Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative.

Since the 2008 publication of the reports of the Commission on Social Determinants of Health and its nine knowledge networks, substantial research has been undertaken to document and describe health inequities. The COVID-19 pandemic has underscored the need for a deeper understanding of, and broader action on, the social determinants of health. Building on this unique and critical opportunity, the World Health Organization is steering a multi-country Initiative to reduce health inequities through an action-learning process in 'Pathfinder' countries. The Initiative aims to develop replicable and reliable models and practices that can be adopted by WHO offices and UN staff to address the social determinants of health to advance health equity. This paper provides an overview of the Initiative by describing its broad theory of change and work undertaken in three regions and six Pathfinder countries in its first year-and-a-half. Participants engaged in the Initiative describe results of early country dialogues and promising entry points for implementation that involve model, network and capacity building. The insights communicated through this note from the field will be of interest for others aiming to advance health equity through taking action on the social determinants of health, in particular as regards structural determinants.

Policy dialogue and participation: a new way of crafting a national health financing strategy in Morocco.

BACKGROUND: Policy dialogue for health policies has started to gain importance in recent years, especially for complex issues such as health financing. Moroccan health financing has faced several challenges during the last years. This study aims to document the Moroccan experience in developing a consolidated health financing strategy according to the policy dialogue approach. It especially considers the importance of conceptualising this process in the Moroccan context. METHOD: We documented the process of developing a health financing strategy in Morocco. It concerned four steps, as follows: (1) summarising health financing evidence in preparation of the policy dialogue; (2) organising the health policy dialogue process with 250 participants (government, private sector, NGOs, civil society, parliamentarians, technical and financial partners); (3) a technical workshop to formulate the strategy actions; and (4) an ultimate workshop for validation with decision-makers. The process lasted 1 year from March 2019 to February 2020. We have reviewed all documents related to the four steps of the process through our active participation in the policy debate and the documentation of two technical workshops to produce the strategy document. RESULTS: The policy dialogue approach showed its usefulness in creating convergence among all health actors to define a national shared vision on health financing in Morocco. There was a high political commitment in the process and all actors officially adopted recommendations on health financing actions. A strategy document produced within a collaborative approach was the final output. This experience also marked a shift from previous top-down approaches in designing health policies for more participation and inclusion. The evidence synthesis played a crucial role in facilitating the debate. The collaborative approach seems to work in favouring national consensus on practical health financing actions. CONCLUSION: The policy dialogue process adopted for health financing in Morocco helped to create collective ownership of health financing actions. Despite the positive results in terms of national mobilisation around the health financing vision in Morocco, there is a need to institutionalise the policy dialogue with a more decentralised approach to consider subnational specificities.

A scoping review of the uses and institutionalisation of knowledge for health policy in low- and middle-income countries.

There is growing interest in how different forms of knowledge can strengthen policy-making in low- and middle-income country (LMIC) health systems. Additionally, health policy and systems researchers are increasingly aware of the need to design effective institutions for supporting knowledge utilisation in LMICs. To address these interwoven agendas, this scoping review uses the Arskey and O'Malley framework to review the literature on knowledge utilisation in LMIC health systems, using eight public health and social science databases. Articles that described the process for how knowledge was used in policy-making, specified the type of knowledge used, identified actors involved (individual, organisation or professional), and were set in specific LMICs were included. A total of 53 articles, from 1999 to 2016 and representing 56 countries, were identified. The majority of articles in this review presented knowledge utilisation as utilisation of research findings, and to a lesser extent routine health system data, survey data and technical advice. Most of the articles centered on domestic public sector employees and their interactions with civil society representatives, international stakeholders or academics in utilising epistemic knowledge for policy-making in LMICs. Furthermore, nearly all of the articles identified normative dimensions of institutionalisation. While there is some evidence of how different uses and institutionalisation of knowledge can strengthen health systems, the evidence on how these processes can ultimately improve health outcomes remains unclear. Further research on the ways in which knowledge can be effectively utilised and institutionalised is needed to advance the collective understanding of health systems strengthening and enhance evidence-informed policy formulation.

Managing non-communicable diseases at health district level in Cambodia: a systems analysis and suggestions for improvement.

