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Introduction Methods Results Conclusions Learning sites have supported intervention development and testing in health care, but studies reflecting on lessons relating to their deployment for health policy and system research (HPSR) in low‐ and middle‐income settings are limited.This experience report draws from learning over three continents and five research and community engagement programs—the oldest starting in 2010—to reflect on the challenges and benefits of doing embedded HPSR in learning sites, and how those have been managed. Its objective is to generate better understanding of their potential and constraints. The report draws from team members' experiential insights and program publications.Challenges relating to initial engagement in the sites included building and maintaining trust, managing partner expectations, and negotiating priority topics and stakeholders. Once the embedded research was underway, sustaining engagement, and managing power dynamics within the group, supporting all participants in developing new skills and managing rapidly changing settings were important. Finally, the complexity of reflecting on action and assessing impact are outlined, along with potential approaches to managing all of these challenges and the variety of gains that have been noted across the programs.We highlight the potential of learning sites to develop relationships, capacities, and local innovations which can strengthen health systems in the long term and some lessons in relation to how to do that, including the importance of stable, long‐term funding as well as developing and recognizing facilitation skills among researchers. Supporting spaces for learning is particularly important when health systems face resource constraints and everyday or acute stressors and shocks. [ABSTRACT FROM AUTHOR]

Background: Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient 'decision space' to make timely locally informed and relevant decisions. Our objectives were to understand decision spaces in terms of constraints and enablers and outline opportunities through which to expand them in an understudied rural context in South Africa. Methods: This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was combined with published documents and research team participant observation to produce findings on three core domains at three levels of the health system. Results: Although capacity for decision making exists in the system, accessing it is frequently made difficult due to a number of intervening factors. While lines of authority are generally well-defined, personal networks take on an important dimension in how stakeholders can act. This is expressed through a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities, and internal accountability which is weak in places for individuals and focused more on meeting performance targets set at higher levels and less on enabling effective local leadership. More generally, political and personal factors are clearly identified at higher levels of the system, whereas at sub-district and facility levels, the dominant theme was constrained capacity. Conclusions: By examining the balance of authority, accountability and capacity across multiple levels of the provincial health system, we are able to identify emergent decision space and areas for enlargement. Creating spaces to support more constructive relationships and dialogue across system levels emerges as important, as well as reinforcing horizontal networks to problem solve, and developing the capacity of link-agents such as community health workers to increase community accountability. [ABSTRACT FROM AUTHOR]

Background: When the COVID pandemic hit the world, there was need for applied guides and training materials to support frontline health care staff to manage patients effectively and safely and to educate themselves and communities. This article reports on the development and piloting of such a set of materials in Sierra Leone, which were based on international evidence but adapted to the local context. Reflecting on this experience, including community and health system barriers and enablers, is important to prepare for future regional shocks. Methods: This study, in Bombali district in 2020, piloted user-friendly COVID guides for frontline health workers (the intervention), which was evaluated using facility checklists (pre and post training), routine data analysis and 32 key informant interviews. Results: Key informants at district, hospital and community health centre levels identified gains from the training and desk guides, including improved diagnosis, triaging, infection prevention and management of patients. They also reported greater confidence to share messages on protection with colleagues and community members, which was needed to encourage continued use of essential services during the pandemic. However, important barriers were also revealed, including the lack of testing facilities, which reduced the sense of urgency, as few cases were identified. Actions based on the Ebola experience, such as setting up testing and isolation centres, which the community avoided, were not appropriate to COVID. Stigma and fear were important factors, although these were reduced with outreach activities. Supplies of essential medicines and personal protective equipment were also lacking. Conclusion: This pilot study demonstrated the relevance and importance of guides adapted to the context, which were able to improve the confidence of health staff to manage their own and the community's fears in the face of a new pandemic and improve their skills. Previous epidemics, particularly Ebola, complicated this by both creating structures that could be revitalised but also assumptions and behaviours that were not adapted to the new disease. Our study documents positive adaptations and resilience by health staff but also chronic system weaknesses (particularly for medicines, supplies and equipment) which must be urgently addressed before the next shock arrives. [ABSTRACT FROM AUTHOR]

Background: Northwest Syria (NWS) is a complex and extremely fragile operating environment, with more than 2.8 million people needing humanitarian assistance. To support a common standard of care delivery and enable coordination among the multiple providers in NWS, WHO developed an Essential Health Services package (EHSP) in 2016-17 and subsequently supported a facility network model to deliver the EHSP. This article provides an evaluation of the network to date, aiming to inform further development of the network and draw wider lessons for application of similar approaches in complex emergency settings. Methods: This mixed method study included document review, participatory, qualitative and quantitative data, gathered in the first half of 2021. Participatory data came from two group model building workshops with 21 funders and implementers. Semi-structured interviews with 81 funders, health professionals and community members were also conducted. Analyses of the workshops and interviews was inductive, however a deductive approach was used for synthesising insights across this and the document review. The final component was a survey of health providers (59 health care professionals) and service users (233 pregnant women and 214 persons living with NCDs) across network and other comparable facilities, analysed using routine descriptive and inferential statistics. Findings across all methods were triangulated. Results: The study finds that the network and its accompanying essential service package were relevant to the dynamic and challenging context, with high but shifting population needs and multiple uncoordinated providers. Judged in relation to its original goals of comprehensive, coordinated services, equitable access and efficient service delivery, the data indicate that gains have been made in all three areas through the network, although attribution is challenging, given the complex environment. The context remains challenging, with shifting boundaries and populations displaced by conflict, difficulties in retaining staff, the need to import medicines and supplies across borders, and governance gaps. Conclusion: This study adds to a very limited literature on coordinated network approaches used to raise care quality and improve referrals and efficiency in a complex emergency setting. Although areas of ongoing challenge, including for sustainability, are noted, the network demonstrated some resilience strategies and can provide lessons for other similar contexts. [ABSTRACT FROM AUTHOR]

Background: Leadership to manage the complex political and technical challenges of moving towards universal health coverage (UHC) is widely recognized as critical, but there are few studies which evaluate how to expand capacities in this area. This article aims to fill some of this gap by presenting the methods and findings of an evaluation of the Leadership for UHC (L4UHC) programme in 2019-2020.Methods: Given the complexity of the intervention and environment, we adopted a theory-driven evaluation approach that allowed us to understand the role of the programme, amongst other factors. Data from a range of sources and tools were compared with a programme theory of change, with analysis structured using an evaluation matrix organized according to the Organisation for Economic Co-operation and Development-Development Assistance Committee (OECD-DAC) criteria. Data sources included key informant (KI) interviews (89 in total); surveys of the 80 workshop participants; a range of secondary data sources; case studies in two countries; and observation of activities and modules by the evaluator.Results: Participants and KIs at the global and country levels reported high relevance of the programme and a lack of alternatives aiming at similar goals. In relation to effectiveness, at the individual level, there was an increase in some competencies, particularly for those with less experience at the baseline. Less change was observed in commitment to UHC as that started at a relatively high level. Understanding of UHC complexity grew, particularly for those coming from a non-health background. Connections across institutional divides for team members in-country increased, although variably across the countries, but the programme has not as yet had a major impact on national coalitions for UHC. Impacts on health policy and practice outcomes were evident in two out of seven countries. We examined factors favouring success and explanatory factors. We identified positive but no negative unintended effects.Conclusions: While noting methodological constraints, the theory-based evaluation approach is found suitable for assessing and learning lessons from complex global programmes. We conclude that L4UHC is an important addition to the global and national health ecosystem, addressing a relevant need with some strong results, and also highlight challenges which can inform other programmes with similar objectives. [ABSTRACT FROM AUTHOR]

Most countries face challenges attracting and retaining health staff in remote areas but this is especially acute in fragile and shock-prone contexts, like Guinea, where imbalances in staffing are high and financial and governance arrangements to address rural shortfalls are weak. The objective of this study was to understand how health staff could be better motivated to work and remain in rural, under-served areas in Guinea. In order to inform the policy dialogue on strengthening human resources for health, we conducted three nationally representative cross-sectional surveys, adapted from tools used in other fragile contexts. This article focuses on the health worker survey. We found that the locational job preferences of health workers in Guinea are particularly influenced by opportunities for training, working conditions, and housing. Most staff are satisfied with their work and with supervision, however, financial aspects and working conditions are considered least satisfactory, and worrying findings include the high proportion of staff favouring emigration, their high tolerance of informal user payments, as well as their limited exposure to rural areas during training. Based on our findings, we highlight measures which could improve rural recruitment and retention in Guinea and similar settings. These include offering upgrading and specialization in return for rural service; providing greater exposure to rural areas during training; increasing recruitment from rural areas; experimenting with fixed term contracts in rural areas; and improving working conditions in rural posts. The development of incentive packages should be accompanied by action to tackle wider issues, such as reforms to training and staff management. [ABSTRACT FROM AUTHOR]

