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PurposeThe purpose of this study is to first assess how the US healthcare financing system is influenced by income variation. Then, it examines whether or not the impact of income variation is asymmetric.Design/methodology/approachFor the analyses of this paper, the autoregressive distributed lag (ARDL) model is implemented to a data set covering the period from 1960 to 2018.FindingsThe results provide evidence that major funding sources of aggregate healthcare expenditure (HCE) respond differently to changes in income. The results also imply that the effect of income is not always symmetric.Originality/valueMany studies have attempted to identify the relationship between income and HCE. A common feature of past studies is that they have only focused on aggregate HCE, while one might be interested in knowing how major funders of aggregate HCE would be affected by changes in income. Another common feature of past studies is that they have assumed that the relationship between income and HCE is symmetric.

The increasing chronicity and multimorbidities associated with people living with HIV have posed important challenges to health systems across the world. In this context, payment models hold the potential to improve care across a spectrum of clinical conditions. This study aims to systematically review the evidence of HIV performance-based payments models. Literature searches were conducted in March 2020 using multiple databases and manual searches of relevant papers. Papers were limited to any study design that considers the real-world utilisation of performance-based payment models applied to the HIV domain. A total of 23 full-text papers were included. Due to the heterogeneity of study designs, the multiple types of interventions and its implementation across distinct areas of HIV care, direct comparisons between studies were deemed unsuitable. Most evidence focused on healthcare users (83%), seeking to directly affect patients' behaviour based on principles of behavioural economics. Despite the variability between interventions, the implementation of performance-based payment models led to either a neutral or positive impact throughout the HIV care continuum. Moreover, this improvement was likely to be cost-effective or, at least, did not compromise the healthcare system's financial sustainability. However, more research is needed to assess the durability of incentives and its appropriate relative magnitude.La creciente cronicidad y multimorbilidades asociadas con las personas que viven con el VIH han planteado importantes desafíos para los sistemas de salud en todo el mundo. En este contexto, los modelos de pago tienen el potencial de mejorar la atención en un espectro de condiciones clínicas. Este estudio tiene como objetivo revisar sistemáticamente la evidencia de los modelos de pagos basados ​​en el desempeño aplicados al dominio del VIH. Las búsquedas bibliográficas se realizaron en marzo de 2020 utilizando múltiples bases de datos y búsquedas manuales de artículos relevantes. Los artículos se limitaron a cualquier diseño de estudio que considere la utilización en el mundo real de modelos de pago basados ​​en el desempeño aplicados al dominio del VIH. Se incluyeron un total de 23 artículos de texto completo. Debido a la heterogeneidad de los diseños de los estudios, los múltiples tipos de intervenciones y su implementación en distintas áreas de la atención del VIH, las comparaciones directas entre diferentes estudios se consideraron inadecuadas. La mayoría de la evidencia se centró en los usuarios de la salud (83%), buscando afectar directamente el comportamiento de los pacientes basándose en los principios de la economía del comportamiento. A pesar de la variabilidad entre las intervenciones, la implementación de modelos de pago basados ​​en el desempeño generó un impacto neutral o positivo en todo el proceso de atención del VIH. Además, es probable que esta mejora sea costo-efectiva o, al menos, no comprometa la sostenibilidad financiera del sistema de salud. Sin embargo, se necesita más investigación para evaluar la durabilidad de los incentivos y su magnitud relativa apropiada.

Economist Peter Heller, writing a seminal paper published in Health, Policy and Planning in 2006, identified five opportunities for expanding fiscal space for health: raising revenue, reprioritizing expenditure, borrowing, using seigniorage and mobilizing external grants. The development of the initial framework marked a significant conceptual advancement in health financing, by situating health reforms within a broader macro-fiscal context. Fifteen years later, fiscal space for health is not viewed simply as a question of finding additional revenues but also as a matter of improving public financial management (PFM) in the health sector, specifically for publicly funded health systems. This paper advances the concept of budgetary space for health, which explores available resources generated through greater overall public expenditure, prioritized budget allocations, and improved PFM. The paper adds a critical component, unpacking the ways through which PFM improvements can maximize budgetary space for health. The approach fits the realities of public finances in the era of the Sustainable Development Goals. The key implication is that PFM aspects should be systematically included in assessments of budgetary space to inform more effective country dialogues between the finance and health sectors.

In India, most healthcare expenses are patients' out-of-pocket payments to private sector providers. Catastrophic health expenditures drive millions of families deeper into poverty. To save poorer households, hundreds of government-funded health insurance schemes have been introduced since the 2000s. These "demand side" schemes suggest that treatments in the private sector will be fully reimbursed. Fieldwork in one of India's largest hospitals shows that GFHIs overpromise. GFHIs are designed to turn patients into co-creators of healthcare value, but instead they deepen individuals' lack of market transparency. Poor patients pay the price for the state's lack of trust in them.

Összefoglaló. Bevezetés: A csípőtáji törések jelentősen terhelik az egészségügyi ellátórendszereket. Magyarországon 13 000–15 000 beteg szenved évente csípőtáji törést, jelentős részük műtéten is átesik. A betegek túlélését vizsgálták a EuroHOPE és BRIDGE kutatások, amelyek a Nemzeti Egészségbiztosítási Alapkezelőnek a finanszírozási célból gyűjtött, esetszintű adataira támaszkodtak. Az ilyen jellegű adatok megbízhatóságát több kutatás vizsgálta eltérő eredményekkel, ezért a további vizsgálatok előtt szükségesnek tartottuk a csípőtáji törésekre vonatkozóan is ellenőrizni őket. Célkitűzés: Egy magyarországi kórház reprezentatívan kiválasztott eseteinek vizsgálatán keresztül annak megállapítása, hogy a finanszírozási adatbázis adatai megfelelnek-e a betegdokumentációban rögzített adatoknak. Módszer: Egy magyarországi kórházba 2015-ben csípőtáji töréssel felvett betegek kórlapjainak anonim, reprezentatív mintáját összevetettük a EuroHOPE és BRIDGE kutatások adatbázisával tíz különböző adatelemre vonatkozóan. Az adatbázisokat rekordszinten párosítottuk, az egyezést adatelemre és rekordra vonatkozóan néztük. Eredmények: A reprezentatív minta 259 esetet tartalmazott. Az adatbázisok összevetése során nem találtunk eltérést a beteg neme, életkora, ápolást indokló fődiagnózisa és az osztályról történő távozás dátuma esetén. Egy eltérést találtunk az osztályos felvétel dátumában, a műtét dátumában öt darabot. A beteg további sorsa esetén tíz eltérést találtunk. A műtéttípusok esetén is alacsony mértékű (2–4 eset) eltérést tapasztaltunk. Jelentős mértékű eltérést a társbetegségek és a szövődmények esetén találtunk. Következtetés: Eredményeink alapján további vizsgálatokhoz felhasználhatók az alfanumerikus kódokat, számokat vagy dátumokat tartalmazó mezők (például fődiagnózis, felvételi és távozási dátumok), a társbetegségekre és a szövődményekre vonatkozó adatok azonban nem alkalmazhatók mélyebb elemzések során. Orv Hetil. 2021; 162(18): 712–719. Summary. Introduction: Hip fractures pose a heavy burden on healthcare systems. In Hungary, 13 000–15 000 patients experience hip fractures, most of them undergo surgery. Their survival was examined by the EuroHOPE and BRIDGE studies, using patient level data from the National Health Insurance Fund. Data from healthcare financing reports have been examined worldwide, with contradicting results, so we considered it necessary to observe data validity for hip fractures before further analysis. Objective: The aim of our study was to observe a representative sample of patient records in a Hungarian hospital in order to validate the finance reports. Method: We matched a representative sample of hip fracture patient records in a Hungarian hospital with hip fractures in 2015 with the database of the EuroHOPE and BRIDGE studies. The databases were matched on record level, the analysis included ten data fields and was conducted for data fields and records. Results: The sample included 259 cases. No differences were observed in the patients’ gender, age and main diagnosis, or dates of discharge. One difference was observed in the dates of admission, and 5 in the dates of surgery. Minor differences were found in the types of surgery (2–4 cases), but the differences between the databases in comorbidities and complications were large. Conclusion: Based on our results, we can conclude that data fields containing alphanumeric codes, numbers or dates (e.g., main diagnosis, admission, discharge and surgery dates) can be used for further analysis, but comorbidity and complication data are not recommended for research purposes. Orv Hetil. 2021; 162(18): 712–719.

