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To achieve the Sustainable Development Goals: Agenda 2030, the government of India has taken several steps to improve healthcare services. Public expenditure plays a crucial role in achieving the agenda of good health and well-being. While the public expenditure on healthcare in India has been quite low around 2.1% of GDP, various financial reforms have been made to improve the fiscal capacity of the states. However, the healthcare expenditure in India has neither been sufficient nor sustainable. The paper highlights that the centralized fiscal federal design in the Indian Constitution poses challenges to revenue generation and mobilization by the States. There has been a huge decline in the revenue-generating ability of the states from 1998-99 to 2020-21 which has reduced the fiscal autonomy of the states by making them dependent for 47% of their resources on the Centre. This declining fiscal autonomy of the states and increasing dependence on the centre for resources affect the public expenditure on healthcare which primarily is the subject matter of the state list. Thus, the paper suggests the need and ways for sustainable healthcare financing in India.

One-third of the global burden of disease is attributed to surgical conditions yet, 5 billion people globally, lack access to surgery. The Lancet Commission on Global Surgery, Obstetrics, and Anesthesia (LCOGS) published guidelines for improving access by reducing catastrophic health expenditures (CHEs) by 2030. This is especially important in Sub-Saharan Africa (SSA) where 90% of the extreme poor reside. In this paper, we provide a narrative review of four studies on CHEs for surgical care in SSA published since 2015. We discuss healthcare financing in the countries and summarize the authors’ key findings of out of pocket payments (OOP) and CHEs. Briefly, the studies enrolled 130 to 300 patients and collected direct OOPs via chart review of health costs or patient interviews. Indirect costs were calculated from lost wages and transportation costs. CHEs were defined as health costs exceeding 10% of the GDP per capita or the household income. Despite healthcare being reported as free in all studies, 60%-90% of surgical patients had CHEs with all costs considered. OOPs persists for medicines and anesthesia that should be covered under any health insurance scheme. In some cases, Indirect costs associated with transportation and wages were major drivers of CHEs for surgery. Without addressing these gaps in coverage more people will risk impoverishment in seeking surgical care in SSA.

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Introduction: In South-Kivu, the health system is underfunded due to numerous constraints. Several initiatives have been tested but are insufficient for increasing and sustaining health financing., Purpose of Research: Analyze the health financing system in South-Kivu, through a mapping as well as quantitative and qualitative analysis of health financing mechanisms., Results: The provincial health financing system is fragmented, with poorly coordinated mechanisms and interventions, leading to duplication of health system strengthening activities in addition to the absence of a mechanism for pooling external funding flows. Costs recovery (i.e. user fees) and external supports are the most widely used schemes while the government hardly contributes to the financing of the provincial health system. Mutual health insurance is supposed to improve access to health care, but its coverage is still extremely low. Results-Based Financing and free health care programs, fully financed by external donors, are irregular and insufficiently sustainable., Conclusions: It would be critical to implement a strategic purchasing model that is anchored in local institutions, owned by all stakeholders, and integrating all existing financing mechanisms, which could be supported by a common fund supporting the provincial health system. The “Single Contract” initiative developed to harmonize, pool, and sustain external programs, could be a good basis in this respect. This would involve strengthening policy dialogue, developing an investment case to support resource mobilization and implementing a joint monitoring and evaluation platform for disbursements led by the provincial health authorities.

The end result of the past 40 years of experience in combating maternal mortality in Mali suggests that the emphasis should be changed, and that giving birth at a maternity hospital should be the basic strategic option chosen. This means creating “compounds set aside for mothers-to-be”, where women approaching the end of their pregnancy will be invited to come and await the onset of labour, and at the same time enjoy the rest they need. However, the prerequisites for such an initiative will be first to guarantee the necessary quality of care in maternity hospitals, by virtue of an accreditation system, and second to ensure that the system is fully operational in terms of referring obstetric emergencies. Giving birth in the woman’s home village will then no longer be regarded as a clearly expressed strategic choice, but as an unintended course of events. The introduction of a subsidised system of fixed-charge obstetric care will remove any financial obstacles, and is a necessary step to ensure the feasibility of such a programme.