A debate about how best to finance essential health care in low- and middle-income settings has been running for decades, with public health systems often failing to provide reliable and adequate funding for primary health care in particular. Since 2000, many have advocated and experimented with performance-based financing as one approach to addressing this problem. More recently, in light of concerns over high transaction costs, mixed results and challenges of sustainability, a less conditional approach, sometimes called direct facility financing, has come into favor. In this commentary, we examine the evidence for the effectiveness of both modalities and argue that they share many features and requirements for effectiveness. In the right context, both can contribute to health system strengthening, and they should be seen as potentially complementary, rather than as rivals. [ABSTRACT FROM AUTHOR]

Background: Sierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs). Facilitated by an international partnership, a project was developed to adapt and pilot desktop guidelines and other clinical support tools to strengthen primary care-based hypertension and diabetes diagnosis and management in Bombali district, Sierra Leone between 2018 and 2019. This study assesses the feasibility of the project through analysis of the processes of intervention adaptation and development, delivery of training and implementation of a care improvement package and preliminary outcomes of the intervention.Methods: A mixed-method approach was used for the assessment, including 51 semi-structured interviews, review of routine treatment cards (retrieved for newly registered hypertensive and diabetic patients from June 2018 to March 2019 followed up for three months) and mentoring data, and observation of training. Thematic analysis was used for qualitative data and descriptive trend analysis and t-test was used for quantitative data, wherever appropriate.Results: A Technical Working Group, established at district and national level, helped to adapt and develop the context-specific desktop guidelines for clinical management and lifestyle interventions and associated training curriculum and modules for community health officers (CHOs). Following a four-day training of CHOs, focusing on communication skills, diagnosis and management of hypertension and diabetes, and thanks to a CHO-based mentorship strategy, there was observed improvement of NCD knowledge and care processes regarding diagnosis, treatment, lifestyle education and follow up. The intervention significantly improved the average diastolic blood pressure of hypertensive patients (n = 50) three months into treatment (98 mmHg at baseline vs. 86 mmHg in Month 3, P = 0.001). However, health systems barriers typical of fragile settings, such as cost of transport and medication for patients and lack of supply of medications and treatment equipment in facilities, hindered the optimal delivery of care for hypertensive and diabetic patients.Conclusion: Our study suggests the potential feasibility of this approach to strengthening primary care delivery of NCDs in fragile contexts. However, the approach needs to be built into routine supervision and pre-service training to be sustained. Key barriers in the health system and at community level also need to be addressed. [ABSTRACT FROM AUTHOR]

Many high- and middle-income countries face challenges in developing and maintaining a health workforce which can address changing population health needs. They have experimented with interventions which overlap with but have differences to those documented in low- and middle-income countries, where many of the recent literature reviews were undertaken. The aim of this paper is to fill that gap. It examines published and grey evidence on interventions to train, recruit, retain, distribute, and manage an effective health workforce, focusing on physicians, nurses, and allied health professionals in high- and middle-income countries. A search of databases, websites, and relevant references was carried out in March 2019. One hundred thirty-one reports or papers were selected for extraction, using a template which followed a health labor market structure. Many studies were cross-cutting; however, the largest number of country studies was focused on Canada, Australia, and the United States of America. The studies were relatively balanced across occupational groups. The largest number focused on availability, followed by performance and then distribution. Study numbers peaked in 2013-2016. A range of study types was included, with a high number of descriptive studies. Some topics were more deeply documented than others-there is, for example, a large number of studies on human resources for health (HRH) planning, educational interventions, and policies to reduce in-migration, but much less on topics such as HRH financing and task shifting. It is also evident that some policy actions may address more than one area of challenge, but equally that some policy actions may have conflicting results for different challenges. Although some of the interventions have been more used and documented in relation to specific cadres, many of the lessons appear to apply across them, with tailoring required to reflect individuals' characteristics, such as age, location, and preferences. Useful lessons can be learned from these higher-income settings for low- and middle-income settings. Much of the literature is descriptive, rather than evaluative, reflecting the organic way in which many HRH reforms are introduced. A more rigorous approach to testing HRH interventions is recommended to improve the evidence in this area of health systems strengthening. [ABSTRACT FROM AUTHOR]

Background: Results-Based Financing (RBF) has proliferated in the health sectors of low and middle income countries, especially those which are fragile or conflict-affected, and has been presented by some as a way of reforming and strengthening strategic purchasing. However, few if any studies have empirically and systematically examined how RBF impacts on health care purchasing. This article examines this question in the context of Zimbabwe's national RBF programme.Methods: The article is based on a documentary review, including 60 documents from 2008 to 2018, and 40 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in Zimbabwe. Interviews and analysis of both datasets followed an existing framework for strategic purchasing, adapted to reflect changes over.Results: We find that some functions, such as assessing service infrastructure gaps, are unaffected by RBF, while others, such as mobilising resources, are partially affected, as RBF has focused on one package of care (maternal and child health services) within the wider essential health care, and has contributed important but marginal costs. Overall purchasing arrangements remain fragmented. Limited improvements have been made to community engagement. The clearest changes to purchasing arrangements relate to providers, at least in relation to the RBF services. Its achievements included enabling flexible resources to reach primary providers, funding supervision and emphasising the importance of reporting.Conclusions: Our analysis suggests that RBF in Zimbabwe, at least at this early stage, is mainly functioning as an additional source of funding and as a provider payment mechanism, focussed on the primary care level for MCH services. RBF in this case brought focus to specific outputs but remained one provider payment mechanism amongst many, with limited traction over the main service delivery inputs and programmes. Zimbabwe's economic and political crisis provided an important entry point for RBF, but Zimbabwe did not present a 'blank slate' for RBF to reform: it was a functional health system pre-crisis, which enabled relatively swift scale-up of RBF but also meant that the potential for restructuring of institutional purchasing relationships was limited. This highlights the need for realistic and contextually tailored expectations of RBF. [ABSTRACT FROM AUTHOR]

Background: The growing burden of non-communicable diseases in low- and middle-income countries presents substantive challenges for health systems. This is also the case in fragile, post-conflict and post-Ebola Sierra Leone, where NCDs represent an increasingly significant disease burden (around 30% of adult men and women have raised blood pressure). To date, documentation of health system challenges and opportunities for NCD prevention and control is limited in such settings. This paper aims to identify opportunities and challenges in provision of NCD prevention and care and highlight lessons for Sierra Leone and other fragile states in the battle against the growing NCD epidemic. Methods: This paper focuses on the case of Sierra Leone and uses a combination of participatory group model building at national and district level, in rural and urban districts, interviews with 28 key informants and review of secondary data and documents. Data is analysed using the WHO's health system assessment guide for NCDs. Results: We highlight multiple challenges typical to those encountered in other fragile settings to the delivery of preventive and curative NCD services. There is limited government and donor commitment to financing and implementation of the national NCD policy and strategy, limited and poorly distributed health workforce and pharmaceuticals, high financial barriers for users, and lack of access to quality-assured medicines with consequent high recourse to private and informal care seeking. We identify how to strengthen the system within existing (low) resources, including through improved clinical guides and tools, more effective engagement with communities, and regulatory and fiscal measures. Conclusion: Our study suggests that NCD prevention and control is of low but increasing priority in Sierra Leone; challenges to addressing this burden relate to huge numbers with NCDs (especially hypertension) requiring care, overall resource constraints and wider systemic issues, including poorly supported primary care services and access barriers. In addition to securing and strengthening political will and commitment and directing more resources and attention towards this area, there is a need for in-depth exploratory and implementation research to shape and test NCD interventions in fragile and post-conflict settings. [ABSTRACT FROM AUTHOR]

Background: The Demand-Driven Evaluations for Decisions (3DE) programme was piloted in Zambia and Uganda in 2012-2015. It aimed to answer evaluative questions raised by policymakers in Ministries of Health, rapidly and with limited resources. The aim of our evaluation was to assess whether the 3DE model was successful in supporting and increasing evidence-based policymaking, building capacity and changing behaviour of Ministry staff.Methods: Using mixed methods, we compared the ex-ante theory of change with what had happened in practice, why and with what results (intended and unintended), including a qualitative assessment of 3DE's contribution. Data sources included a structured quality assessment of the five impact evaluations produced, 46 key informant interviews at national and international levels, structured extraction from 170 programme documents, a wider literature review of relevant topics, and a political economy analysis conducted in Zambia.Results: We found that 3DE had a very limited contribution to changing evidence-based policymaking, capacity and behaviour in both countries as a result of having a number of aspirations not all compatible with one another. Co-developing evaluation questions was more time-consuming than anticipated, Ministry evidence needs did not fit neatly into questions suitable for impact evaluations and constricted timeframes for undertaking trials did not necessarily produce the most effective results and value for money. The evaluation recommended a focusing of objectives and a more strategic approach to strengthening evaluative demand and capacity.Conclusions: Lessons emerge that are likely to apply in other low- and middle-income settings, such as the importance of supporting evaluative thinking and capacity within wider institutions, of understanding the political economy of evidence use and its uptake, and of allowing for some flexibility in terms of programme targets. Fixating on one type of evidence is unhelpful in the context of institutions like ministries of health, which require a wide range of evidence to plan and deliver programmes. In addition, having success tied to indicators, such as number of 'policy decisions made', provides potentially perverse incentives and neglects arguably more important aspects such as incremental programmatic adjustments and improved implementation. [ABSTRACT FROM AUTHOR]