BACKGROUND: Cambodia developed its public health system along the principles of the district model and geared its services towards managing communicable diseases and maternal and child health issues. In line with other countries in the region, non-communicable diseases have emerged as a leading cause of adult mortality. We assessed the current capacity of the Cambodian district health system to manage hypertension and diabetes, with a focus on access to medicine for these chronic conditions. METHODS: A case study whereby in three purposely selected districts in an equal number of provinces a total of 74 informants were interviewed: 27 health care providers and administrators, 30 community representatives and 17 managers of specific non-communicable diseases interventions and social health protection schemes. Questions related to the World Health Organization's health system building blocks. Data analysis involved coding, indexing, charting and mapping the data. Following these exercises all information was analysed by kind of respondent and their respective answer to the question concerned. Responses by respondents of three groups of interviewees were compared when appropriate. At 14 health centres and 3 district hospitals the availability of key medicines for hypertension and diabetes in accordance with the National Essential Drug List was assessed. This was also done for essential tools and equipment to diagnose these two conditions. RESULTS: Although there was agreement amongst nearly all interviewees that non-communicable diseases were prevalent, the district health system, including all health systems building blocks and the referral system, was inadequately developed to effectively deal with these conditions. Medicines supply was erratic and the quantity provided allowed for few patients to be treated, for a short period only, mainly at secondary or tertiary level. CONCLUSIONS: Because of the public health, social and economic importance of non-communicable diseases, a rapid response is required. Given the current Cambodian situation, such response may initially be a diagonal approach, with non-communicable diseases services integrated in the National HIV/AIDS Programme. This should happen together with a reorientation of the health system to enable a horizontal approach to non-communicable diseases management in the long term.

Improving access to medicines for non-communicable diseases in rural India: a mixed methods study protocol using quasi-experimental design.

BACKGROUND: India has the distinction of financing its healthcare mainly through out-of-pocket expenses by individual families contributing to catastrophic health expenditure and impoverishment. Nearly 70 % of the expenditure is on medicines purchased at private pharmacies. Patients with chronic ailments are especially affected, as they often need lifelong medicines. Over the past years in India, there have been several efforts to improve drug availability at government primary health centres. In this study, we aim to understand health system factors that affect utilisation and access to generic medicines for people with non-communicable diseases. METHODS: This study aims to understand if (and how) a package of interventions targeting primary health centres and community participation platforms affect utilisation and access to generic medicines for people with non-communicable diseases in the current district context in India. This study will employ a quasi-experimental design and a qualitative theory-driven approach. PHCs will be randomly assigned to one of three arms of the intervention. In one arm, PHCs will receive inputs to optimise service delivery for non-communicable diseases, while the second arm will receive an additional package of interventions to strengthen community participation platforms for improving non-communicable disease care. The third arm will be the control. We will conduct household and facility surveys, before and after the intervention and will estimate the effect of the intervention by difference-in-difference analysis. Sample size for measuring effects was calculated based on obtaining at least 30 households for each primary health centre spread across three distance-based clusters. Primary outcomes include availability and utilisation of medicines at primary health centres and out-of-pocket expenditure for medicines by non-communicable disease households. Focus group discussions with patients and in-depth interviews with health workers will also be conducted. Qualitative and process documentation data will be used to explain how the intervention could have worked. DISCUSSION: By taking into consideration several health system building blocks and trying to understand how they interact, our study aims to generate evidence for health planners on how to optimise health services to improve access to medicines. TRIAL REGISTRATION: Protocol registered on Clinical Trials Registry of India with registration identifier number CTRI/2015/03/005640 on 17(th) March 2015.

Health systems research for policy change: lessons from the implementation of rapid assessment protocols for diabetes in low- and middle-income settings.