Background Out-of-pocket (OOP) payments for healthcare have been increasing steadily in Bangladesh, which deteriorates the financial risk protection of many households. Methods We aimed to investigate the incidence of catastrophic health expenditure (CHE) and impoverishment from OOP payments and their determinants. We employed nationally representative Household Income and Expenditure Survey 2016 data with a sample of 46 076 households. A household that made OOP payments of >10% of its total or 40% of its non-food expenditure was considered to be facing CHE. We estimated the impoverishment using both national and international poverty lines. Multiple logistic models were employed to identify the determinants of CHE and impoverishment. Results The incidence of CHE was estimated as 24.6% and 10.9% using 10% of the total and 40% of non-food expenditure as thresholds, respectively, and these were concentrated among the poor. About 4.5% of the population (8.61 million) fell into poverty during 2016. Utilization of private facilities, the presence of older people, chronic illness and geographical location were the main determinants of both CHE and impoverishment. Conclusion The financial hardship due to OOP payments was high and it should be reduced by regulating the private health sector and covering the care of older people and chronic illness by prepayment-financing mechanisms.

OBJECTIVES To explore contextual factors associated with overall dental service use, and investigate whether these factors influenced choice of the type of service according to the healthcare financing alternatives (public services; out-of-pocket services; and private health insurance), by adults and older individuals, based on the most recent Andersen's behavioural model. METHODS Cross-sectional study with individual data on 17,305 adults from 177 Brazilian municipalities in the National Oral Health Survey (SBBrasil 2010). Municipal-level information was obtained from health information systems and census data. Multilevel multinomial logistic regression was carried out for multivariable analysis. RESULTS In the previous year, 38.2% of the individuals visited the dentist; of which 21.4% used out-of-pocket spending, 11.6% used public services and 5.2% private dental insurance. Municipalities with population coverage of public primary dental care >80% had higher chances of using public services (OR = 1.28, 95%CI:1.00-1.64) than those with ≤60%, but lower chances of using private insurance (OR = 0.56, 95%CI:0.38-0.83). Municipalities with population coverage of private dental insurance > 5% had lower chances of using public services (OR = 0.62, 95%CI:0.47-0.81) than those with

In this paper we adopt a growth accounting projection model to estimate and characterize health-financing needs in Brazil as well as to assess the extent to which financing needs may diverge from spending capacity in the future. We estimate an annual increase of 0.71% in the share of projected financing needs relative to GDP, with excess growth rates being 0.74% and 0.69% for the public and private health sectors, respectively. Institutional reforms and public spending restrictions may leverage public-private segmentation in health financing throughout the next decades, thus potentially leading to losses of equity in the system. Our projections contribute to a scant empirical literature on health financing sustainability in low- and middle-income countries and shed light on the role of spending capacity and institutional constraints over the path towards universal health coverage.

Background and Aims More than 292 million people are living with hepatitis B worldwide and are at risk of death from liver cirrhosis and liver cancer. The World Health Organization (WHO) has set global targets for the elimination of viral hepatitis as a public health threat by 2030. However, current levels of global investment in viral hepatitis elimination programmes are insufficient to achieve these goals. Methods To catalyse political commitment and to encourage domestic- and international-financing, we used published modelling data and key stakeholder interviews to develop an investment framework to demonstrate the return on investment for viral hepatitis elimination. Results The framework utilizes a public health approach to identify evidence-based national activities that reduce viral hepatitis-related morbidity and mortality, as well as international activities and critical enablers that allow countries to achieve maximum impact on health outcomes from investment to achieve WHO 2030 elimination targets. Conclusion Focusing on hepatitis B, this health policy paper employs the investment framework to estimate the substantial economic benefits of investing in the elimination of hepatitis B and demonstrates how such investments could be cost-saving by 2030., Graphical abstract, Highlights • The WHO has set global targets for elimination of hepatitis B by 2030 • To date, global investment in hepatitis B elimination activities has been limited • We have developed a global investment framework for the elimination of hepatitis B to guide domestic and international investment • This Health Policy paper outlines evidence to support the financial returns on investment in hepatitis B elimination, identifies national and international activities to achieve hepatitis B elimination targets and identifies potential funding sources • The goal of this investment framework is to pave the way for countries to build the economic case for investment in national hepatitis B elimination programmes.

Objective The purpose of this study was to review changes in public health finance since the 2012 Institute of Medicine (IOM) report "For the Public's Health: Investing in a Healthier Future." Design Qualitative study involving key informant interviews. Setting and participants Purposive sample of US public health practitioners, leaders, and academics expected to be knowledgeable about the report recommendations, public health practice, and changes in public health finance since the report. Main outcome measures Qualitative feedback about changes to public health finance since the report. Results Thirty-two interviews were conducted between April and May 2019. The greatest momentum toward the report recommendations has occurred predominantly at the state and local levels, with recommendations requiring federal action making less progress. In addition, much of the progress identified is consensus building and preparation for change rather than clear changes. Overall, progress toward the recommendations has been slow. Conclusions Many of the achievements reported by respondents were characterized as increased dialogue and individual state or local progress rather than widespread, identifiable policy or practice changes. Participants suggested that public health as a field needs to achieve further consensus and a uniform voice in order to advocate for changes at a federal level. Implications for policy and practice Slow progress in achieving 2012 IOM Finance Report recommendations and lack of a cohesive voice pose threats to the public's health, as can be seen in the context of COVID-19 emergency response activities. The pandemic and the nation's inadequate response have highlighted deficiencies in our current system and emphasize the need for coordinated and sustained core public health infrastructure funding at the federal level.