Background: Few studies look at policy making in the health sector in the aftermath of a conflict or crisis and even fewer specifically focus on Human Resources for Health, which is a critical domain for health sector performance. The main objective of the article is to shed light on the patterns and drivers of post-conflict policy-making. In particular, we explore whether the post-conflict period offers increased chances for the opening of 'windows for opportunity' for change and reform and the potential to reset health systems. Methods: This article uses a comparative policy analysis framework. It is based on qualitative data, collected using three main tools - stakeholder mapping, key informant interviews and document reviews - in Uganda, Sierra Leone, Cambodia and Zimbabwe. Results: We found that HRH challenges were widely shared across the four cases in the post-conflict period but that the policy trajectories were different - driven by the nature of the conflicts but also the wider context. Our findings suggest that there is no formula for whether or when a 'window of opportunity' will arise which allows health systems to be reset. Problems are well understood in all four cases but core issues - such as adequate pay, effective distribution and HRH management - are to a greater or lesser degree unresolved. These problems are not confined to post-conflict settings, but underlying challenges to addressing them - including fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutions - are liable to be even more acute in these settings. The role of the MoH emerged as weaker than expected, while the shift from donor dependence was clearly not linear and can take a considerable time. Conclusions: Windows of opportunity for change and reform can occur but are by no means guaranteed by a crisis - rather they depend on a constellation of leadership, financing, and capacity. Recognition of urgency is certainly a facilitator but not sufficient alone. Post-conflict environments face particularly severe challenges to evidence-based policy making and policy implementation, which also constrain their ability to effectively use the windows which are presented. [ABSTRACT FROM AUTHOR]

Background: The objectives of this study were to understand the labour market dynamics among health workers, including their preferences and concerns, and to assess the skills, competence and performance (i.e. the 'know-do gap') of doctors working in Timor-Leste. Methods: This cross-sectional survey was implemented in all 13 districts of Timor-Leste in 2014. We surveyed 443 health workers, including 175 doctors, 150 nurses and 118 midwives (about 20% of the health workers in the country). We also observed 632 clinical consultations with doctors, including 442 direct clinical observations, and tested 190 vignettes. Results: The study highlights some positive findings, including the gender balance of health workers overall, the concentration of doctors in rural areas, the high overall reported satisfaction of staff with their work and high motivation, the positive intention to stay in the public sector, the feeling of being well prepared by training for work, the relatively frequent and satisfactory supervisions, and the good attitudes towards patients as identified in observations and vignettes. However, some areas require more investigations and investments. The overall clinical performance of the doctors was very good in terms of attitude and moderate in regard to history taking, health education and treatment. However, the average physical examination performance score was low. Doctors performed better with simulated cases than the real cases in general, which means they have better knowledge and skills than they actually demonstrated. The factors that were significantly associated with the clinical performance of doctors were location of the health facility (urban doctors were better) and consultation time (cases with more consultation time were better). Regression analysis suggests that lack of knowledge was significantly associated with lack of performance, while lack of motivation and equipment were not significant. Conclusions: The survey provides essential information for workforce planning and for developing training policies and terms and conditions that will attract and retain health workers in rural service. Improving the work environment and performance of doctors working in rural health facilities and ensuring compliance with clinical protocols are two priority areas needed to improve the performance of doctors in Timor-Leste. [ABSTRACT FROM AUTHOR]

Background: Timor-Leste built its health workforce up from extremely low levels after its war of independence, with the assistance of Cuban training, but faces challenges as the first cohorts of doctors will shortly be freed from their contracts with government. Retaining doctors, nurses and midwives in remote areas requires a good understanding of health worker preferences. Methods: The article reports on a discrete choice experiment (DCE) carried out amongst 441 health workers, including 173 doctors, 150 nurses and 118 midwives. Qualitative methods were conducted during the design phase. The attributes which emerged were wages, skills upgrading/specialisation, location, working conditions, transportation and housing. Findings: One of the main findings of the study is the relative lack of importance of wages for doctors, which could be linked to high intrinsic motivation, perceptions of having an already highly paid job (relative to local conditions), and/or being in a relatively early stage of their career for most respondents. Professional development provides the highest satisfaction with jobs, followed by the working conditions. Doctors with less experience, males and the unmarried are more flexible about location. For nurses and midwives, skill upgrading emerged as the most cost effective method. Conclusions: The study is the first of its kind conducted in Timor-Leste. It provides policy-relevant information to balance financial and non-financial incentives for different cadres and profiles of staff. It also augments a thin literature on the preferences of working doctors (as opposed to medical students) in low and middle income countries and provides insights into the ability to instil motivation to work in rural areas, which may be influenced by rural recruitment and Cuban-style training, with its emphasis on community service. [ABSTRACT FROM AUTHOR]

Background: Northern Uganda suffered 20 years of conflict which devastated lives and the health system. Since 2006, there has been investment in reconstruction, which includes efforts to rebuild the health workforce. This article has two objectives: first, to understand health workers' experiences of working in public and private not-for-profit (PNFP) sectors during and after the conflict in Northern Uganda, and second, to understand the factors that influenced health workers' movement between public and PNFP sectors during and after the conflict.Methods: A life history approach was used with 26 health staff purposively selected from public and PNFP facilities in four districts of Northern Uganda. Staff with at least 10 years' experience were selected, which resulted in a sample which was largely female and mid-level. Two thirds were currently employed in the public sector and just over a third in the PNFP sector. A thematic data analysis was guided by the framework analysis approach, analysis framework stages and ATLAS.ti software version 7.0.Results: Analysis reveals that most of the current staff were trained in the PNFP sector, which appears to offer higher quality training experiences. During the conflict period, the PNFP sector also functioned more effectively and was relatively better able to support its staff. However, since the end of the conflict, the public sector has been reconstructed and is now viewed as offering a better overall package for staff. Most reported movement has been in that direction, and many in the PNFP sector state intention to move to the public sector. While there is sectoral loyalty on both sides and some bonds created through training, the PNFP sector needs to become more competitive to retain staff so as to continue delivering services to deprived communities in Northern Uganda.Conclusions: There has been limited previous longitudinal analysis of how health staff perceive different sectors and why they move between them, particularly in conflict-affected contexts. This article adds to our understanding, particularly for mid-level cadres, and highlights the need to ensure balanced health labour market incentives which take into account not only the changing context but also needs at different points in individuals' life cycles and across all core service delivery sectors. [ABSTRACT FROM AUTHOR]

The need for evidence-based practice calls for research focussing not only on the effectiveness of interventions and their translation into policies, but also on implementation processes and the factors influencing them, in particular for complex health system policies. In this paper, we use the lens of one of the health system's ‘building blocks’, human resources for health (HRH), to examine the implementation of official policies on HRH incentives and the emergence of informal practices in three districts of Sierra Leone. Our mixed-methods research draws mostly from 18 key informant interviews at district level. Data are organised using a political economy framework which focuses on the dynamic interactions between structure (context, historical legacies, institutions) and agency (actors, agendas, power relations) to show how these elements affect the HRH incentive practices in each district. It appears that the official policies are re-shaped both by implementation challenges and by informal practices emerging at local level as the result of the district-level dynamics and negotiations between District Health Management Teams (DHMTs) and nongovernmental organisations (NGOs). Emerging informal practices take the form of selective supervision, salary supplementations and per diems paid to health workers, and aim to ensure a better fit between the actors' agendas and the incentive package. Importantly, the negotiations which shape such practices are characterised by a substantial asymmetry of power between DHMTs and NGOs. In conclusion, our findings reveal the influence of NGOs on the HRH incentive package and highlight the need to empower DHMTs to limit the discrepancy between policies defined at central level and practices in the districts, and to reduce inequalities in health worker remuneration across districts. For Sierra Leone, these findings are now more relevant than ever as new players enter the stage at district level, as part of the Ebola response and post-Ebola reconstruction. [ABSTRACT FROM AUTHOR]

Ebola seems to be a particular risk in conflict affected contexts. All three of the countries most affected by the 2014-15 outbreak have a complex conflict-affected recent history. Other major outbreaks in the recent past, in Northern Uganda and in the Democratic Republic of Congo are similarly afflicted although outbreaks have also occurred in stable settings. Although the 2014-15 outbreak in West Africa has received more attention than almost any other public health issue in recent months, very little of that attention has focused on the complex interaction between conflict and its aftermath and its implications for health systems, the emergence of the disease and the success or failure in controlling it. The health systems of conflict-affected states are characterized by a series of weaknesses, some common to other low and even middle income countries, others specifically conflict-related. Added to this is the burden placed on health systems by the aggravated health problems associated with conflict. Other features of post conflict health systems are a consequence of the global institutional response. Comparing the experience of Northern Uganda and Sierra Leone in the emergence and management of Ebola outbreaks in 2000-1 and in 2014-15 respectively highlights how the various elements of these conflict affected societies came together with international agencies responses to permit the outbreak of the disease and then to successfully contain it (in Northern Uganda) or to fail to do so before a catastrophic cost had been incurred (in Sierra Leone). These case studies have implications for the types of investments in health systems that are needed to enable effective response to Ebola and other zoonotic diseases where they arise in conflict- affected settings. [ABSTRACT FROM AUTHOR]