BACKGROUND: As many challenges exist for access to diabetes care in developing countries, the International Insulin Foundation developed a Rapid Assessment tool and implemented this approach to identify barriers to care and propose concrete recommendations for decision makers. The objective of this paper is to identify the factors that contributed to informing and influencing policymakers with regards to this work. METHODS: A documentary review comprised Stage 1. Stage 2 used an online questionnaire to gain insight from users of the Rapid Assessment results. Based on Stages 1 and 2, Stage 3 comprised in-depth interviews with a total of nine individuals (one individual each from the six participating countries; two individuals from the World Health Organization; one "Global Diabetes Advocate"). Interviews were analyzed based on a list of themes developed from Stage 2. RESULTS: Stage 1 led to the identification of various types of documents referring to the results. The online questionnaire had a response rate of 33%. Respondents directly involved in the assessment had a "Good" or "Very Good" appreciation of most aspects and scored these higher than those not directly involved. From the interviews, formalized methods and close collaboration between the international team and local partners were strengths. Trust and a relationship with local partners were also seen as assets. All stakeholders valued the results and the credibility of the data generated. Local partners felt that more could have been done for dissemination. CONCLUSION: This study shows the importance of specific results from the different assessments. In addressing complex issues having external experts involved was seen as an advantage. The uptake of results was due to the credibility of the research which was influenced by a mix of the people involved, past assessments, trusted local partners, and the use of the results by knowledge brokers, such as the World Health Organization. Through these brokers, others gained ownership of the data. The methods used and the fact that this data was grounded in a local context also reinforced its value. Despite limitations, this study offers a unique perspective where a similar research approach was taken in six countries.

Stakeholders' perspectives on access-to-medicines policy and research priorities in Latin America and the Caribbean: face-to-face and web-based interviews.

BACKGROUND: This study aims to rank policy concerns and policy-related research issues in order to identify policy and research gaps on access to medicines (ATM) in low- and middle-income countries in Latin America and the Caribbean (LAC), as perceived by policy makers, researchers, NGO and international organization representatives, as part of a global prioritization exercise. METHODS: Data collection, conducted between January and May 2011, involved face-to-face interviews in El Salvador, Colombia, Dominican Republic, and Suriname, and an e-mail survey with key-stakeholders. Respondents were asked to choose the five most relevant criteria for research prioritization and to score policy/research items according to the degree to which they represented current policies, desired policies, current research topics, and/or desired research topics. Mean scores and summary rankings were obtained. Linear regressions were performed to contrast rankings concerning current and desired policies (policy gaps), and current and desired research (research gaps). RESULTS: Relevance, feasibility, and research utilization were the top ranked criteria for prioritizing research. Technical capacity, research and development for new drugs, and responsiveness, were the main policy gaps. Quality assurance, staff technical capacity, price regulation, out-of-pocket payments, and cost containment policies, were the main research gaps. There was high level of coherence between current and desired policies: coefficients of determination (R2) varied from 0.46 (Health system structure; r = 0.68, P <0.01) to 0.86 (Sustainable financing; r = 0.93, P <0.01). There was also high coherence between current and desired research on Rational selection and use of medicines (r = 0.71, P <0.05, R2 = 0.51), Pricing/affordability (r = 0.82, P <0.01, R2 = 0.67), and Sustainable financing (r = 0.76, P <0.01, R2 = 0.58). Coherence was less for Health system structure (r = 0.61, P <0.01, R2 = 0.38). CONCLUSIONS: This study combines metrics approaches, contributing to priority setting methodology development, with country and regional level stakeholder participation. Stakeholders received feedback with the results, and we hope to have contributed to the discussion and implementation of ATM research and policy priorities in LAC.

UHC in Morocco: a bottom-up estimation of public hospitals' financing size based on a costing database.

BACKGROUND: Morocco is engaged in a health system reform aimed at generalizing health insurance across the whole population by 2025. This study aims to build a national database of costs at all levels of public hospitals in Morocco and craft this database as a resource for further use in a strategic purchasing system. It also aims at estimating the funding gap and the budget that should be secured for public hospitals in Morocco to fully play their roles in the current ambitious reform. METHOD: A costing study was implemented in 39 hospitals in 12 regions of Morocco (10 provincial hospitals, 11 regional hospitals, and 18 teaching hospitals). Using the hospital costing approach, we adapted and validated nationally our methodology to generate a database of unit costs based on data from 2019. All perspectives on cost were considered. Data collection was performed by cadres from MoH and facilitated by the WHO country office in Morocco. The production of the cost database allowed the development of a bottom-up estimation of the financing size for public health hospitals. RESULTS: The study showed the feasibility of large-scale costing in the context of Morocco. The ownership of MoH and adherence to the process ensured the high quality of the collected data. There are many differences in unit costs for the same services moving from one hospital to another, which indicates existing inefficiencies. The database will contribute to shaping the strategic purchasing mechanism within the generalized health insurance schemes. The studied hospitals could be used as references to systematically update the billing system for health insurance.

Unravelling collaborative governance dynamics within healthcare networks: a scoping review.