Basket fund, an innovative approach for intermediate health system level financing in the Democratic Republic of Congo: Implementation process and challenges., Background: Universal health coverage should allow countries to establish a financing strategy in order to guarantee the health of the population., Aim: Our objective was to describe the process and preliminary results of the implementation of the basket fund approach as a mode of financing the intermediate level (provincial health divisions) of the Congolese health system., Setting: The study was conducted in the provincial health divisions (PHDs), representing the intermediate level of the health system in the Democratic Republic of Congo, where the basket fund approach has been implementedMethods: We conducted a mixed-methods convergent study as part of the evaluation of the basket fund approach in the Democratic Republic of Congo, five years after its introduction (2014-2019). Data was collected through a document review and individual interviews by telephone. A descriptive analysis of the quantitative data was conducted using Statistical Package for Social Sciences (SPSS) version 24 software. The qualitative data were analysed by thematic analysis using a pre-established thematic framework., Results: The implementation of the basket fund approach was effective in some (PHDs) (53.8% in 2016). The operating costs of the PHDs varied according to the size, density and number of health zones covered. In the PHDs where the basket fund was operational, this approach appeared to contribute to improved planning and management in the use of resources, the partnership between technical and financial partners (TFPs and PHDs) and incentives for the performance of PHD agents., Conclusion: In the DRC, the basket fund approach has contributed to improved collaboration between donors in the health sector and facilitated the decentralisation of funding planning to the provincial level.

The Programme d'Appui aux Stratégies Sociales, (PASS), is a non-profit health and social protection expertise organization that extends the activities of the Programme d'Appui aux Stratégies Mutuelles de Santé, managed by Expertise France from 2015 to 2020. The structure has been operational since August 2019 thanks to the support of two French mutualist groups, the Vyv Group and the Fédération Nationale de la Mutualité Française (FNMF), in the form of a non-profit simplified joint stock company. Starting from its original base of support for the development of mutual health coverage, PASS has broadened its field of intervention to include health and social protection projects, policies and systems, with a particular focus on issues related to women and children. PASS thus proposes an expertise built around 3 strategic areas of activity which are: (1) support for mutual health financing mechanisms (audit, studies, consulting, training); (2) support for the strengthening of health services built in conjunction with public policies; and (3) provision of expertise and operational capacities in response to various health and social protection issues. Based in Abidjan, Côte d'Ivoire, PASS is extending its activities to other French-speaking African countries., Competing Interests: Les auteurs ne déclarent aucun conflit d'intérêts. Encadré n° 1Ce qu'il faut retenir du PASS en quelques chiffres c'est: 1 bureau à Abidjan;6 relais permanents dans la zone UEMOA;+ de 10 faîtières ouest-africaines et d'Afrique centrale appuyées et formées;+ de 200 mutuelles bénéficiant d'accompagnement et de formation;+ de 10 événements majeurs organisés en Afrique pour la promotion de la mutualité et de la protection sociale;+ de 70 newsletters éditées et diffusées;+ de 4 000 membres de la communauté PASS (Facebook – Twitter – LinkedIn).Encadré n° 2 Un programme transformé pour de nouveaux défis Dans sa logique de développement et comme l'avaient souhaité ses financeurs, le programme s'est aujourd'hui transformé en une structure pérenne et auto-financée. Au terme de sa « première vie » qui s'est achevée le 31 décembre 2020, le programme a commencé depuis août 2019 une transformation structurelle. De programme financé, il devient, une société par actions simplifiées à but non lucratif, de droit ivoirien, portée par deux structures mutualistes françaises à savoir le Groupe Vyv et la Fédération Nationale de la Mutualité Française (FNMF). Devenu Programme d'Appui aux Stratégies Sociales, la nouvelle version du PASS se présente comme un acteur majeur de développement. Un pôle d'expertise en santé et en protection sociale, qui se fixe pour mission de contribuer à l'amélioration du bien-être des populations sur le continent africain, en vue d'un meilleur accès à la santé et aux filets de protection sociale à des coûts abordables, ou sans contrepartie, lorsqu'il s'agit de communautés et de groupes en situation de vulnérabilité sévère. La structure se construit autour de: L'appui aux mécanismes solidaires de financement de la santé de type mutualiste (audit, études, conseil, formation)L'appui au renforcement des services de santé bâtis en lien avec les politiques publiquesL'apport en expertise et en capacités opérationnelles en réponse à diverses problématiques ponctuelles de santé et de protection sociale, (Copyright © 2021 SFMTSI.)