Background: Human resources for health represent an essential component of health systems and play a key role to accelerate progress towards universal health coverage. Many countries in sub-Saharan Africa face challenges regarding the availability, distribution and performance of health workers, which could be in part addressed by providing effective financial incentives. Methods: Based on an overview of the existing literature, the paper highlights the gaps in the existing research in low-income countries exploring the different components of health workers' incomes. It then proposes a novel approach to the analysis of financial incentives and delineates a research agenda, which could contribute to shed light on this topic. Findings: The article finds that, while there is ample research that investigates separately each of the incomes health workers may earn (for example, salary, fee-for-service payments, informal incomes, "top-ups" and per diems, dual practice and non-health activities), there is a dearth of studies which look at the health workers' "complex remuneration", that is, the whole of the financial incentives available. Little research exists which analyses simultaneously all revenues of health workers, quantifies the overall remuneration and explores its complexity, its multiple components and their features, as well as the possible interaction between income components. However, such a comprehensive approach is essential to fully comprehend health workers' incentives, by investigating the causes (at individual and system level) of the fragmentation in the income structure and the variability in income levels, as well as the consequences of the "complex remuneration" on motivation and performance. This proposition has important policy implications in terms of devising effective incentive packages as it calls for an active consideration of the role that "complex remuneration" plays in determining recruitment, retention and motivation patterns, as well as, more broadly, the performance of health systems. Conclusions: This paper argues that research focusing on the health workers' "complex remuneration" is critical to address some of the most challenging issues affecting human resources for health. An empirical research agenda is proposed to fill the gap in our understanding. [ABSTRACT FROM AUTHOR]

Background: Human resources for health are self-evidently critical to running a health service and system. There is, however, a wider set of social issues which is more rarely considered. One area which is hinted at in literature, particularly on fragile and conflict-affected states, but rarely examined in detail, is the contribution which health staff may or do play in relation to the wider state-building processes. This article aims to explore that relationship, developing a conceptual framework to understand what linkages might exist and looking for empirical evidence in the literature to support, refute or adapt those linkages. Methods: An open call for contributions to the article was launched through an online community. The group then developed a conceptual framework and explored a variety of literatures (political, economic, historical, public administration, conflict and health-related) to find theoretical and empirical evidence related to the linkages outlined in the framework. Three country case reports were also developed for Afghanistan, Burundi and Timor-Leste, using secondary sources and the knowledge of the group. Findings: We find that the empirical evidence for most of the linkages is not strong, which is not surprising, given the complexity of the relationships. Nevertheless, some of the posited relationships are plausible, especially between development of health cadres and a strengthened public administration, which in the long run underlies a number of state-building features. The reintegration of factional health staff post-conflict is also plausibly linked to reconciliation and peace-building. The role of medical staff as part of national elites may also be important. Conclusions: The concept of state-building itself is highly contested, with a rich vein of scepticism about the wisdom or feasibility of this as an external project. While recognizing the inherently political nature of these processes, systems and sub-systems, it remains the case that state-building does occur over time, driven by a combination of internal and external forces and that understanding the role played in it by the health system and health staff, particularly after conflicts and in fragile settings, is an area worth further investigation. This review and framework contribute to that debate. [ABSTRACT FROM AUTHOR]

Human resources for health (HRH) will have to be strengthened if universal health coverage (UHC) is to be achieved. Existing health workforce benchmarks focus exclusively on the density of physicians, nurses and midwives and were developed with the objective of attaining relatively high coverage of skilled birth attendance and other essential health services of relevance to the health Millennium Development Goals (MDGs). However, the attainment of UHC will depend not only on the availability of adequate numbers of health workers, but also on the distribution, quality and performance of the available health workforce. In addition, as noncommunicable diseases grow in relative importance, the inputs required from health workers are changing. New, broader health-workforce benchmarks -- and a corresponding monitoring framework -- therefore need to be developed and included in the agenda for UHC to catalyse attention and investment in this critical area of health systems. The new benchmarks need to reflect the more diverse composition of the health workforce and the participation of community health workers and mid-level health workers, and they must capture the multifaceted nature and complexities of HRH development, including equity in accessibility, sex composition and quality. [ABSTRACT FROM AUTHOR]

Background: Performance-based financing is increasingly being applied in a variety of contexts, with the expectation that it can improve the performance of health systems. However, while there is a growing literature on implementation issues and effects on outputs, there has been relatively little focus on interactions between PBF and health systems and how these should be studied. This paper aims to contribute to filling that gap by developing a framework for assessing the interactions between PBF and health systems, focusing on low and middle income countries. In doing so, it elaborates a general framework for monitoring and evaluating health system reforms in general. Methods: This paper is based on an exploratory literature review and on the work of a group of academics and PBF practitioners. The group developed ideas for the monitoring and evaluation framework through exchange of emails and working documents. Ideas were further refined through discussion at the Health Systems Research symposium in Beijing in October 2012, through comments from members of the online PBF Community of Practice and Beijing participants, and through discussion with PBF experts in Bergen in June 2013. Results: The paper starts with a discussion of definitions, to clarify the core concept of PBF and how the different terms are used. It then develops a framework for monitoring its interactions with the health system, structured around five domains of context, the development process, design, implementation and effects. Some of the key questions for monitoring and evaluation are highlighted, and a systematic approach to monitoring effects proposed, structured according to the health system pillars, but also according to inputs, processes and outputs. Conclusions: The paper lays out a broad framework within which indicators can be prioritised for monitoring and evaluation of PBF or other health system reforms. It highlights the dynamic linkages between the domains and the different pillars. All of these are also framed within inter-sectoral and wider societal contexts. It highlights the importance of differentiating short term and long term effects, and also effects (intended and unintended) at different levels of the health system, and for different sectors and areas of the country. Outstanding work will include using and refining the framework and agreeing on the most important hypotheses to test using it, in relation to PBF but also other purchasing and provider payment reforms, as well as appropriate research methods to use for this task. [ABSTRACT FROM AUTHOR]

Background: The last decade has seen widespread retreat from user fees with the intention to reduce financial constraints to users in accessing health care and in particular improving access to reproductive, maternal and newborn health services. This has had important benefits in reducing financial barriers to access in a number of settings. If the policies work as intended, service utilization rates increase. However this increases workloads for health staff and at the same time, the loss of user fee revenues can imply that health workers lose bonuses or allowances, or that it becomes more difficult to ensure uninterrupted supplies of health care inputs. This research aimed to assess how policies reducing demand-side barriers to access to health care have affected service delivery with a particular focus on human resources for health. Methods: We undertook case studies in five countries (Ghana, Nepal, Sierra Leone, Zambia and Zimbabwe). In each we reviewed financing and HRH policies, considered the impact financing policy change had made on health service utilization rates, analysed the distribution of health staff and their actual and potential workloads, and compared remuneration terms in the public sectors. Results: We question a number of common assumptions about the financing and human resource inter-relationships. The impact of fee removal on utilization levels is mostly not sustained or supported by all the evidence. Shortages of human resources for health at the national level are not universal; maldistribution within countries is the greater problem. Low salaries are not universal; most of the countries pay health workers well by national benchmarks. Conclusions: The interconnectedness between user fee policy and HRH situations proves difficult to assess. Many policies have been changing over the relevant period, some clearly and others possibly in response to problems identified associated with financing policy change. Other relevant variables have also changed. However, as is now well-recognised in the user fee literature, co-ordination of health financing and human resource policies is essential. This appears less well recognised in the human resources literature. This coordination involves considering user charges, resource availability at health facility level, health worker pay, terms and conditions, and recruitment in tandem. All these policies need to be effectively monitored in their processes as well as outcomes, but sufficient data are not collected for this purpose. [ABSTRACT FROM AUTHOR]

Background: A paradigm shift in global health policy on user fees has been evident in the last decade with a growing consensus that user fees undermine equitable access to essential health care in many low and middle income countries. Changes to fees have major implications for human resources for health (HRH), though the linkages are rarely explicitly examined. This study aimed to examine the inter-linkages in Zimbabwe in order to generate lessons for HRH and fee policies, with particular respect to reproductive, maternal and newborn health (RMNH). Methods: The study used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011. Results: The past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Human resources are constrained in managing current demand and any growth in demand by high external and internal migration, and low remuneration, amongst other factors. We find that nurses and midwives are evenly distributed across the country (at least in the public sector), though doctors are not. This means that for four provinces, there are not enough doctors to provide more complex care, and only three provinces could provide cover in the event of all deliveries taking place in facilities. Conclusions: This analysis suggests that there is a strong case for reducing the financial burden on clients of RMNH services and also a pressing need to improve the terms and conditions of key health staff. Numbers need to grow, and distribution is also a challenge, suggesting the need for differentiated policies in relation to rural areas, especially for doctors and specialists. The management of user fees should also be reviewed, particularly for non-Ministry facilities, which do not retain their revenues, and receive limited investment in return from the municipalities and district councils. Overall public investment in health needs to grow. [ABSTRACT FROM AUTHOR]