Health prepayment, a key indicator under the Sustainable Development Goals monitoring framework, is strongly associated with household financial protection; however, the impact of government health budget on the level of prepayment has rarely been discussed.To address the following research questions. (1) Does a higher government health budget translate into higher prepayment rates in the healthcare financing system? (2) What are the effects of government health budget on public prepayment and private prepaid plans? (3) What are the heterogeneities between groups of countries with different income levels and public health prepayment systems?Analysis of panel co-integration, impulse response function, and variance decomposition were conducted in 34 Organisation for Economic Co-operation and Development (OECD) members for the period 1995-2016.Government health budget has a long-running equilibrium relationship with the level of public and total prepayment. However, a stable relationship could not be confirmed with private prepaid plans. Moreover, government health budget played a significant positive role in explaining the fluctuations in the total and public prepayments over a long time, that is, 51 and 37 periods, respectively. Considering differences between groups of countries, the impacts are greater for those with higher income levels and more public-dominated health-financing systems.Government health budget has a long-time relationship with the levels of both total prepaid expenditure and public prepayment. By contrast, it does not systematically crowd out private prepaid plans.أثر الميزانية الحكومية على مستويات الدفع المسبق في مجال الصحة: دلائل مستمدة من بلدان منظمة التعاون والتنمية في الميدان الاقتصادي.ينج تشانج، جاك فانيست، وينكينج بان، ليوي تشانج.يرتبط الدفع المسبق للحصول على الخدمات الصحية، وهو مؤشر رئيسي في إطار رصد أهداف التنمية المستدامة، بصورة وثيقة بالحماية المالية للأسر؛ غير أنه من النادر أن تجري مناقشة تأثير الميزانية الحكومية للصحة على مستويات الدفع المسبق.هدفت هذه الدراسة إلى الرد على الأسئلة البحثية التالية: (1) هل يُترجَم ارتفاع مخصصات الميزانية الحكومية للصحة إلى ارتفاع معدلات الدفع المسبق في نظام تمويل الرعاية الصحية؟ (2) ما هي آثار الميزانية الحكومية للصحة على خطط الدفع المسبق العامة وخطط الدفع المسبق الخاصة؟ (3) ما هي أوجه التفاوت بين مجموعات البلدان المختلفة من حيث مستويات الدخل ونُظُم الدفع المسبق في مجال الصحة العامة؟.أجري تحليل تآلف المجموعة، ووظيفة الاستجابة الاندفاعية، وتحليل التفكك التبايني في 34 عضواً في منظمة التعاون والتنمية في الميدان الاقتصادي خلال الفترة من 1995 وحتى 2016.هناك علاقة طويلة الأمد ومتوازنة بين الميزانية الحكومية للصحة ومستوى الدفع المسبق العام وإجمالي الدفع المسبق. ومع ذلك، لم يتسن تأكيد وجود علاقة مستقرة مع خطط الدفع المسبق الخاصة. وعلاوة على ذلك، فقد أدت الميزانية الحكومية للصحة دوراً إيجابياً هاماً في تفسير التقلبات في إجمالي الدفع المسبق والدفع المسبق العام على مدى فترة طويلة بلغت 51 و 37 دورة على التوالي. وبالنظر إلى الاختلافات بين مجموعات البلدان، فإن الآثار المترتبة تكتسي أهمية أكبر بالنسبة للبلدان التي لديها مستويات دخل أعلى ونُظُم تمويل صحي يهيمن عليها القطاع العام أكثر من أي قطاع آخر.هناك علاقة ممتدة بين الميزانية الحكومية للصحة ومستويات إجمالي الإنفاق المدفوع مقدماً والدفع المسبق العام على حد سواء. وعلى العكس من ذلك، فإن الميزانية الحكومية لا تتنافس مع خطط الدفع المسبق الخاصة.Impact du budget de l’État sur les niveaux de prépaiement pour les soins de santé : données probantes des pays membres de l’OCDE.Le prépaiement pour les soins de santé, un indicateur clé du cadre de suivi des objectifs de développement durable, est fortement associé à la protection financière des ménages ; toutefois, l’impact du budget public de la santé sur le niveau de prépaiement a rarement été examiné.Répondre aux questions de recherche suivantes. 1) Une augmentation du budget public de la santé se traduitelle par des taux de prépaiement plus élevés dans le système de financement des soins de santé ? 2) Quels sont les effets du budget public de la santé sur le prépaiement public et les systèmes privés de prépaiement ? 3) Quelles sont les hétérogénéités entre les groupes de pays ayant des niveaux de revenu et des systèmes de prépaiement de santé différents ?Pour la période 1995-2016, 34 membres de l'Organisation de coopération et de développement économiques (OCDE) ont procédé à une analyse de la co-intégration des panels, de la fonction de réponse impulsive et de la décomposition des variances.Le budget public de la santé est depuis longtemps en équilibre avec le niveau des prépaiements publics et totaux. Cependant, une relation stable n'a pas pu être confirmée avec les systèmes privés de prépaiement. En outre, le budget de la santé a joué un rôle positif important en expliquant les fluctuations de l’ensemble des prépaiements et des prépaiements publics sur une longue période, c'est-à-dire 51 et 37 périodes, respectivement. Compte tenu des différences entre groupes de pays, les impacts sont plus importants pour ceux dont les niveaux de revenu sont plus élevés et dont les systèmes de financement de la santé sont plus à dominante publique.Le budget public de la santé est lié depuis longtemps aux niveaux du total des dépenses prépayées et des prépaiements publics. En revanche, il ne permet pas de supplanter systématiquement les systèmes privés de prépaiement.

Background Health insurance is an important mechanism to prevent financial hardship in the process of accessing health care. Since the launch of Nigeria’s National Health Insurance Scheme (NHIS) in 2005, only 5% of Nigerians have health insurance and 70% still finance their healthcare through Out-Of-Pocket (OOP) expenditure. Understanding the contextualized perspectives of stakeholders involved in NHIS is critical to advancing and implementing necessary reforms for expanding health insurance coverage at national and sub-national levels in Nigeria. This study explored the perspectives of sub-national level actors/stakeholders on the design and implementation challenges of Nigeria’s NHIS. Methods A descriptive case study design was used in this research. Data were collected in Ibadan, Oyo State in 2016 from health insurance regulators, healthcare providers, and policymakers. Key informant interviews (KII) were conducted among purposively selected stakeholders to examine their perspectives on the design and implementation challenges of Nigeria’s National Health Insurance Scheme. Data were analysed using inductive and deductive thematic approaches with the aid of NVIVO software package version 11. Results Implementation challenges identified include abject poverty, low level of awareness, low interest (in the scheme), superstitious beliefs, inefficient mode of payment, drug stock-out, weak administrative and supervisory capacity. The scheme is believed to have provided more coverage for the formal sector, its voluntary nature and lack of legal framework at the subnational levels were seen as the overarching policy challenge. Only NHIS staff currently make required financial co-contribution into the scheme, as all other federal employees are been paid for by the (federal) government. Conclusions Sub-national governments should create legal frameworks establishing compulsory health insurance schemes at the subnational levels. Effective and efficient platforms to get the informal sector enrolled in the scheme is desirable. CBHI schemes and the currently approved state supported health insurance programmes may provide a more acceptable platform than NHIS especially among the rural informal sector. These other two should be promoted. Awareness and education should also be raised to enlighten citizens. Stakeholders need to address these gaps as well as poverty.

This article explores longitudinal trends of healthcare financing and mortality levels among the children under 5 (U5) years of age in the BRICS nations between 2000 and 2015. This analysis is based on the relevant secondary data obtained from the WHO data repository and various other publicly available sources. Inferential statistical tools like linear regression analysis was carried out to test the relationship between dependent and independent variables. The results indicate an inverse relationship between current health expenditure and U5 child deaths, revealing a decline of 29,000 U5 child deaths and 19,000 infant deaths for every US$1increase in per capita healthcare expenditure. Further, neonatal deaths declined by 1.74% and infant deaths 2.8%, while U5 child deaths declined by 4.6% per annum. India spends lowest among the BRICS nations—about US$63 per capita, while out-of-pocket expenditure (OOPE) is highest at 69.3%. Countries with higher per capita government health expenditure have better health indicators. This article, therefore, calls for strengthening public investment in healthcare to improve health outcomes.

Background Research output on global neurosurgery (GNS) has exponentially increased in recent years. As research efforts increase, we must first analyze how the current body of GNS literature fits into the macroscopic schema of systems-based policies. The aim of this study was to identify and categorize GNS research based on health system domains. Methods PubMed, CINAHL, and Embase were searched for GNS literature published from 1999 to 2019. Then, health system domains were defined and itemized based on publicly available documents from the Program in Global Surgery and Social Change. This items chart was subsequently used to categorize the GNS literature into health system domains. Results A total 63 articles were determined to focus on a health system domain. Of these articles, 6 focused on multiple domains, yielding an adjusted total of 70 articles. Overall, the most represented health system domain was service delivery (21 articles), followed by workforce (19), infrastructure (15), financing (12) and information management (3). A total of 30 low- and middle-income countries (LMICs) were represented across all articles. In addition, the first author was affiliated with an institution from a high-income country for 71.4% of the articles. Conclusions This review highlighted the pressing need for more research into information management in the context of GNS. In addition, health system–focused GNS literature represented only 20% of all LMICs (30/143). The trends in authorship should be noted, because many ethical (and practical) issues may arise if there is a disconnect in the objectives of the authors and the neurosurgeons in LMICs.