Reform and Performance of the Provincial Health Inspectorate and the Provincial Division of Health of South Kivu in the Democratic Republic of Congo., Background: The intermediate level incorporated both the Provincial Health Inspectorate (IPS) and the Provincial Health Division (DPS) of Health. The new constitution of 2006 gave impetus to decentralisation, which became effective in 2015. The reform introduced at the intermediate level clearly separated the IPS and the DPS. This article assesses the effect of this reform on the performance of IPS and DPS in South Kivu, Democratic Republic of Congo., Methodology: The study is evaluative before and after and covers the period from 2012 to 2017. It uses mixed methods: three techniques were used to collect data including observation, document review and individual interviews. The analysis of the quantitative data concerned the evolution of the indicators; that of qualitative data was carried out by themes from two theoretical models: the ministerial functional framework and the 'Strengths, Weaknesses, Opportunities and Threats' analysis framework (SWOT analysis). Scores were assigned to each managerial function according to their level of performance for better comparison., Results: After the reform, a decline in the performance score of activities devolved to IPS is noted, mainly due to the low funding of activities. On the other hand, in the DPS, the evolution of the score is favorable, because of the strong support given to the reform at this level by the partners and the government. The alignment of partners to a single contract for funding DPS activities is observed. The weak financing of the health sector by the government remains a weak point, however, and the brain drain a threat to institutional sustainability. The introduction of the single financing contract constitutes an opportunity to improve the performance of the provincial management team., Discussion and Conclusion: The study shows the improvement in the performance of managerial functions of the DPS and the regression to the IPS. The low funding of IPS by the Congolese government could jeopardise the reform.

Introduction: The sustainability of medical assistance, considered necessary in middle-income countries, requires permanent regulation. In Morocco, the medical assistance scheme (MAS) is confronted with the lack of regulation tools and the difficulty of affixing these tools effectively in the absence of a regulator. In this sense, the shortcomings of the current practice of its regulation should be identified in order to recommend actions and tools to improve its implementation and guarantee its continuity., Methods: The analysis and the proposed recommendations are based on the review of the available literature, the review of the legal texts framing the basic medical coverage and the analysis of the current practice of regulation of the MAS., Results: The regulation of the MAS was not treated in the same way as the compulsory health insurance. There is no proper regulator as the case of the compulsory health insurance. In substance, the planned measures remain very insufficient and scattered between several actors and sometimes difficult to apply. Based on a reference framework designed along four axes (resources, expenditures, health care offer and population), the analysis identified fifteen actions and tools to correct deficiencies and support its sustainability., Conclusion: The proposed recommendations need a durable commitment from all the actors who must trigger as quickly as possible urgent actions to optimize the implementation of the medical assistance scheme and improve its perception in the citizen.

Introduction: Five years after its implementation, the Medical Assistance scheme (Ramed) has been able to cover more than eleven million people. Nevertheless, its financing remains the main challenge. Its initial financial structure was exceeded after its implementation. A reconfiguration of the financial package has become a necessity in order to guarantee sustainable financing., Methods: A review of the literature and a situational analysis through disseminated reports and documents made it possible to identify the initial financial package and its limits in order to design a new financial package., Results: The current financing is out of step with the regulations, which has a negative impact on it. Funds are insufficient to cover needs and do not even exceed half of the planned funding, set at three billion dirhams, due to a partial collection of resources. In order to meet the needs of the beneficiaries and follow their growing rhythm, at least 4 billion dirhams annually must be collected. This amount can only be ensured with a revision of the contributions of the State and local authorities., Conclusion: The current funds do not meet the needs, which undermines the social acceptability of the regime and threatens its sustainability. It is essential to improve its funding through a diversity of resources and more commitment from stakeholders to ensure sustainable funding managed according to the principles of good governance.

Over the last few years, many therapeutic innovations have been approved and marketed in France, within a strained financial setting. Legal dispositions allowed manufacturers (LEEM - les enterprises du medicament) and the economic committee for health products (CEPS) to contract various confidential market access agreements to contain health product expenses. The purposes of this article are to define and describe these different existing market access agreements and to open discussion on their applicability to the problematic of immune-oncology drugs financing. Financial agreements, which led to major savings (discounts refunded to the public payer), have not responded completely to the therapeutic innovations financing problems. Performance agreements (funding based on real-life data and effectiveness of the drug) constitute a hope for health products financing, but major methodological challenges for their use in routine restrict them to rare cases only today. Even though several financial agreements could partly respond to this problematic, use of performance agreements could really constitute an interesting track to tackle this issue., (Copyright © 2018. Published by Elsevier Masson SAS.)