Background: Pregnant women were offered free access to health care through National Health Insurance (NHIS) membership in Ghana in 2008, in the latest phase of policy reforms to ensure universal access to maternal health care. During the same year, free membership was made available to all children (under-18). This article presents an exploratory qualitative analysis of how the policy of free maternal membership was developed and how it is being implemented. Methods: The study was based on a review of existing literature - grey and published - and on a key informant interviews (n = 13) carried out in March-June 2012. The key informants included representatives of the key stakeholders in the health system and public administration, largely at national level but also including two districts. Results: The introduction of the new policy for pregnant women was seen as primarily a political initiative, with limited stakeholder consultation. No costing was done prior to introduction, and no additional funds provided to the NHIS to support the policy after the first year. Guidelines had been issued but beyond collecting numbers of women registered, no additional monitoring and evaluation have yet been put in place to monitor its implementation. Awareness of the under-18 s policy amongst informants was so low that this component had to be removed from the final study. Initial barriers to access, such as pregnancy tests, were cited, but many appear to have been resolved now. Providers are concerned about the workload related to services and claims management but have benefited from increased financial resources. Users still face informal charges, and are reported to have responded differentially, with rises in antenatal care and in urban areas highlighted. Policy sustainability is linked to the survival of the NHIS as a whole. Conclusions: Ghana has to be congratulated for its persistence in trying to address financial barriers. However, many themes from previous evaluations of exemptions policies in Ghana have recurred in this study - particularly, the difficulties of getting timely reimbursement to facilities, of controlling charging of patients, and of reaching the poorest. This suggests that providing free care through a national health insurance system has not solved systemic weaknesses. The wider concerns about raising the quality of care, and ensuring that all supply-side and demand-side elements are in place to make the policy effective will also take a longer term and bigger commitment. [ABSTRACT FROM AUTHOR]

Abstract: There has been a growing concern with post-conflict and fragile states over the past decade, both in relation to their high level of health and development needs but also for the risk they pose to the wider international community. This paper presents an exploratory literature review to analyse the themes and findings of recent writing on one important pillar of the health system – health financing – in these countries. It finds that here is a growing but still very limited literature. Most of the insights from existing literature relate to the role of donors. There is a need for more work on access to care and equity over the post-conflict period, the mix and sequencing of financing mechanisms, resource allocation, regulation, public financial management, payment systems and incentives at facility and health worker levels, and on overall health financing strategies and their possible contribution to wider state-building. Topics which have received attention, such as contracting and non-state actors, could benefit from more rigorous analysis with a longer time perspective. A longitudinal approach, which examines how decisions taken in the immediate post-conflict period may or may not influence longer term developments, would provide important insights. As health systems in fragile and post-conflict states are often forced to innovate, they can generate useful lessons for other settings too. [Copyright &y& Elsevier]

Background: There is a growing interest in using pay-for-performance mechanisms in low and middle-income countries in order to improve the performance of health care providers. However, at present there is a dearth of independent evaluations of such approaches which can guide understanding of their potential and risks in differing contexts. This article presents the results of an evaluation of a project managed by an international non-governmental organisation in one district of Pakistan. It aims to contribute to learning about the design and implementation of pay-for-performance systems and their impact on health worker motivation.Methods: Quantitative analysis was conducted of health management information system (HMIS) data, financial records, and project documents covering the period 2007-2010. Key informant interviews were carried out with stakeholders at all levels. At facility level, in-depth interviews were held, as were focus group discussions with staff and community members.Results: The wider project in Battagram had contributed to rebuilding district health services at a cost of less than US$4.5 per capita and achieved growth in outputs. Staff, managers and clients were appreciative of the gains in availability and quality of services. However, the role that the performance-based incentive (PBI) component played was less clear--PBI formed a relatively small component of pay, and did not increase in line with outputs. There was little evidence from interviews and data that the conditional element of the PBIs influenced behaviour. They were appreciated as a top-up to pay, but remained low in relative terms, and only slightly and indirectly related to individual performance. Moreover, they were implemented independently of the wider health system and presented a clear challenge for longer term integration and sustainability.Conclusions: Challenges for performance-based pay approaches include the balance of rewarding individual versus team efforts; reflecting process and outcome indicators; judging the right level of incentives; allowing for very different starting points and situations; designing a system which is simple enough for participants to comprehend; and the tension between independent monitoring and integration in a national system. Further documentation of process and cost-effectiveness, and careful examination of the wider impacts of paying for performance, are still needed. [ABSTRACT FROM AUTHOR]

Background: Motivation and retention of health workers, particularly in rural areas, is a question of considerable interest to policy-makers internationally. Many countries, including Vietnam, are debating the right mix of interventions to motivate doctors in particular to work in remote areas. The objective of this study was to understand the dynamics of the health labour market in Vietnam, and what might encourage doctors to accept posts and remain in-post in rural areas.Methods: This study forms part of a labour market survey which was conducted in Vietnam in November 2009 to February 2010. The study had three stages. This article describes the findings of the first stage - the qualitative research and literature review, which fed into the design of a structured survey (second stage) and contingent valuation (third stage). For the qualitative research, three tools were used - key informant interviews at national and provincial level (6 respondents); in-depth interviews of doctors at district and commune levels (11 respondents); and focus group discussions with medical students (15 participants).Results: The study reports on the perception of the problem by national level stakeholders; the motivation for joining the profession by doctors; their views on the different factors affecting their willingness to work in rural areas (including different income streams, working conditions, workload, equipment, support and supervision, relationships with colleagues, career development, training, and living conditions). It presents findings on their overall satisfaction, their ranking of different attributes, and willingness to accept different kinds of work. Finally, it discusses recent and possible policy interventions to address the distribution problem.Conclusions: Four typical 'directions of travel' are identified for Vietnamese doctors - from lower to higher levels of the system, from rural to urban areas, from preventive to curative health and from public to private practice. Substantial differences in income from formal and informal sources all reinforce these preferences. While non-financial attributes are also important for Vietnamese doctors, the scale of the difference of opportunities presents a considerable policy challenge. Significant salary increases for doctors in hard-to-staff areas are likely to have some impact. However, addressing the differentials is likely to require broader market reforms and regulatory measures. [ABSTRACT FROM AUTHOR]

Lack of access to quality care is the main obstacle to reducing maternal mortality in low-income countries. In many settings, women must pay out-of-pocket fees, resulting in delays, some of them fatal, and catastrophic expenditure that push households into poverty. Various innovative approaches have targeted the poor or exempted specific services, such as cesarean deliveries. We analyzed 8 case studies to better understand current experiments in reducing financial barriers to maternal care. Although service utilization increased in most of the settings, concerns remain about quality of care, equity between rich and poor patients and between urban and rural residents, and financial sustainability to support these new strategies. [ABSTRACT FROM AUTHOR]

Background: There is a growing movement, globally and in the Africa region, to reduce financial barriers to health care generally, but with particular emphasis on high priority services and vulnerable groups. Objective: This article reports on the experience of implementing a national policy to exempt women from paying for delivery care in public, mission and private health facilities in Ghana. Design: Using data from a complex evaluation which was carried out in 2005-2006, lessons are drawn which can inform other countries starting or planning to implement similar service-based exemption policies. Results: On the positive side, the experience of Ghana suggests that delivery exemptions can be effective and cost-effective, and that despite being universal in application, they can benefit the poor. However, certain 'negative' lessons are also drawn from the Ghana case study, particularly on the need for adequate funding, and for strong institutional ownership. It is also important to monitor the financial transfers which reach households, to ensure that providers are passing on benefits in full, while being adequately reimbursed themselves for their loss of revenue. Careful consideration should also be given to staff motivation and the role of different providers, as well as quality of care constraints, when designing the exemptions policy. All of this should be supported by a proactive approach to monitoring and evaluation. Conclusion: The recent movement towards making delivery care free to all women is a bold and timely action which is supported by evidence from within and beyond Ghana. However, the potential for this to translate into reduced mortality for mothers and babies fundamentally depends on the effectiveness of its implementation. [ABSTRACT FROM AUTHOR]