Purpose: The objective of the paper is to review historical developments and the current setup of healthcare financing models in Central Europe. Methodology: A systematic narrative approach has been taken with the research emphasis on a critical literature review and analyses of healthcare spending statistical data. Findings: A comparison between different models currently in place seems to suggest the existence of patterns leading to improved quality of the healthcare service proposition that is critically impacted by a financing model. Implications: The findings have practical implications since different results have been achieved in countries choosing different models but starting from practically the same point. That realisation should serve as a foundation for further work on this subject, potentially leading to adjustments to financing models chosen by some countries. Value: The paper offers a comparative analysis of the healthcare system financing evolution in four Central European Countries and an overview of their current state.

Background Social media has globalised compassion enabling requests for donations to spread beyond geographical boundaries. The use of social media for medical crowdfunding links people with unmet healthcare needs to charitable donors. There is no doubt that fundraising campaigns using such platforms facilitates access to financial resources to the benefit of patients and their caregivers. Main text This paper reports on a critical review of the published literature and information from other online resources discussing medical crowdfunding and the related ethical questions. The review highlighted the benefits of crowdfunding as well as the under-exploration of the risk of having patients’ desires and human rights undermined during online fundraising campaigns. Majority of these campaigns get initiated on behalf of the patients, especially the very sick and dependant. The ethical questions raised relate to the voluntariness of informed consent and the possibility of patients being used as a means to an end. Vulnerability of patients may expose them to coercion, undue influence, manipulation, and violation of their human rights. The success of these campaigns is influenced by the digital skills, pre-existing social networks and, the emotional potency. Healthcare is a public good, and online market forces should not determine access to essential health services. The benefits of crowdfunding cannot be subverted, but it can perpetuate unintended injustices, especially those arising from socio-economic factors. Conclusions Policymakers ought to monitor the utilisation of crowdfunding sites to identify policy failures and unmet essential health care needs responsible for driving individuals to use these platforms. The upholding of human rights and the fundamental respect of the individual’s wishes is a moral imperative. The need for an ethics framework to guide different stakeholders during medical crowdfunding needs further examination.

Background The world aims to achieve universal health coverage by removing all forms of financial barriers to improve access to healthcare as well as reduce maternal and child deaths by 2030. Although free maternal healthcare has been embraced as a major intervention towards this course in some countries in sub-Saharan Africa (SSA), the perception of the quality of healthcare may influence utilization and maternal health outcomes. We systematically mapped literature and described the evidence on maternal perceptions of the quality of care under the free care financing policies in SSA. Methods We employed the Arskey and O’Malley’s framework to guide this scoping review. We searched without date limitations to 19th May 2019 for relevant published articles in PubMed, Google Scholar, Web of Science, Science Direct, and CINAHL using a combination of keywords, Boolean terms, and medical subject headings. We included primary studies that involved pregnant/post-natal mothers, free maternal care policy, quality of care, and was conduct in an SSA country. Two reviewers independently screened the articles at the abstract and full-text screening guided by inclusion and exclusion criteria. All relevant data were extracted and organized into themes and a summary of the results reported narratively. The recent version of the mixed methods appraisal tool was used to assess the methodological quality of the included studies. Results Out of 390 studies, 13 were identified to have evidence of free maternal healthcare and client perceived quality of care. All the 13 studies were conducted in 7 different countries. We found three studies each from Ghana and Kenya, two each in Burkina Faso and Nigeria, and a study each from Niger, Sierra Leone, and Tanzania. Of the 13 included studies, eight reported that pregnant women perceived the quality of care under the free maternal healthcare policy to be poor. The following reasons accounted for the poor perception of service quality: long waiting time, ill-attitudes of providers, inadequate supply of essential drugs and lack of potable water, unequal distribution of skilled birth attendants, out-of-pocket payment and weak patient complaint system. Conclusion This study suggests few papers exist that looked at maternal perceptions of the quality of care in the free care policy in SSA. Considering the influence mothers perceptions of the quality of care can have on future health service utilisation, further studies at the household, community, and health facility levels are needed to help unearth and address all hidden quality of care challenges and improve maternal health services towards attaining the sustainable development goals on maternal and child health.