In many countries, healthcare systems suffer from fragmentation between hospitals and primary care. In response, many governments institutionalized healthcare networks (HN) to facilitate integration and efficient healthcare delivery. Despite potential benefits, the implementation of HN is often challenged by inefficient collaborative dynamics that result in delayed decision-making, lack of strategic alignment and lack of reciprocal trust between network members. Yet, limited attention has been paid to the collective dynamics, challenges and enablers for effective inter-organizational collaborations. To consider these issues, we carried out a scoping review to identify the underlying processes for effective inter-organizational collaboration and the contextual conditions within which these processes are triggered. Following appropriate methodological guidance for scoping reviews, we searched four databases [PubMed (n = 114), Web of Science (n = 171), Google Scholar (n = 153) and Scopus (n = 52)] and used snowballing (n = 22). A total of 37 papers addressing HN including hospitals were included. We used a framework synthesis informed by the collaborative governance framework to guide data extraction and analysis, while being sensitive to emergent themes. Our review showed the prominence of balancing between top-down and bottom-up decision-making (e.g. strategic vs steering committees), formal procedural arrangements and strategic governing bodies in stimulating participative decision-making, collaboration and sense of ownership. In a highly institutionalized context, the inter-organizational partnership is facilitated by pre-existing legal frameworks. HN are suitable for tackling wicked healthcare issues by mutualizing resources, staff pooling and improved coordination. Overall performance depends on the capacity of partners for joint action, principled engagement and a closeness culture, trust relationships, shared commitment, distributed leadership, power sharing and interoperability of information systems To promote the effectiveness of HN, more bottom-up participative decision-making, formalization of governance arrangement and building trust relationships are needed. Yet, there is still inconsistent evidence on the effectiveness of HN in improving health outcomes and quality of care.

Health policy and systems research in access to medicines: a prioritized agenda for low- and middle-income countries.

OBJECTIVES: To identify priority policy issues in access to medicines (ATM) relevant for low- and middle-income countries, to identify research questions that would help address these policy issues, and to prioritize these research questions in a health policy and systems research (HPSR) agenda. METHODS: The study involved i) country- and regional-level priority-setting exercises performed in 17 countries across five regions, with a desk review of relevant grey and published literature combined with mapping and interviews of national and regional stakeholders; ii) interviews with global-level stakeholders; iii) a scoping of published literature; and iv) a consensus building exercise with global stakeholders which resulted in the formulation and ranking of HPSR questions in the field of ATM. RESULTS: A list of 18 priority policy issues was established following analysis of country-, regional-, and global-level exercises. Eighteen research questions were formulated during the global stakeholders' meeting and ranked according to four ranking criteria (innovation, impact on health and health systems, equity, and lack of research). The top three research questions were: i) In risk protection schemes, which innovations and policies improve equitable access to and appropriate use of medicines, sustainability of the insurance system, and financial impact on the insured? ii) How can stakeholders use the information available in the system, e.g., price, availability, quality, utilization, registration, procurement, in a transparent way towards improving access and use of medicines? and iii) How do policies and other interventions into private markets, such as information, subsidies, price controls, donation, regulatory mechanisms, promotion practices, etc., impact on access to and appropriate use of medicines? CONCLUSIONS: Our HPSR agenda adopts a health systems perspective and will guide relevant, innovative research, likely to bear an impact on health, health systems and equity.

Governance Roles and Capacities of Ministries of Health: A Multidimensional Framework.

The lack of capacity for governance of Ministries of Health (MoHs) is frequently advanced as an explanation for health systems failures in low- and middle-income countries (LMICs). But do we understand what governance capacities MoHs should have? Existing frameworks have not fully captured the dynamic and contextually determined role of MoHs, and there are few frameworks that specifically define capacities for governance. We propose a multidimensional framework of capacities for governance by MoHs that encompasses both the "hard" (de jure, explicit and functional) and "soft" (de facto, tacit, and relational) dimensions of governance, and reflects the diversification of their mandates in the context of the Sustainable Development Goals (SDGs). Four case studies illustrate different aspects of the framework. We hope that the framework will have multiple potential benefits including benchmarking MoH governance capacities, identifying and helping analyze capacity gaps, and guiding strategies to strengthen capacity.

Comparison of appropriateness of Nutri-Score and other front-of-pack nutrition labels across a group of Moroccan consumers: awareness, understanding and food choices.