In resource-poor countries, the high cost of user fees for deliveries limits access to skilled attendance, and contributes to maternal and neonatal mortality and the impoverishment of vulnerable households. A growing number of countries are experimenting with different approaches to tackling financial barriers to maternal health care. This paper describes an innovative scheme introduced in Ghana in 2003 to exempt all pregnant women from payments for delivery, in which public, mission and private providers could claim back lost user fee revenues, according to an agreed tariff. The paper presents part of the findings of an evaluation of the policy based on interviews with 65 key informants in the health system at national, regional, district and facility level, including policymakers, managers and providers. The exemption mechanism was well accepted and appropriate, but there were important problems with disbursing and sustaining the funding, and with budgeting and management. Staff workloads increased as more women attended, and levels of compensation for services and staff were important to the scheme's acceptance. At the end of 2005, a national health insurance scheme, intended to include full maternal health care cover, was starting up in Ghana, and it was not yet clear how the exemptions scheme would fit into it. Dans les pays pauvres, le montant élevé des contributions demandées aux patientes pour les accouchements limite l'accès à des soins de qualité, tout en contribuant à la mortalité maternelle et néonatale et à l'appauvrissement des ménages vulnérables. Un nombre croissant de pays expérimentent différentes méthodes pour lever les obstacles financiers aux soins de santé maternelle. Un projet novateur, introduit au Ghana en 2003, exonérait toutes les femmes enceintes du paiement des accouchements et prévoyait que les praticiens publics, privés et des missions pouvaient récupérer leurs honoraires perdus, conformément à un barème convenu. L'article présente une partie des conclusions d'une évaluation de cette politique, sur la base d'entretiens avec 65 informateurs clés dans le système de santé aux niveaux national, régional, des districts et des maternités, notamment des responsables politiques, des gestionnaires et des praticiens. Le mécanisme d'exonération a été bien accepté et était satisfaisant, mais il connaissait de graves problèmes de décaissement des fonds et de maintien du financement, ainsi que de budgétisation et de gestion. La charge de travail du personnel a augmenté car davantage de femmes ont demandé des soins, et les niveaux de compensation pour les services et le personnel étaient importants pour l'acceptation du projet. Fin 2005, un plan national d'assurance maladie, devant couvrir totalement les soins de santé maternelle, démarrait au Ghana et la manière dont le projet d'exonération s'y adapterait n'était pas encore claire. En los países con pocos recursos, el alto costo de las tarifas por partos limita el acceso a asistencia calificada y contribuye a la mortalidad materna y neonatal y al empobrecimiento de hogares vulnerables. En un creciente número de países se está experimentando con diferentes estrategias para afrontar los obstáculos financieros a los servicios de salud materna. En este artículo se describe un plan innovador presentado en Ghana en 2003 para eximir a todas las mujeres embarazadas de pagos por parto, mediante el cual los prestadores de servicios públicos, misioneros y privados pueden reclamar ingresos perdidos de tarifas de usuarias, de acuerdo con una tarifa acordada. Se expone parte de los resultados de una evaluación de la política basada en entrevistas con 65 informantes clave (incluidos formuladores de políticas, administradores y prestadores de servicios) del sistema de salud a nivel nacional, regional, distrital y local. El mecanismo de exención fue bien aceptado y apropiado, pero hubo problemas importantes con el desembolso y sustento del financiamiento, así como con los presupuestos y la administración. El volumen de trabajo del personal aumentó a medida que se atendían más mujeres, y los niveles de remuneración por servicios y personal fueron esenciales para la aceptación del plan. A fines de 2005, se estaba iniciando en Ghana un plan nacional de seguro médico, con el objetivo de incluir cobertura completa de servicios de salud materna, pero aún no era claro cómo el plan de exenciones se integraría a éste. [ABSTRACT FROM AUTHOR]

Background: This article describes a survey of health workers and traditional birth attendants (TBAs) which was carried out in 2005 in two regions of Ghana. The objective of the survey was to ascertain the impact of the introduction of a delivery fee exemption scheme on both health workers and those providers who were excluded from the scheme (TBAs). This formed part of an overall evaluation of the delivery fee exemption scheme. The results shed light not only on the scheme itself but also on the general productivity of a range of health workers in Ghana. Methods: A structured questionnaire was developed, covering individual and household characteristics, working hours and practices, sources of income, and views of the exemptions scheme and general motivation. After field testing, this was administered to 374 respondents in 12 districts of Central and Volta regions. The respondents included doctors, medical assistants (MAs), public and private midwives, nurses, community health nurses (CHNs), and traditional birth attendants, both trained and untrained. Results: Health workers were well informed about the delivery fee exemptions scheme and their responses on its impact suggest a realistic view that it was a good scheme, but one that faces serious challenges regarding financial sustainability. Concerning its impact on their morale and working conditions, the responses were broadly neutral. Most public sector workers have seen an increased workload, but counterbalanced by increased pay. TBAs have suffered, in terms of client numbers and income, while the picture for private midwives is mixed. The survey also sheds light on pay and productivity. The respondents report long working hours, with a mean of 54 hours per week for community nurses and up to 129 hours per week for MAs. Weekly reported client loads in the public sector range from a mean of 86 for nurses to 269 for doctors. Over the past two years, reported working hours have been increasing, but so have pay and allowances (for doctors, allowances now make up 66% of their total pay). The lowest paid public health worker now earns almost ten times the average gross national income (GNI) per capita, while the doctors earn 38.5 times GNI per capita. This compares well with average government pay of four times GNI per capita. Comparing pay with outputs, the relatively high number of clients reported by doctors reduces their pay differential, so that the cost per client - $1.09 - is similar to a nurse's (and lower than a private midwife's). Conclusion: These findings show that a scheme which increases demand for public health services while also sustaining health worker income and morale, is workable, if well managed, even within the relatively constrained human resources environment of countries like Ghana. This may be linked to the fact that internal comparisons reveal Ghana's health workers to be well paid from public sector sources. [ABSTRACT FROM AUTHOR]

Children under the age of 18 years represent 62 percent of the poor in Uganda. To date, their perspective has not been incorporated in the many poverty analyses that have been conducted. The survey reported in this paper asked children between the ages of 10 and 14 years about their perceptions of poverty, and also about the effectiveness of local government in addressing issues of concern to them. The survey found that children have a different perspective on poverty from that of the adult key informants consulted in our sample; they have a positive view of their own potential role in mitigating poverty, and are highly critical of the current performance of local government. [ABSTRACT FROM AUTHOR]

In 2002 Save the Children UK carried out a study of child poverty in Uganda, as part of the on-going Uganda Participatory Poverty Assessment Programme. Using participants from all regions of the country, the researchers asked children about their perceptions of poverty and anti-poverty strategies, as well as questioning adult key informants about trends in child poverty, vulnerable groups and the effectiveness of government policies in tackling child poverty. This article reports on one aspect of the study, looking at the different indicators that children use to assess poverty, and comparing these with official poverty monitoring indicators. It finds that while some areas—notably, health, education and water and sanitation—are well documented, others, which may be as, or more significant to children's welfare, such as child abuse or quality of parental care, are almost totally neglected. A more holistic framework for assessing child poverty is proposed. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Due to the weaknesses of the public health system and its low reach, especially in border areas, provision of health services by non-state actors (NSAs) has historically played an important role in Myanmar. NSAs include local and international NGOs and civil society organisations (CSOs), but also Ethnic Health Organisations (EHOs) in the border areas, as well as the private (for profit) sector. This study aims to understand the changing role of NSAs in the shifting political environment of Myanmar between 2010 and 2022, and to explore their contribution to health system resilience. Methods: Our study includes three main components: a documentary review (n = 22), key informant interviews (KIIs) at central level (n = 14) and two township-level case studies (13 KIIs, 4 FGDs). Mostly qualitative data were collected in 2022 and synthesized, using a health system resilience framework to structure the analysis. Results: During the transition period (2010–2014) and the new political era (2015–2020), while the country gradually transitioned to a democratic system, the government increasingly recognized NSAs. Initially, engagement with NSAs remained focused on disease-specific activities and government oversight was limited, but later it expanded to health system strengthening, including the start of a "convergence" with ethnic health systems. Progress was relatively slow, but defined by a clear vision and plans. The military coup of February 2021 brought a halt to this progress. Collaboration between government and NSAs was interrupted, and NSAs restored previous practices and parallel systems. Initially, most health service provision stopped, but with time coping strategies emerged, which showed the capacity of NSAs to absorb the shocks (focusing on basic services; using informal communication channels; maintaining buffer stocks of supplies) and adapt (changing modes of delivery and supply chains, and adjusting HRH training). Conclusions: The study highlights the role of NSAs during crises, and provides insights on how the resilience capacities built over time by NSAs to provide services in adverse circumstances have informed the response to the latest crisis. While strategies of absorption and adaptation are noted in the study, we did not identify any transformation strategy – which might indicate the difficulty of NSAs to introduce radical changes when subjected to multiple shocks and a hostile political environment. [ABSTRACT FROM AUTHOR]