Primary health care offers a cost-effective route to achieving universal health coverage (UHC). However, primary health-care systems are weak in many low- and middle-income countries and often fail to provide comprehensive, people-centred, integrated care. We analysed the primary health-care systems in 20 low- and middle-income countries using a semi-grounded approach. Options for strengthening primary health-care systems were identified by thematic content analysis. We found that: (i) despite the growing burden of noncommunicable disease, many low- and middle-income countries lacked funds for preventive services; (ii) community health workers were often under-resourced, poorly supported and lacked training; (iii) out-of-pocket expenditure exceeded 40% of total health expenditure in half the countries studied, which affected equity; and (iv) health insurance schemes were hampered by the fragmentation of public and private systems, underfunding, corruption and poor engagement of informal workers. In 14 countries, the private sector was largely unregulated. Moreover, community engagement in primary health care was weak in countries where services were largely privatized. In some countries, decentralization led to the fragmentation of primary health care. Performance improved when financial incentives were linked to regulation and quality improvement, and community involvement was strong. Policy-making should be supported by adequate resources for primary health-care implementation and government spending on primary health care should be increased by at least 1% of gross domestic product. Devising equity-enhancing financing schemes and improving the accountability of primary health-care management is also needed. Support from primary health-care systems is critical for progress towards UHC in the decade to 2030.Les soins de santé primaires offrent l'itinéraire le plus économique vers une couverture maladie universelle (CMU). Pourtant, les systèmes dont ils dépendent demeurent fragiles dans de nombreux pays à faible et moyen revenu. La plupart du temps, ils sont incapables de fournir un modèle de soins intégral, intégré et centré sur la personne. Nous avons donc analysé les systèmes de soins de santé primaires dans 20 pays à faible et moyen revenu en adoptant une approche partiellement basée sur la réalité. Les options de renforcement des systèmes de soins de santé primaires ont été identifiées par le biais d'une analyse de contenu thématique. Nous avons constaté que: (i) malgré le fardeau de plus en plus lourd des maladies non transmissibles, nombre de pays à faible et moyen revenu ne possédaient pas les fonds suffisants pour assurer des services de prévention; (ii) les professionnels de santé au sein des communautés manquaient fréquemment de ressources, de soutien et de formation; (iii) les frais non remboursables dépassaient 40% des dépenses de santé dans la moitié des pays étudiés, ce qui entraîne des inégalités; et enfin, (iv) les régimes d'assurance maladie étaient entravés par la fragmentation des systèmes publics et privés, le sous-financement, la corruption et la piètre mobilisation des travailleurs informels. Dans 14 pays, le secteur privé n'était pratiquement soumis à aucune réglementation. Par ailleurs, l'engagement communautaire dans les soins de santé primaires était dérisoire dans les États où les services étaient majoritairement privatisés. Dans certains pays, la décentralisation avait débouché sur une fragmentation des soins de santé primaires. Les performances se révélaient meilleures lorsque des avantages financiers avaient trait à la réglementation et à l'amélioration de la qualité, et l'implication était forte au sein de la communauté. Le processus d'élaboration des politiques devrait être accompagné des ressources nécessaires pour l'instauration d'un système de soins de santé primaires, et les gouvernements devraient accroître leurs dépenses en la matière d'au moins 1% du produit intérieur brut. Il est également impératif de définir des régimes de financement favorisant l'équité et de promouvoir la fiabilité de la gestion des soins de santé primaires. La contribution des systèmes de soins de santé primaires est essentielle à la progression vers une CMU à l'horizon 2030.La atención primaria de salud brinda una vía rentable para lograr la cobertura sanitaria universal (CSU). Sin embargo, los sistemas de atención primaria de salud son deficientes en muchos países de ingresos medios y bajos y con frecuencia no ofrecen una atención integral y centrada en las personas. Se analizaron los sistemas de atención primaria de salud en 20 países de ingresos medios y bajos mediante un enfoque semifundamentado. Se determinaron las alternativas para fortalecer los sistemas de atención primaria de salud por medio de un análisis de contenido temático. Se concluyó que: i) a pesar de la creciente carga de las enfermedades no transmisibles, muchos países de ingresos medios y bajos no disponían de fondos para los servicios preventivos; ii) con frecuencia los profesionales sanitarios de la comunidad carecían de recursos, de apoyo y de capacitación; iii) los gastos directos superaban el 40 % del gasto total en salud en la mitad de los países analizados, lo que afectaba a la equidad; y iv) los planes de seguro médico presentaban dificultades debido a la fragmentación de los sistemas públicos y privados, la falta de financiamiento, la corrupción y la escasa participación de los trabajadores informales. La mayor parte del sector privado de 14 países no estaba regulado. Además, la participación de la comunidad en la atención primaria de salud era muy reducida en los países donde los servicios estaban privatizados en gran medida. Por otra parte, la descentralización de la atención primaria de salud causó la fragmentación de la misma en algunos países. La rentabilidad mejoró cuando los incentivos financieros se vincularon con la regulación y el mejoramiento de la calidad, además de que la participación de la comunidad fue significativa. La formulación de las políticas debería contar con el apoyo de recursos suficientes para prestar los servicios de atención primaria de salud y el gasto público en atención primaria de salud debería aumentar por lo menos en un 1 % del producto interno bruto. Asimismo, es necesario elaborar planes de financiamiento que aumenten la equidad y mejoren la rendición de cuentas de la gestión de la atención primaria de salud. El apoyo de los sistemas de atención primaria de salud es fundamental para avanzar hacia la CSU de aquí a 2030.تقدم الرعاية الصحية الأولية وسيلة فعالة من حيث التكلفة لتحقيق تغطية صحية شاملة (UHC). إلا أن أنظمة الرعاية الصحية الأولية ضعيفة في العديد من البلدان منخفضة الدخل ومتوسطة الدخل، وغالبًا ما تفشل في توفير رعاية شاملة ومتكاملة ومرتكزة على الإنسان. قمنا بتحليل أنظمة الرعاية الصحية الأولية في 20 بلدًا منخفض الدخل ومتوسط الدخل باستخدام أسلوب شبه أساسي. تم تحديد خيارات لتعزيز أنظمة الرعاية الصحية الأولية من خلال تحليل المحتوى المواضيعي. توصلنا إلى ما يلي: (1) على الرغم من العبء المتزايد للأمراض غير المعدية، فإن العديد من البلدان منخفضة الدخل ومتوسطة الدخل افتقرت إلى أموال الخدمات الوقائية؛ و(2) كان العاملون في القطاع الصحي المجتمعي في كثير من الأحيان يعانون من نقص الموارد وضعف الدعم والافتقار إلى التدريب؛ و(3) تجاوز الإنفاق الشخصي 40% من إجمالي الإنفاق الصحي في نصف البلدان التي شملتها الدراسة، وهو ما أثر على العدالة؛ و(4) تعرضت أنظمة التأمين الصحي بسبب تجزئة الأنظمة العامة والخاصة، ونقص التمويل، والفساد، وضعف مشاركة العمال غير الرسميين. كان القطاع الخاص غير منظم بشكل كبير في 14 بلدًا. بالإضافة إلى ذلك، كانت مشاركة المجتمع في الرعاية الصحية الأولية ضعيفة في البلدان التي كانت الخدمات مخصخصة فيها إلى حد كبير. أدت اللامركزية في بعض البلدان إلى تجزئة الرعاية الصحية الأولية. تحسن الأداء عندما تم ربط الحوافز المالية بالتنظيم وتحسين الجودة، وكانت مشاركة المجتمع قوية. يجب دعم وضع السياسات بواسطة الموارد الكافية لتنفيذ الرعاية الصحية الأولية، كما يجب زيادة الإنفاق الحكومي على الرعاية الصحية الأولية بنسبة 1% على الأقل من الناتج المحلي الإجمالي. كما أن هناك حاجة إلى وضع مخططات تمويل لتعزيز العدالة، وتحسين المساءلة بخصوص إدارة الرعاية الصحية الأولية. يعد الدعم الناتج من أنظمة الرعاية الصحية الأولية أمرًا حيويًا لإحراز التقدم نحو تحقيق التغطية الصحية الشاملة (UHC) في العقد الحالي حتى عام 2030.初级卫生保健为实现全民健康覆盖 (UHC) 提供了一种经济有效的途径。然而在许多中低收入国家，初级卫生保健体系非常薄弱，常常无法提供全面的以人为本的综合保健。我们利用半扎根的研究方法分析了 20 个中低收入国家的初级卫生保健体系。通过分析主题内容确定了加强初级保健体系的备选方案。我们发现：(I) 尽管非传染性疾病负担日益沉重，但许多中低收入国家仍缺乏预防服务资金；(ii) 社区卫生工作者通常资源配备不足，无法获得良好的支持，并且缺乏相应培训；(iii) 在所研究的一半国家中，医疗自费超出卫生支出总额的 40％，不利于实现公平；(iv) 公共和私人体系分散、资金不足、腐败以及非正式员工参与不足，阻碍了健康保险计划的实施。14 个国家中，私营部门基本上不受监管。此外，服务基本私有化的国家，社区很少参与初级卫生保健。一些国家权力下放，促使其初级保健分散。当财政激励措施与法规和质量提升相结合，，并且社区参与度增强时，绩效便会有所改善。应该为初级卫生保健的决策制定提供充足的资源，并将政府在初级卫生保健方面的支出至少增加国内生产总值的 1％。还需要制定提升公平的融资方案，加强初级卫生保健管理的问责。初级卫生保健体系的支持对于在截止 2030 年的十年中实现 UHC 至关重要。.Первичная медико-санитарная помощь предлагает экономически эффективный метод обеспечения всеобщего охвата услугами здравоохранения (ВОУЗ). Тем не менее системы первичной медико-санитарной помощи слабо развиты во многих странах с низким и средним уровнем доходов и часто не способны обеспечить комплексное, ориентированное на людей медицинское обслуживание. Авторы проанализировали системы первичной медико-санитарной помощи в 20 странах с низким и средним уровнем доходов, используя метод полуобоснованной теории. Варианты укрепления систем первичной медико-санитарной помощи были определены в ходе анализа тематического содержания. Авторы выяснили следующее: (i) несмотря на растущее бремя неинфекционных заболеваний, многие страны с низким и средним уровнем доходов испытывают недостаток средств для профилактических услуг; (ii) работники здравоохранения на уровне сообществ часто не имеют достаточного количества ресурсов, поддержки и квалификации; (iii) расходы из собственных средств превышают 40% от общих расходов в сфере здравоохранения в половине исследованных стран, что способствует увеличению неравенства; (iv) работе схем медицинского страхования препятствует раздробленность государственных и частных систем, недостаток финансирования, коррупция и низкая степень участия неофициальных работников. В 14 странах частный сектор практически не регулировался. Более того, участие населения в первичной медико-санитарной помощи было низким в странах со значительной степенью приватизации услуг. В некоторых странах децентрализация привела к раздробленности сферы первичной медико-санитарной помощи. Показатели улучшились, когда финансовое стимулирование было связано с регулированием и повышением качества услуг, а также активным участием местного населения. Формирование политики должно подкрепляться соответствующими ресурсами для реализации первичной медико-санитарной помощи, а государственные расходы на первичную медико-санитарную помощь должны быть увеличены как минимум на 1% от валового внутреннего продукта. Также необходимо разработать схемы финансирования, способствующие уменьшению неравенства, и повысить подотчетность в управлении первичной медико-санитарной помощью. Поддержка со стороны систем первичной медико-санитарной помощи имеет решающее значение для достижения ВОУЗ в период до 2030 года.

