primary Health Centres (PHCs) to Family Health Centres (FHCs, similar to the national model of health and wellness centres (HWCs)), with the proactive provision of a package of primary care services for the population in an administrative area. We report on a component of Aardram's monitoring and evaluation framework for primary health care, where tracer input, output, and outcome indicators were selected using a modified Delphi process and field tested. A conceptual framework and indicator inventory were developed drawing upon literature review and stakeholder consultations, followed by mapping of manual registers currently used in PHCs to identify sources of data and processes of monitoring. The indicator inventory was reduced to a list using a modified Delphi method, followed by facility-level field testing across three districts. The modified Delphi comprised 25 participants in two rounds, who brought the list down to 23 approved and 12 recommended indicators. Three types of challenges in monitoring indicators were identified: appropriateness of indicators relative to local use, lack of clarity or procedural differences among those doing the reporting, and validity of data. Further field-testing of indicators, as well as the revision or removal of some may be required to support ongoing health systems reform, learning, monitoring and evaluation.

Estimating a cost-effectiveness threshold for health care decision-making in South Africa

Cost-effectiveness thresholds are important decision rules that determine whether health interventions represent good value for money. In low- and middle-income countries, the World Health Organization (WHO) one to three times per capita gross domestic product (GDP) per disability-adjusted life years (DALYs) averted has been the most widely used threshold for informing resource allocation decisions. However, in 2016, the WHO withdrew recommendations for using this threshold, creating a significant vacuum in South Africa and many countries that rely on results of cost-effectiveness analyses for making resource allocation decisions. This study estimates a cost-effectiveness threshold that reflects the health opportunity cost of health spending in South Africa using a three-step approach. First, marginal returns to health spending was estimated as health spending elasticity for crude death rates using a fixed effect estimation approach. Second, the opportunity cost of health spending was estimated as DALYs averted. Finally, a cost per DALY averted threshold was estimated as the inverse of the marginal product of health spending. We show that 1% of total health spending in 2015 (equivalent to approximately ZAR 1.54 billion/USD 120.7 million) averted 1050 deaths, 34 180 years of life lost, 5880 years lived with disability and 40 055 DALYs. The cost-effectiveness threshold was estimated at approximately ZAR 38 500 (USD 3015) per DALY averted, ∼53% of South Africa’s per capita GDP in 2015 (ZAR 72 700/USD 5700) and lower than the previously recommended one to three times per capita GDP. As South Africa moves towards implementing universal health coverage reforms through National Health Insurance by 2025, the adoption of a threshold that reflects health opportunity costs will be crucial for ensuring efficiency in the allocation of scarce resources. This study provides useful insight into the magnitude of the health opportunity cost of health spending in South Africa and highlights the need for further research.

Perspectives of Healthcare Workers, National and Regional Policy Stakeholders on the Management of Chronic Lung Disease in Five Sub-Saharan African Countries: Tale of a Vicious Cycle of Neglect