Introduction: Neglected tropical diseases (NTDs) are an important global health challenge, however, little is known about how to effectively finance NTD related services. Integrated management in particular, is put forward as an efficient and effective treatment modality. This is a background study to a broader health economic evaluation, seeking to document the costs of integrated case management of NTDs versus standard care in Liberia. In the current study, we document barriers and facilitators to NTD care from a health financing perspective. Methods: We carried out key informant interviews with 86 health professionals and 16 national health system policymakers. 46 participants were active in counties implementing integrated case management and 40 participants were active in counties implementing standard care. We also interviewed 16 patients and community members. All interviews were transcribed and analysed using the thematic framework approach. Findings: We found that decentralization for NTD financing is not yet achieved – financing and reporting for NTDs is still centralized and largely donor-driven as a vertical programme; government involvement in NTD financing is still minimal, focused mainly on staffing, but non-governmental organisations (NGOs) or international agencies are supporting supply and procurement of medications. Donor support and involvement in NTDs are largely coordinated around the integrated case management. Quantification for goods and budget estimations are specific challenges, given the high donor dependence, particularly for NTD related costs and the government's limited financial role at present. These challenges contribute to stockouts of medications and supplies at clinic level, while delays in payments of salaries from the government compromise staff attendance and retention. For patients, the main challenges are high transportation costs, with inflated charges due to fear and stigma amongst motorbike taxi riders, and out-of-pocket payments for medication during stockouts and food/toiletries (for in-patients). Conclusion: Our findings contribute to the limited work on financing of SSSD services in West African settings and provide insight on challenges and opportunities for financing and large costs in accessing care by households, which is also being exacerbated by stigma. [ABSTRACT FROM AUTHOR]

The article comments on the paper "Global, regional, and national levels and causes of maternal mortality during 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013" by N. J. Kassebaum and colleagues. Topics discussed include factors that may influence maternal mortality, monitoring of social gradients in maternal mortality, the Millennium Development Goals (MDGs).

Background: All health systems struggle to meet health needs within constrained resources. This is especially true for low-income countries. It is critical that they can learn from wider contexts in order to improve their performance. This article examines policy transfer and evidence use linked to it in low- and middle-income settings. The objective was to inform international investments in improved learning across health systems.Methods: The article uses a comparative case study design, drawing on case studies conducted in Bangladesh, Burkina Faso, Cambodia, Ethiopia, Georgia, Nepal, Rwanda and Solomon Islands. One or two recent health system reforms were selected in each case and 148 key informants were interviewed in total, using a semi-structured tool focused on different stages of the policy cycle. Interviewees were selected for their engagement in the policy process and represented political, technical, development partner, non-governmental, academic and civil society constituencies. Data analysis used a framework approach, allowing for new themes to be developed inductively, focusing initially on each case and then on patterns across cases.Results: The selected policies demonstrated a range of influences of externally imposed, co-produced and home-grown solutions on the development of initial policy ideas. Eventual uptake of policy was strongly driven in most settings by local political economic considerations. Policy development post-adoption demonstrated some strong internal review, monitoring and sharing processes but there is a more contested view of the role of evaluation. In many cases, learning was facilitated by direct personal relationships with local development partner staff. While barriers and facilitators to evidence use included supply and demand factors, the most influential facilitators were incentives and capacity to use evidence.Conclusions: These findings emphasise the agency of local actors and the importance of developing national and sub-national institutions for gathering, filtering and sharing evidence. Developing demand for and capacity to use evidence appears more important than augmenting supply of evidence, although specific gaps in supply were identified. The findings also highlight the importance of the local political economy in setting parameters within which evidence is considered and the need for a conceptual framework for health system learning. [ABSTRACT FROM AUTHOR]

Introduction The COVID-19 pandemic has tested the resilience capacities of health systems worldwide and highlighted the need to understand the concept, pathways, and elements of resilience in different country contexts. In this study, we assessed the health system response to COVID-19 in Nepal and examined the processes of policy formulation, communication, and implementation at the three tiers of government, including the dynamic interactions between tiers. Nepal was experiencing the early stages of federalization reform when COVID-19 pandemic hit the country, and clarity in roles and capacity to implement functions were the prevailing challenges, especially among the subnational governments. Methods We adopted a cross-sectional exploratory design, using mixed methods. We conducted a desk-based review of all policy documents introduced in response to COVID-19 from January to December 2020, and collected qualitative data through 22 key informant interviews at three tiers of government, during January-March 2021. Two municipalities were purposively selected for data collection in Lumbini province. Our analysis is based on a resilience framework that has been developed by our research project, ReBUILD for Resilience, which helps to understand pathways to health system resilience through absorption, adaptation and transformation. Results In the newly established federal structure, the existing emergency response structure and plans were utilized, which were yet to be tested in the decentralized system. The federal government effectively led the policy formulation process, but with minimal engagement of sub-national governments. Local governments could not demonstrate resilience capacities due to the novelty of the federal system and their consequent lack of experience, confusion on roles, insufficient management capacity and governance structures at local level, which was further aggravated by the limited availability of human, technical and financial resources. Conclusions The study findings emphasize the importance of strong and flexible governance structures and strengthened capacity of subnational governments to effectively manage pandemics. The study elaborates on the key areas and pathways that contribute to the resilience capacities of health systems from the experience of Nepal. We draw out lessons that can be applied to other fragile and shock-prone settings. [ABSTRACT FROM AUTHOR]

Background: Frontline managers and health service providers are constrained in many contexts from responding to community priorities due to organizational cultures focused on centrally defined outputs and targets. This paper presents an evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme-a collaborative learning platform embedded in the local health system in Mpumalanga, South Africa-for strengthening of rural primary healthcare (PHC) systems. The programme aims to address exclusion from access to health services by generating and acting on research evidence of practical, local relevance.Methods: Drawing on existing links in the provincial and national health systems and applying rapid, participatory evaluation techniques, we evaluated the first action-learning cycle of the VAPAR programme (2017-19). We collected data in three phases: (1) 10 individual interviews with programme stakeholders, including from government departments and parastatals, nongovernmental organizations and local communities; (2) an evaluative/exploratory workshop with provincial and district Department of Health managers; and (3) feedback and discussion of findings during an interactive workshop with national child health experts.Results: Individual programme stakeholders described early outcomes relating to effective research and stakeholder engagement, and organization and delivery of services, with potential further contributions to the establishment of an evidence base for local policy and planning, and improved health outcomes. These outcomes were verified with provincial managers. Provincial and national stakeholders identified the potential for VAPAR to support engagement between communities and health authorities for collective planning and implementation of services. Provincial stakeholders proposed that this could be achieved through a two-way integration, with VAPAR stakeholders participating in routine health planning and review activities and frontline health officials being involved in the VAPAR process. Findings were collated into a revised theory of change.Conclusions: The VAPAR learning platform was regarded as a feasible, acceptable and relevant approach to facilitate cooperative learning and community participation in health systems. The evaluation provides support for a collaborative learning platform within routine health system processes and contributes to the limited evaluative evidence base on embedded health systems research. [ABSTRACT FROM AUTHOR]

The authors reflect on performance based financing in medical care in low and middle income countries. They argues that performance based financing has been marketed as a strategy for improving health care delivery and for helping to reach the Millennium Development Goals. Thy argue that additional research on performance based financing is needed to be able to determine if it is useful in low and middle income countries.

Introduction: Lebanon is a middle-income country facing substantial fragility features. Its health profile shows a high burden of NCD morbidity and mortality. This paper intends to analyse the political economy of NCD prevention and control in Lebanon. Methods: This study adopted a literature-based case study research design using a problem-driven political economy analysis framework. A total of 94 peer-reviewed articles and documents from the grey literature published before June 2019 were retrieved and analysed. Results: Lebanon's political instability and fragile governance negatively affect its capacity to adapt a Health-in-All-Policies approach to NCD prevention and enable the blocking of NCD prevention policies by opposed stakeholders. Recent economic crises limit the fiscal capacity to address health financing issues and resulting health inequities. NCD care provision is twisted by powerful stakeholders towards a hospital-centred model with a powerful private sector. Stakeholders like the MOPH, UN agencies, and NGOs have been pushing towards changing the existing care model towards a primary care model. An incremental reform has been adopted to strengthen a network of primary care centres, support them with health technologies and improve the quality of primary care services. Nevertheless, outpatient services that are covered by other public funds remain specialist-led without much institutional regulation. Conclusion: Our study revealed a locked equilibrium in NCD prevention policymaking in Lebanon, but with an incremental progress in service delivery reforms towards a primary care model. Advocacy and close monitoring by policy entrepreneurs (such as civil society) could initiate and sustain the implementation of policy change and care model reforms. [ABSTRACT FROM AUTHOR]

Background: While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. Methods: CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making. Results: CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. Conclusions: Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making. [ABSTRACT FROM AUTHOR]