Context Governments at all levels work to ensure a healthy public, yet financing, organization, and delivery of public health services differ across the United States. A 2012 Institute of Medicine Finance report provided a series of recommendations to ensure a high-performing and adequately funded public health infrastructure. Objectives This review examines the influence of the Finance report's 10 recommendations on public health policy and practice. Design This review utilized peer-reviewed and gray literature published since 2012. Eligibility criteria Documents that address at least one of the Finance report's 10 recommendations and contain information on either official actions taken in response to the Finance report or evidence of the report's influence on the practice community. Results Of 2394 unique documents found, a total of 56 documents met the eligibility criteria. Review of these 56 documents indicated that the most substantial activity related to the recommendations was focused on the "minimum package of public health services" concept and establishment of a uniform chart of accounts. Discussion Progress has been mixed on the Finance report recommendations. Improved tracking and auditing of public health activity appears to be advancing, yet financial benchmarks remain unmet. Challenges remain in determining actual investment in public health and equitable resource allocation approaches. State and local health department use of cost estimation methodology and a uniform chart of accounts tool has contributed to an increase in understanding and improvement in public health spending. Conclusions The Finance report has served as a strong impetus for advocating for an increased investment in governmental public health. Efforts are bolstered by informed public health practitioners and stakeholders but often stymied by policy makers who must balance complex competing issues and priorities. Although many successes have occurred, further work is needed toward improving investment in the nation's public health.

Background The current study examines self-reported professional practices and attitudes of Israeli neuropsychologists, in an attempt to understand how they contribute to funding of neuropsychological assessment (NPA) through the Israeli healthcare system. Methods Two hundred seventy-nine neuropsychologists (176 board-certified experts and 103 interns) participated in an online survey that targeted characteristics of NPA practice in Israel, attitudes toward NPA, and familiarity with healthcare referral procedures. Results Overall, 68% of respondents conducted NPA, with a smaller proportion of experts (56%) doing so than interns (88%). The most common purpose of NPA was to provide treatment recommendations, and respondents listed indications for NPA that matched indications for neuropsychological rehabilitation. Almost two thirds of respondents reported that none of the NPAs that they performed received healthcare funding. While all practitioners believed that the healthcare system should fund NPA, the majority demonstrated lack of familiarity with referral procedures. Conclusions To increase referral rates and create effective neuropsychological services within the Israeli healthcare system, neuropsychologists should work more closely with physicians in integrated care teams. In addition, they should engage in greater advocacy activities that will emphasize the need for publicly funded NPA.

Background Corruption is widespread in Nigeria’s health sector but the reasons why it exists and persists are poorly understood and it is often seen as intractable. We describe a consensus building exercise in which we asked health workers and policy-makers to identify and prioritise feasible responses to corruption in the Nigerian health sector. Methods We employed three sequential activities. First, a narrative literature review identified which types of corruption are reported in the Nigerian health system. Second, we asked 21 frontline health workers to add to what was found in the review (based on their own experiences) and prioritise them, based on their significance and the feasibility of assessing them, by means of a consensus building exercise using a Nominal Group Technique (NGT). Third, we presented their assessments in a meeting of 25 policy-makers to offer their views on the practicality of implementing appropriatemeasures. Results Participants identified 49 corrupt practices from the literature review and their own experience as most important in the Nigerian health system. The NGT prioritised: absenteeism, procurement-related corruption, underthe-counter payments, health financing-related corruption, and employment-related corruption. This largely reflected findings from the literature review, except for the greater emphasis on employment-related corruption from the NGT. Absenteeism, Informal payments and employment-related corruption were seen as most feasible to tackle. Frontline workers and policy-makers agreed that tackling corrupt practices requires a range of approaches. Conclusion Corruption is recognized in Nigeria as widespread but often seems insurmountable. We show how a structured approach can achieve consensus among multiple stakeholders, a crucial first step in mobilizing action to address corruption.

Introduction Numerous sub-Saharan African countries have experimented with performance-based financing (PBF) with the goal of improving health system performance. To date, few articles have examined the implementation of this type of complex intervention in Francophone West Africa. This qualitative research aims to understand the process of implementing a PBF pilot project in Mali's Koulikoro region. Method We conducted a contrasted multiple case study of performance in 12 community health centres in three districts. We collected 161 semi-structured interviews, 69 informal interviews and 96 non-participant observation sessions. Data collection and analysis were guided by the Consolidated Framework for Implementation Research adapted to the research topic and local context. Results Our analysis revealed that the internal context of the PBF implementation played a key role in the process. High-performing centres exercised leadership and commitment more strongly than low-performing ones. These two characteristics were associated with taking initiatives to promote PBF implementation and strengthening team spirit. Information regarding the intervention was best appropriated by qualified health professionals. However, the limited duration of the implementation did not allow for the emergence of networks or champions. The enthusiasm initially generated by PBF quickly dissipated, mainly due to delays in the implementation schedule and the payment modalities. Conclusion PBF is a complex intervention in which many actors intervene in diverse contexts. The initial level of performance and the internal and external contexts of primary healthcare facilities influence the implementation of PBF. Future work in this area would benefit from an interdisciplinary approach combining public health and anthropology to better understand such an intervention. The deductive–inductive approach must be the stepping-stone of such a methodological approach.

Nomads and labor migrants constitute a vulnerable group beset with high healthcare costs due to lack of health insurance coverage. Their inability to pay for health care constitutes a threat to their well-being and health risk to the host community as they have higher morbidity from diseases and serve as a reservoir of infective agents. This study investigated how nomads and labor migrants pay and cope with necessary healthcare costs. A cross-sectional study was carried out among 323 migrants in four local government areas of Oyo State, which were selected purposively. A pretested semi-structured questionnaire that sought information on respondents’ sociodemographics, healthcare payment methods and coping strategies were employed. Data were analyzed using descriptive statistics and chi-square test to test the association between categorical variables at P ≤ 0.05. The mean age of the respondents was 34.4 ± 1.4 years and 53.2% were farmers. Of the 200 respondents who had used the formal healthcare system, 13 (6.5%) obtained free services via the National Health Insurance Scheme (NHIS) and 187 (93.2%) paid out of pocket for service. Coping with health bills, 115 (62.2%) paid from savings, 34 (18.4%) borrowed money, and 58 (31.4%) sold property. Those with formal education were more likely to pay through NHIS (χ2 = 9.7, P = 0.002). Nomads/migrants in this study have demonstrated the inability to cope with payment of health bills, suggesting the need to look into the policy on healthcare funding/support to migrants and educationally disadvantaged persons. The creation of prepaid pooled payment systems such as social and community health insurance schemes is suggested.