Background: Chronic lung diseases are among the top four non communicable diseases (NCDs), associated with 80% of premature mortality worldwide, debilitating health, and poor quality of life for survivors. Common risk factors for lung diseases include exposure to biomass fuels, environmental pollution, tobacco smoke, hereditary factors, and lower respiratory tract infections. Low-and-middle-income countries bear the biggest burden of chronic lung diseases, due to increasing exposures to risk factors, and weak health systems.To manage this rising threat, countries need to orient their systems towards chronic disease management, strengthen their primary healthcare systems even as they pursue universal health coverage reforms. This paper draws on the views and experiences of health systems actors to explore the current challenges to improving high quality, accessible care for chronic lung diseases.Methods: We explored the perspectives of policy stakeholders on management of chronic lung diseases in five Sub-Saharan African countries, Kenya, Malawi, Sudan, Tanzania, and Uganda. Data were collected between May 2018 and March 2019 through key informant interviews and in-depth interviews with government officials, representatives of non-governmental organizations supporting various health system functions, and healthcare workers of 36 healthcare facilities. Data were analysed using the framework approach.Findings: We identified intersecting vicious cycles of neglect of chronic lung health at both the strategic policy level and the healthcare facility level. At strategic policy level, low diagnostic capacity, weak recording and reporting systems limit the availability of reliable data on the burden of disease, which negatively affects inclusion in policy, and in turn budgetary allocations for diagnostic equipment, training, and medicines. At the service level, lack of budgetary allocations for equipment and training of staff, constrains diagnostic capacity, which, along with limited availability of appropriate medicines reduces service delivery quality and collection of appropriate data within healthcare facilities. These vicious cycles leave health systems ill equipped to respond to the rising burden of chronic lung disease, an issue that has been brought into sharp focus as countries plan for dealing with post COVID lung disease. Interpretation: 1. There is increasing recognition among policymakers that NCDs, including CLD are rising in LMICs.2. CLDs are under-diagnosed, under-reported and underfunded leading to a vicious cycle of invisibility and neglect at all levels of the health system.3. Appropriate diagnosis and CLD management require strengthening of the health systems, particularly at the primary healthcare level.Funding Statement: This research was funded by the National Institute for Health Research (NIHR (IMPALA, grant reference 16/136/35) using UK aid from the UK Government to support global health research.Declaration of Interests: None declared.Ethics Approval Statement: The Liverpool School of Tropical Medicine Ethics Committee approved these studies separately (Kenya: protocol 18-054; Uganda: protocol 18-037; Malawi: protocol M1803; Tanzania and Sudan; protocol 18-043). Additionally, each approved was by in-country committees.

Opening the 'implementation black-box' of the user fee exemption policy for caesarean section in Benin: a realist evaluation.

To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low- and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. We selected two hospitals with contrastive outcomes. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We identified two main causal pathways. First, in the state-owned hospital, which has a public-oriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor. We found that trust, perceived coercion, adherence to policy goals, perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes. Compliance with the policy depended on enforcement by hierarchical authority and bottom-up pressure. Persuasion depended on the alignment of the policy with personal and organizational values. Incentives may determine the adoption if they influence the local stakeholder’s revenue are trustworthy and perceived as fairly allocated. Failure to anticipate the differential responses of implementers will prevent the proper implementation of user fee exemption policies and similar universal health coverage reforms.

Implementation Research to Strengthen Health Care Financing Reforms Toward Universal Health Coverage in Indonesia: A Mixed-Methods Approach to Real-World Monitoring.

Universal health coverage reforms are complex and impact numerous processes, institutions, and individuals. To know whether reforms are being implemented as planned and working as envisioned, policy makers and managers need information and insights on bottlenecks. The United States Agency for International Development (USAID) provided support to build implementation research (IR) capacity and to conduct cycles of research to help Indonesia understand how its single-payer national insurance reform, Jaminan Kesehatan Nasional (JKN), was affecting primary care. Two cycles of IR in Indonesia focused on effects of JKN financing on primary care, as determined through a consultative process with stakeholders at national and district levels. This process generated questions relevant for implementers and policy makers and strengthened government interest in findings. Research was conducted in 5 diverse districts, and methods included key informant interviews, focus groups, document review, health worker surveys, and analysis of service delivery data. Cycle 1 findings showed an uneven understanding of JKN regulations, unequal implementation readiness, and limited evidence of improved productivity. JKN capitation payments did not increase health worker satisfaction or motivate additional effort. Informed by these findings, regulations were rewritten and the capitation payment formula was redesigned to include payment conditional on performance. Cycle 2 found that health workers experienced increased workloads because of increased enrollment in JKN and the requirement that people access primary care before being referred to higher levels of care. In addition, health workers indicated they did not experience the payment system to be fair. Instead of payment being conditional on performance, they indicated it was primarily determined by education and tenure, with only some districts incorporating a small payment component based on behaviors, such as attendance, and performance. The health workers said they preferred to be paid based on achieving primary care targets. Conducting IR so that questions are relevant and the process of finding and sharing answers is timely and cost-effective requires high-level skills, but support to build IR capacity has potential to make a lasting impact.