BACKGROUND: The front of pack nutrition label Nutri-Score, intended to help consumers orient their choices towards foods that are more favorable to health, was developed in France and applied in several European countries. Consideration is underway for its use in Morocco. This study aims to assess Moroccan consumers' perception and objective understanding of Nutri-Score and 4 other nutritional information labels (Health Star Rating, Health warning, Reference Intakes and Multiple Trafic Light) and their impact on purchase intentions. METHODS: 814 participants were asked to choose among 3 food classes (yoghurts, biscuits and cold cuts), which ones they would prefer to buy among three products with different nutritional profiles and then to rank them according to their nutritional quality. Participants first performed these tasks without a visible nutritional label, and then, after being randomized to one of five labels tested, with the nutritional label visible on front of packs. Next, the full set of tested labels was presented to the participants who were asked a series of questions regarding their preferences, the attractiveness of the labels, their perceptions, intention to use and the trustworthiness placed in the labels. RESULTS: Compared to the Reference Intake, the Nutri-Score (OR = 2.48 [1.53-4.05], p < 0.0001), was associated with the highest improvement in the ability to correctly classify foods based on their nutritional quality. The percentage of participants who improved their food choice was higher than those who worsened it for all the labels. For yogurts and cookies, the most significant improvements were observed for the Nutri-Score and the Reference Intakes: Concerning the perception of labels, the Nutri-Score is the label that received the highest number of positive responses, whether concerning the ease of being spotted (82.2%), of being understood (74%), and to provide rapid information (68.8%). The Nutri-Score was ranked as the preferred label by 64.9% of the participants. CONCLUSION: The Nutri-Score appears to be the most effective nutritional information system to inform consumers about the nutritional quality of foods in Morocco, where it could constitute a useful tool to help consumers in their food choices in situations of purchase.

Pre-hospital care time intervals among victims of road traffic injuries in Iran. A cross-sectional study.

BACKGROUND: Road traffic injuries (RTIs) are a major public health problem, requiring concerted efforts both for their prevention and a reduction of their consequences. Timely arrival of the Emergency Medical Service (EMS) at the crash scene followed by speedy victim transportation by trained personnel may reduce the RTIs' consequences. The first 60 minutes after injury occurrence--referred to as the "golden hour"--are vital for the saving of lives. The present study was designed to estimate the average of various time intervals occurring during the pre-hospital care process and to examine the differences between these time intervals as regards RTIs on urban and interurban roads. METHOD: A retrospective cross-sectional study was designed and various time intervals in relation to pre-hospital care of RTIs identified in the ambulance dispatch centre in Urmia, Iran from 20 March 2005 to 20 March 2007. All cases which resulted in ambulance dispatches were reviewed and those that had complete data on time intervals were analyzed. RESULTS: In total, the cases of 2027 RTI victims were analysed. Of these, 61.5% of the subjects were injured in city areas. The mean response time for city locations was 5.0 minutes, compared with 10.6 minutes for interurban road locations. The mean on-scene time on the interurban roads was longer than on city roads (9.2 vs. 6.1 minutes, p < 0.001). Mean transport times from the scene to the hospital were also significantly longer for interurban incidents (17.1 vs. 6.3 minutes, p < 0.001). The mean of total pre-hospital time was 37.2 (+/-17.2) minutes with a median of 32.0. Overall, 72.5% of the response interval time was less than eight minutes. CONCLUSION: The response, transport and total time intervals among EMS responding to RTI incidents were longer for interurban roads, compared to the city areas. More research should take place on needs-to and access-for EMS on city and interurban roads. The notification interval seems to be a hidden part of the post-crash events and indirectly affects the "golden hour" for victim management and it needs to be measured through the establishment of the surveillance systems.

Decision-making and health system strengthening: bringing time frames into perspective.

In many low-and middle-income countries, health systems decision-makers are facing a host of new challenges and competing priorities. They must not only plan and implement as they used to do but also deal with discontented citizens and health staff, be responsive and accountable. This contributes to create new political hazards susceptible to disrupt the whole execution of health plans. The starting point of this article is the observation by the first author of the limitations of the building-blocks framework to structure decision-making as for strengthening of the Moroccan health system. The management of a health system is affected by different temporalities, the recognition of which allows a more realistic analysis of the obstacles and successes of health system strengthening approaches. Inspired by practice and enriched thanks a consultation of the literature, our analytical framework revolves around five dynamics: the services dynamic, the programming dynamic, the political dynamic, the reform dynamic and the capacity-building dynamic. These five dynamics are differentiated by their temporalities, their profile, the role of their actors and the nature of their activities. The Moroccan experience suggests that it is possible to strengthen health systems by opening up the analysis of temporalities, which affects both decision-making processes and the dynamics of functioning of health systems.