Introduction This study aimed to evaluate the costs of CRS and HIPEC and treatment of the related postoperative complications in the public healthcare system. We also aimed to identify the risk factors that increase the cost of CRS and HIPEC. Materials and methods We retrospectively evaluated 80 patients who underwent CRS and HIPEC between February 2016 and November 2018 in the Department of Surgery, University Hospital of Olomouc, Czech Republic. Intraoperative factors and postoperative complications were assessed. The treatment cost included the surgery, hospital stay, intensive care unit (ICU) admission, pharmaceutical charges including medication, hospital supplies, pathology, imaging, and allied healthcare services. Results The postoperative morbidity rate was 50%, and the mortality rate was 2.5%. The mean length of hospitalisation and ICU admission was 15.44 ± 8.43 and 6.15 ± 4.12 for all 80 patients and 10.73 ± 2.93 and 3.73 ± 1.32, respectively, for 40 patients without complications, and 20.15 ± 13.93 and 8.58 ± 6.92, respectively, for 40 patients with complications. The total treatment cost reached €606,358, but the total reimbursement was €262,931; thus, the CRS and HIPEC profit margin was €-343,427. Multivariate analysis showed that blood loss ≥1.000 ml (p = 0.03) and grade I–V Clavien-Dindo complications (p Conclusion The Czech public health insurance system does not fully compensate for the costs of CRS and HIPEC. Hospital losses remain the main limiting factor for further improving these procedures. Furthermore, treatment costs increase with increasing severity of postoperative complications.

The healthcare repayment system in America is highly flawed due to several factors such as uncontrolled costs, unequal access, varied reimbursement systems, and complex patient interfaces. In fact, it is rated the worst among the eleven developed nations analyzed in the Commonwealth Fund’s evaluation conducted every three years. We propose a novel three-tiered model for healthcare repayment designed to fulfill the needs of the patients, the providers, the payers and the nation as a whole. We hypothesized that our new plan may spread cost between multiple entities and offer better coverage and access to care. Our model uses a shared-cost approach wherein the total risk expenditure becomes the responsibility of various stakeholders including the government, insurance industry, hospitals, patients, providers as well as the nation’s economy. While there is no perfect solution to healthcare in America, we believe our three-tiered model can create an economically balanced solution to break deadlock between party lines and result in better outcomes and patient care.

BackgroundThe report from the World Health Organization (WHO) reveals that health spending worldwide remains highly unequal as more than 80% of the world’s population live in low and middle-income countries but only account for about 20% of global health expenditure. Another report by the WHO on the state of health financing in Africa published in 2013 intimates that countries that are part of their member states are still on the average level in meeting set goals in financing key health projects. ObjectiveThe study set out to investigate the association between public and private spending and health status for eight selected African countries, namely Burundi, Eritrea, Ethiopia, Kenya, Rwanda, Sudan, Tanzania and Uganda. Health status indicators include the incidence of tuberculosis, mortality rates, maternal deaths and prevalence of HIV. MethodsDescriptive statistics and pairwise correlation are used to assess the relationship between healthcare spending and health status. Random and fixed effect models are further employed to provide insights into the association between descriptive statistics and pairwise correlation. We used annual data from the year 2000 to 2014 obtained from world development indicators.ResultsThe relationship between healthcare spending (public and private) and health status is statistically significant. Public healthcare expenditure has a higher association than private expenditure in reducing the mortality rate, tuberculosis and HIV for the average country in our sample. For example, an increase in public healthcare spending is negatively associated and statistically significant at 5% or better in reducing female mortality, male mortality, tuberculosis and HIV. Private healthcare spending is more impactful in the area of maternal deaths, where it is associated negatively and statistically significant at 1%. An increase in private healthcare spending is linked to a reduction in maternal deaths. We also compared the association between an increase in healthcare spending on males versus females and observed that public health expenditure impacts the health status of both sexes equally, however, private health expenditure provides a greater positive benefit to males. It is worth remembering that two goals of the United Nations agenda on sustainable development are gender equality and ensuring healthcare for all. ConclusionThe findings of this research call for the selected African countries to pay more attention to public healthcare expenditure in order to improve health status, especially since private healthcare which provides access to healthcare facilities for some poor people leads to costs that are a burden. So, future research should focus on analyzing components of private healthcare spending such as direct household out-of-pocket spending, private insurance and direct service payments by private corporations as dependent variables to understand what form of private investment should be encouraged.

Developing a national surgical, obstetric, and anesthesia plan is an important first step for countries to strengthen their surgical systems and improve surgical care. Barriers to successful implementation of these plans include data collection, scalability, and financing, yet surgical system strengthening efforts are gaining momentum in achieving universal access to emergency and essential surgical care.

Lyme disease remains a contested illness in Canada, thereby making the diagnostic and treatment journeys difficult for some people. One outcome of this is that increasing numbers of people are turning to medical crowdfunding to support access to alternative therapies, non-local health care providers and assist with managing the costs of everyday life. In this analysis, we qualitatively explore the narratives shared in Canadians’ crowdfunding campaigns to support Lyme disease treatment or diagnosis to identify whether or not any common elements shared in these narratives exist, and if so, what they are. We identified 238 campaigns for inclusion from three prominent crowdfunding platforms. Thematic analysis of the campaign narratives shows four consistent themes shared in these campaigns: what is lost (e.g. bodily ability), what is missing (e.g. local care options), what is sought (e.g. funds to cover treatment abroad) and what is hoped for (e.g. return to wellbeing). These themes demonstrate the highly personal and emotional nature of medical crowdfunding, particularly in the context of a contested illness that may lead some to question the legitimacy of one’s financial need. This analysis contributes valuable new insights to the nascent scholarship on medical crowdfunding, and particularly to our understanding of how people communicate about their health and bodily needs on this public platform. It also identifies important directions for future research, including the potential for crowdfunding narratives to be used for advocacy.

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.

Introduction Disparities in the healthcare system imply potential risks for vulnerable groups whose needs are not appropriately met. Total joint arthroplasty (TJA) is successful in treating end-stage arthritis, resulting in increased demand for the procedure, however remains underused in both sexes, especially in women. Although multiple studies assessed the differences in postoperative morbidities between sexes, there remains a lack in understanding patients' preoperative clinical profile and nonclinical demographics. The aim of this study is to provide a population-based epidemiologic assessment of preoperative risk factors and sex disparities and assess differences in outcomes following TJA. Methods The National Inpatient Sample database from 2006 to 2011 was analyzed. Patients who underwent primary total knee and hip arthroplasty were identified and stratified into two cohorts of male and female, and demographic data and comorbidities were collected. Postoperative complications, length of stay, total charges, and discharge destination were measured for matched cohorts. Results Female patients present for TJAs at an older average age, are less likely to present with AIDS, alcohol abuse, coagulopathy, congestive heart failure, drug abuse, liver disease, peripheral vascular disease, and renal failure, and are more likely to present with anemia, autoimmune disorders, chronic obstructive pulmonary disease, depression, obesity, and valvular disease. Postoperatively, the average length of stay for female patients was markedly higher (3.52 versus 3.39) and a lower percentage went home (59% versus 73%). Overall, female patients experience greater odds of any complication while in-patient. Discussion This study highlighted sex differences in areas that could account for the underuse of the procedure in both sexes, with women affected to a greater extent. Understanding these factors will help address the unmet needs of both sexes after TJA by encouraging future studies and provider education to ensure that all patients are able to access the necessary procedures for pain relief and functional improvement.

INTRODUCTION AND AIMS Governments across the globe invest considerable amounts in funding alcohol and other drug (AOD) treatment. Little attention however has been paid to the ways AOD service providers are chosen and how they are paid. This study sought to examine the perceptions of Australian AOD treatment purchasers and providers regarding different purchasing and payment mechanisms. DESIGN AND METHODS Qualitative interviews with AOD treatment providers and purchasers (N = 197) were undertaken across the eight Australian states/territories and the Commonwealth. Data were collated against six main AOD treatment purchasing and payment mechanisms (as identified in the literature), then an inductive, comparative analysis to assign codes was conducted, followed by interpretive analysis to explore emergent themes. RESULTS Five main themes were identified in relation to AOD treatment payment and purchasing mechanisms: (i) applying private sector principles to purchasing; (ii) innovation, sector stability and addressing client needs; (iii) performance monitoring and measuring outcomes; (iv) the threat to designated funding for AOD treatment; and (v) the costs and benefits of having multiple funding sources. DISCUSSION AND CONCLUSIONS In many countries reforms are taking place in the health sector consistent with New Public Management principles. These principles, when applied to AOD treatment, have included introducing competition, output and outcomes-based funding models, standards and accountability. Purchaser and providers identified both strengths and weaknesses and highlighted the overarching concern that implementation of any (mix) of these mechanisms should always be underpinned by a client-centred and not a finance-centred approach.