Introduction: Performance-based financing (PBF) approach is a public health intervention, whose effects on the pillars of this system are often not measured, especially with regard to the information system and to the effectiveness of public health interventions., Methods: Our cross-sectional study was conducted in Benin in 67 health units randomly drawn from two PBF_HSS (Health Systems Strengthening) health zones and two PBF_NHSSP (Health Sector Support Program) areas, all experiencing PBF, and from two areas where the PBF had not been implemented. It allowed to evaluate the quality of the information and the effectiveness of public health interventions. The quality index and the performance scores of the system components were used to compare the strata covered by the PBF and the noncovered strata., Results: The quality of the information system and of the effectiveness of public health interventions was average in the three strata, with a higher quality index in the PBF_HSS (77%) and PBF_NHSSP (74%) strata than in the Non_PBF (67%) strata. Health system quality distribution was more favorable in the strata covered by PBF. The components achieving a good performance were "demographic information", "results and essential analyzes" and "statistic support archiving". However, the essential components of the PBF and of the information system were "supervision" and "reporting" that continued to have an average QI two years after the beginning of the intervention., Conclusion: The average quality of the information system and of the effectiveness of public health interventions could be improved by respecting the instructions of the PBF, especially when the quality of this system becomes a priority for the PBF.

Can money be used as a tool in the resocialisation of patients? Other than the clinical and institutional issues which its use within a therapeutic day centre raises, it can nevertheless help the caregiver bring projects to fruition and the patients to become engaged in them., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objectives: This article assesses the controversy around performance-based financing (PBF) and its contribution to the reform of health systems. It aims to reduce tensions between the different camps by restructuring the debate., Methods: Our approach was to organize an indirect dialogue between critics and supporters of PBF, based on the framework developed by Norman Daniels. This analytical framework is non-partisan and uses clear and objective criteria. The interviews were carried out in two rounds (first the critics, then the supporters) and were then analyzed. Parts of answers were regrouped according to the most common sectoral themes while also highlighting major areas of disagreement., Results: The interviews revealed some areas of convergence around PBF; the strategy is considered to be a complementary strategy to other strategies; such as those which aim to improving financial access to health care. The analysis also revealed disagreements based on misunderstandings of claims often ascribed to PBF, or lack of sufficient evidence, or asymmetrical information between experts., Conclusions: Several questions polarize PBF discussions. However, better structuring of convergent and divergent areas and arguments should facilitate a synthesis, at least to some extent. Experts need to adopt an objective approach with universally accepted criteria, for the benefit of all.

Background: The planning of human medical resources has been in progress since 1996. The aim of this paper is to describe the process which occurred in Belgium and to point out its assets and limits., Methods: Literature review, analysis of the Belgian legislation at national and community (Flemish and French-speaking) level and analysis of the projection model., Results: In Belgium, planniing is performed at two different levels of power. Firstly, the federal State determines the number of physicians who will access to the professional titles enabling them to obtain reimbursement of care by Health Funds. It is sustained by a supply projection type " stock and flows", an assessment of the number of required physicians (including healthcare expenditures by age and sex) and the purpose of equalizing Dutch-speaking and French-speaking medical densities. Secondly, Communities, are responsible for training and, as such, are organizing the selection at this level : entrance examination in the North and various selection procedures (now repealed) in the South., Conclusion: Worldwide, the managers of medical planning are faced with decisions related to appropriate numbers for human resources, given population needs, use of services and professional productivity. They have to address concerns from medical surplus to shortage. The case study of Belgium provides insight of various parameters which should be taken into account for national planning of physicians. It also shows the difficulty to assess a complex future and the factors which often hinder the implementation of evidence-based decisions.

Financial barriers represent a major obstacle to access to health care in sub-Saharan Africa and thus to the implementation of the Bamako Initiative. We describe an experience in which a civil society organization financed a free healthcare campaign in a rural health district in Cameroon. In all, 2,073 patients received free consultations, laboratory tests, and drugs. Adults older than 40 years accounted for 55.7% of all patients. The most frequent diseases were: osteoarticular conditions (24.1%), malaria (20.8%), and intestinal parasitosis (12.5%). In health systems financed mainly by cost recovery, some population needs remain uncovered by health services. There is a need to involve and reinforce the role of civil society in health system financing. It can help to pool more funds and improve the management of health resources to increase financial access to health care for poor people.