Barriers to access and the purchasing function of health equity funds: lessons from Cambodia.

PROBLEM: High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very low incomes. Their impact on access to health services must be carefully examined. APPROACH: Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers. LOCAL SETTING: Two-thirds of total health expenditure consists of patients' out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes. RELEVANT CHANGES: HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care. LESSONS LEARNED: HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully.

The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence.

One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: 'Voting with feet' (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); 'Close to ground' (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and 'Watching the watchers' (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance.

Health systems changes after decentralisation: progress, challenges and dynamics in Pakistan.

Decentralisation is widely practised but its scrutiny tends to focus on structural and authority changes or outcomes. Politics and process of devolution implementation needs to be better understood to evaluate how national governments use the enhanced decision space for bringing improvements in the health system and the underlying challenges faced. We use the example of Pakistan's radical, politically driven provincial devolution to analyse how national structures use decentralisation opportunities for improved health planning, spending and carrying out transformations to the health system. Our narrative draws on secondary data sources from the PRIMASYS study, supplemented with policy roundtable notes from Pakistan. Our analysis shows that in decentralised Pakistan, health became prioritised for increased government resources and achieved good budgetary use, major strides were made contextualised sector-wide health planning and legislations, and a proliferation seen in governance measures to improve and regulate healthcare delivery. Despite a disadvantaged and abrupt start to devolution, high ownership by politicians and bureaucracy in provincial governments led to resourcing, planning and innovations. However, effective translation remained impeded by weak institutional capacity, feeble federal-provincial coordination and vulnerability to interference by local elites. Building on this illustrative example, we propose (1) political management of decentralisation for effective national coordination, sustaining stable leadership and protecting from political interfere by local elites; (2) investment in stewardship capacity in the devolved structures as well as the central ministry to deliver on new roles.

From Scheme to System (Part 2): Findings from Ten Countries on the Policy Evolution of Results-Based Financing in Health Systems.

Abstract- This article presents the enablers and barriers to the scaling-up of results-based financing (RBF) programs. It draws on the Alliance for Health Policy and Systems Research's multicountry program of research Taking Results Based Financing From Scheme to System, which compared the scale-up of RBF interventions over four phases-generation, adoption, institutionalization, and expansion-across ten countries. Comparing country experiences reveals broad lessons on scale up of RBF for each of the scale-up phases. Though the coming together of global, national, and regional contextual factors was key to the development of pilot projects, national factors were important to scale up these pilots to national programs, including a political context favoring results and transparency, the presence of enabling policies and institutions, and the presence of policy entrepreneurs at the national level. The third transition, from program to policy, was enabled by the availability of domestic financial resources, legislative and financing arrangements to enhance health facility autonomy, and technical and political leadership within and beyond the Ministry of Health. The article provides lessons learned on RBF policy evolution, emphasizing the importance of phase-specific groups of actors, the need to tailor advocacy messages to enable scale-up, the influence of political feasibility on policy content, and policy processes to build national ownership and enable health system strengthening.

From Scheme to System (Part 1): Notes on Conceptual and Methodological Innovations in the Multicountry Research Program on Scaling Up Results-Based Financing in Health Systems.

Abstract-This article presents conceptual and methodological developments made in analyzing the scale up of results-based financing (RBF) as part of a multicountry research program supported by the Alliance for Health Policy and Systems Research. Following a brief overview of the research process, the article proposes a new five-dimensional conceptualization of scale-up (population coverage, service coverage, health system integration, cross-sectoral diffusion, and knowledge expansion) to capture various facets of RBF scale-up. It also presents how Walt and Gilson's health policy triangle framework was modified to identify the enablers and barriers to scale-up in the country case studies included in this research program. The article then puts forth a four-phase model of scale-up, including phases of generation, adoption, institutionalization, and expansion, developed for the purpose of this research program. The article concludes by providing some lessons learned on the use of the methods and theoretical frameworks developed for this multicountry research program.