Background: Northwest Syria (NWS) is a conflict area with challenging political, economic, demographic and social dynamics. The region has a high number of internally displaced persons with increasingly disrupted delivery of basic services, including healthcare. Mental health needs have been increasing in the region while the infrastructure and capacity of the health sector has been negatively affected by the conflict. This study aimed to explore the provision of mental health and psychosocial support (MHPSS) services to communities in NWS (including healthcare workers) and to assess the experiences of beneficiaries with MHPSS services. Methods: The study followed a mixed-methods research design that included qualitative and participatory methods (44 semi-structured interviews and a group model building workshop with 15 participants) as well as a survey with 462 beneficiaries. Results: Findings suggested an improvement of MHPSS services in the region over the last few years due to the creation of a specific Technical Working Group for MHPSS that contributed to assessment of community needs and support of the MHPSS response. The key elements of this response were: (1) training non-specialized health workers to address the shortage in specialized providers; (2) securing funding and coordination of services between different organizations; and (3) addressing gaps in the availability and geographical distribution of other needed resources, such as medicines. While those elements contributed to improving access to services and the quality of services—especially among health workers seeking MHPSS services—findings suggested gaps in the sustainability of services and a need to scale up those interventions in an integrated approach. Conclusion: The study findings add to the evidence base on the challenges in scaling up MHPSS interventions and their long-term sustainability concerns. Priority actions should address the intermittent funding of the MHPSS response, incorporate MHPSS outputs and outcomes in the reimbursement of routine services, improve coordination between health partners and non-health actors in order to expand the scope of MHPSS response, and address the inequitable availability of resources in the region. [ABSTRACT FROM AUTHOR]

Background: Human resources for health represent an essential component of health systems and play a key role to accelerate progress towards universal health coverage. Many countries in sub-Saharan Africa face challenges regarding the availability, distribution and performance of health workers, which could be in part addressed by providing effective financial incentives.Methods: Based on an overview of the existing literature, the paper highlights the gaps in the existing research in low-income countries exploring the different components of health workers' incomes. It then proposes a novel approach to the analysis of financial incentives and delineates a research agenda, which could contribute to shed light on this topic.Findings: The article finds that, while there is ample research that investigates separately each of the incomes health workers may earn (for example, salary, fee-for-service payments, informal incomes, "top-ups" and per diems, dual practice and non-health activities), there is a dearth of studies which look at the health workers' "complex remuneration", that is, the whole of the financial incentives available. Little research exists which analyses simultaneously all revenues of health workers, quantifies the overall remuneration and explores its complexity, its multiple components and their features, as well as the possible interaction between income components. However, such a comprehensive approach is essential to fully comprehend health workers' incentives, by investigating the causes (at individual and system level) of the fragmentation in the income structure and the variability in income levels, as well as the consequences of the "complex remuneration" on motivation and performance. This proposition has important policy implications in terms of devising effective incentive packages as it calls for an active consideration of the role that "complex remuneration" plays in determining recruitment, retention and motivation patterns, as well as, more broadly, the performance of health systems.Conclusions: This paper argues that research focusing on the health workers' "complex remuneration" is critical to address some of the most challenging issues affecting human resources for health. An empirical research agenda is proposed to fill the gap in our understanding. [ABSTRACT FROM AUTHOR]

Background: High salt intake is a major risk factor for hypertension, which in turn contributes to cardiovascular diseases, the major cause of death from non communicable diseases (NCDs). Research is limited on social mobilisation interventions to tackle NCDs, including in fragile health settings such as Sierra Leone. Methods: Participatory action research methods were used to develop a social mobilisation intervention for salt reduction in Bombali District, Sierra Leone. A team of 20 local stakeholders were recruited to develop and deliver the intervention. Stakeholder workshop reports and interviews were used to record outcomes, enablers, and barriers to the intervention. Focus group discussions were used to observe knowledge, attitudes, and behaviours of community members pre- and post- the intervention. Results: Stakeholders showed enthusiasm and were well engaged in the social mobilisation process around salt reduction. They developed radio jingles, radio show talks, organised community awareness raising meetings, school sensitisation outreaches, and door to door engagements. Stakeholders reported benefiting personally through developing their own skills and confidence in communication and felt positive about their role in educating their community. The interventions led to reported increased awareness of risks of high salt intake and NCDs, resulting in a reduction of salt use in the community, leading to perceived health gains. However, salt reduction was also met with some resistance due to social factors. Local community structures were also reactivated to work on the interventions and connect the community to the local health facility, which saw an increase in patients having their blood pressure checked. The comparison villages also experienced an increase in awareness and perceived reductions in salt intake behaviours. This was as messages had cascaded via the radio and initial focus group discussions. The social mobilisation stakeholders also agreed on future activities that could continue at no or low cost. Conclusion: Social mobilisation interventions can provide low-cost strategies to tackle NCDs in fragile settings such as Sierra Leone through the utilisation of community structures. However, more research is required to ascertain the key enablers for replicability and if such successes can be sustained over a longer follow up period. [ABSTRACT FROM AUTHOR]

Background: While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. Methods: CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making. Results: CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. Conclusions: Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making. [ABSTRACT FROM AUTHOR]

Background: Despite international evidence supporting community participation in health for improved health outcomes and more responsive and equitable health systems there is little practical evidence on how to do this. This work sought to understand the process involved in collective implementation of a health-related local action plan developed by multiple stakeholders. Methods: Communities, government departments and non-government stakeholders convened in three iterative phases of a participatory action research (PAR) learning cycle. Stakeholders were involved in problem identification, development, and implementation of a local action plan, reflection on action, and reiteration of the process. Participants engaged in reflective exercises, exploring how factors such as power and interest impacted success or failure. Results: The local action plan was partially successful, with three out of seven action items achieved. High levels of both power and interest were key factors in the achievement of action items. For the achieved items, stakeholders reported that continuous interactions with one another created a shift in both power and interest through ownership of implementation processes. Participants who possessed significant power and influence were able to leverage resources and connections to overcome obstacles and barriers to progress the plan. Lack of financial support, shifting priorities and insufficient buy-in from stakeholders hindered implementation. Conclusion: The process offered new ways of thinking and stakeholders were supported to generate local evidence for action and learning. The process also enabled exploration of how different stakeholders with different levels of power and interest coalesce to design, plan, and act on evidence. Creation of safe spaces was achievable, meanwhile changing stakeholders' level of power and interest was possible but challenging. This study suggests that when researchers, service providers and communities are connected as legitimate participants in a learning platform with access to information and decision-making, a shift in power and interest may be feasible. [ABSTRACT FROM AUTHOR]

Background: A paradigm shift in global health policy on user fees has been evident in the last decade with a growing consensus that user fees undermine equitable access to essential health care in many low and middle income countries. Changes to fees have major implications for human resources for health (HRH), though the linkages are rarely explicitly examined. This study aimed to examine the inter-linkages in Zimbabwe in order to generate lessons for HRH and fee policies, with particular respect to reproductive, maternal and newborn health (RMNH).Methods: The study used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011.Results: The past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Human resources are constrained in managing current demand and any growth in demand by high external and internal migration, and low remuneration, amongst other factors. We find that nurses and midwives are evenly distributed across the country (at least in the public sector), though doctors are not. This means that for four provinces, there are not enough doctors to provide more complex care, and only three provinces could provide cover in the event of all deliveries taking place in facilities.Conclusions: This analysis suggests that there is a strong case for reducing the financial burden on clients of RMNH services and also a pressing need to improve the terms and conditions of key health staff. Numbers need to grow, and distribution is also a challenge, suggesting the need for differentiated policies in relation to rural areas, especially for doctors and specialists. The management of user fees should also be reviewed, particularly for non-Ministry facilities, which do not retain their revenues, and receive limited investment in return from the municipalities and district councils. Overall public investment in health needs to grow. [ABSTRACT FROM AUTHOR]

Background: Performance-based financing is increasingly being applied in a variety of contexts, with the expectation that it can improve the performance of health systems. However, while there is a growing literature on implementation issues and effects on outputs, there has been relatively little focus on interactions between PBF and health systems and how these should be studied. This paper aims to contribute to filling that gap by developing a framework for assessing the interactions between PBF and health systems, focusing on low and middle income countries. In doing so, it elaborates a general framework for monitoring and evaluating health system reforms in general.Methods: This paper is based on an exploratory literature review and on the work of a group of academics and PBF practitioners. The group developed ideas for the monitoring and evaluation framework through exchange of emails and working documents. Ideas were further refined through discussion at the Health Systems Research symposium in Beijing in October 2012, through comments from members of the online PBF Community of Practice and Beijing participants, and through discussion with PBF experts in Bergen in June 2013.Results: The paper starts with a discussion of definitions, to clarify the core concept of PBF and how the different terms are used. It then develops a framework for monitoring its interactions with the health system, structured around five domains of context, the development process, design, implementation and effects. Some of the key questions for monitoring and evaluation are highlighted, and a systematic approach to monitoring effects proposed, structured according to the health system pillars, but also according to inputs, processes and outputs.Conclusions: The paper lays out a broad framework within which indicators can be prioritised for monitoring and evaluation of PBF or other health system reforms. It highlights the dynamic linkages between the domains and the different pillars. All of these are also framed within inter-sectoral and wider societal contexts. It highlights the importance of differentiating short term and long term effects, and also effects (intended and unintended) at different levels of the health system, and for different sectors and areas of the country. Outstanding work will include using and refining the framework and agreeing on the most important hypotheses to test using it, in relation to PBF but also other purchasing and provider payment reforms, as well as appropriate research methods to use for this task. [ABSTRACT FROM AUTHOR]