The uptake and implementation of universal health coverage (UHC) is primarily a political, rather than a technical, exercise, with contested ideas and diverse stakeholders capable of facilitation or resistance—even veto—of the policy uptake. This narrative systematic review, undertaken in 2018, sought to identify all peer-reviewed publications dealing with concepts relating to UHC through a political economy framing. Of the 627 papers originally identified, 55 papers were directly relevant, with an additional eight papers added manually on referral from colleagues. The thematic analysis adapted Fox and Reich’s framework of ideas and ideologies, interests and institutions to organize the analysis. The results identified a literature strong in its exploration of the ideologies and ideas that underpin UHC, but with an apparent bias in authorship towards more rights-based, left-leaning perspectives. Despite this, political economy analyses of country case studies suggested a more diverse political framing for UHC, with the interests and institutions engaged in implementation drawing on pragmatic and market-based mechanisms to achieve outcomes. Case studies offered limited detail on the role played by specific interests, though the influence of global development trends was evident, as was the role of donor organizations. Most country case studies, however, framed the development of UHC within a narrative of national ownership, with steps in implementation often critical political milestones. The development of institutions for UHC implementation was predicated largely on available infrastructure, with elements of that infrastructure—federal systems, user fees, pre-existing insurance schemes—needing to be accommodated in the incremental progress towards UHC. The need for technical competence to deliver ideological promises was underlined. The review concludes that, despite the disparate sources for the analyses, there is an emerging shared narrative in the growing literature around the political economy of UHC that offers an increasing awareness of the political dimensions to UHC uptake and implementation.

Background: Performance-based financing (PBF) is promoted to improve the quality and quantity of healthcare services in low-income countries. Despite the complexity of the intervention, little attention has been given to studying its unintended consequences. Our objective is to increase evidence on the unintended consequences of PBF in Burkina Faso. Methods: Using the diffusion of innovations theory, we conducted a multiple case study. The cases were 6 healthcare facilities in two districts. Between April 2015 and 2016, we collected data through 101 semi-structured interviews, discussions, observations, and documents. We conducted thematic analysis using a hybrid deductive-inductive approach. Secondary data was used to illustrate the evolution of reported services. We conducted a cross-case synthesis to identify the results arising independently from more than 1 case. Results: A desirable unintended consequence of PBF was that 3 facilities limited the sale of non-prescribed medication to encourage patients to consult. Undesirable unintended consequences were found in the majority of facilities including fixation on measures rather than on underlying objectives, the pursuit of narrow and less relevant performance indicators, gaming, and teaching trainees improper practices. Providers in all facilities deliberately manipulated medical registers and documents, such that the reported quantity and quality of care differed from what was actually delivered. While most participants indicated that PBF was more advantageous than previous practices, the long payment delays were a source of dissatisfaction and demotivation across all facilities. Dissatisfaction also emerged in relation to the distribution of subsidies and the non-attribution of quality points for services delivered by certain staff considered "unqualified" in guidelines. Results in many facilities revealed suboptimal planning, a perception of the intervention as "budgetivorous," as well as tensions related to the principle of managerial autonomy. Conclusion: PBF led to numerous unintended consequences that could undermine the intervention’s effectiveness. The findings contribute to a more comprehensive picture of the consequences of implementing PBF. Policy-makers can use the results of this study to devise effective strategies before, during and after the implementation of the intervention to minimize undesirable unintended consequences and promote desirable ones.

AR-DRG system for classification hospital episodes was implemented in Serbia to improve efficiency and transparency in the health system.L3H3, IQR, and 10th-95th percentile methods were used to identify outlier episodes in the classification. Classification efficiency and within-group homogeneity were measured by an adjusted reduction in variance (R2) and a coefficient of variation (CV).There were 246,131 hospital episodes with a total 1,651,913 bed days from 14 hospitals. All episodes were classified into 652 groups of which 441 had CV lower than 100%. "Medical groups" accounted for 51% of groups and for 72% of episodes. Chemotherapy and vaginal delivery were the highest volume groups, with 5% and 4% of total episodes. Major diagnostic category 6 (MDC 6, Diseases of the digestive system) was the highest volume MDC, accounting for 11% of episodes. "Day-cases" and "prolonged hospitalisation" accounted for 21% and 3% of episodes, respectively. The average length of stay varied from 5.6 to 8.2 days. Adjusted R2 was 0.3 for untrimmed data. Trimming by L3H3, IQR, and 10th-95th percentile method improved the value of adjusted R2 to 0.61, 0.49, and 0.51, identifying 24%, 7%, and 7% of total cases as outliers, respectively. Mental diseases (MDC 19) remained the lowest adjusted R2 in untrimmed and trimmed datasets.A long length of stay and a small percentage of "day-cases" characterized hospital activity in Vojvodina. Trimming methods significantly improved DRG efficiency. Future studies should consider cost data.Klasifikacijski sistem hospitalizacij AR-DRG je bil v Srbiji vpeljan za izboljšanje učinkovitosti in preglednosti zdravstvenega sistema.Za prepoznavanje odstopanj v klasifikaciji so bile uporabljene metode L3H3, IQR, in 10.-95. percentila. Učinkovitost klasifikacije in homogenosti znotraj skupine primerljivih primerov diagnoz sta bili izmerjeni s prilagojenim zmanjšanjem neskladij (R2) in koeficientom razlik (CV).Zabeleženih je bilo 246.131 hospitalizacij s skupnim številom 1.651.913 preležanih dni v 14 bolnišnicah. Vse hospitalizacije so bile razvrščene v 652 skupin, od tega jih je imelo 441 vrednost CV nižjo od 100 %. »Kliničnih skupin« je bilo 51 % od vseh skupin in 72 % od vseh hospitalizacij. Kemoterapija in vaginalni porod sta po obsegu največji skupini s 5 % in 4 % vseh hospitalizacij. Skupina primerljivih primerov diagnoz 6 (MDC 6, bolezni prebavnega sistema) je največja, in sicer zavzema 11 % vseh hospitalizacij. »Dnevne obravnave« obsegajo 22 % in »podaljšane hospitalizacije« 3 % hospitalizacij. Povprečno trajanje hospitalizacije se giblje med 5,6 in 8,2 dni. Prilagojeni R2 se obravnava za 0,3 neprirezanih podatkov. Aplikacija metod L3H3, IQR, in 10.-95. percentila je izboljšala vrednost prilagojenega R2 na 0,61, 0,49 in 0,51, esktremne vrednosti so se pojavljale v 24 %, 7 % in 7 % vseh primerov. Duševne bolezni (MDC 19) imajo najnižji prilagojen R2 v neprirezanih in prirezanih podatkovnih setih.Bolnišnično dejavnost v Vojvodini označuje dolgotrajna hospitalizacija in nizek delež dnevnih obravnav. Metode prirezovanja so opazno izboljšale učinkovitost DRG. Prihodnje raziskave naj vključijo še stroškovni vidik.

Effectively responding to global health emergencies requires substantial financial commitment from many stakeholders, including governments, multilateral agencies, and nongovernmental organizations. A major current policy challenge needs attention: how to better coordinate investment among actors aiming to address a common problem, disease outbreaks. For donors who commit colossal sums of money to outbreak response, the current model is neither efficient nor transparent. Innovative approaches to coordinate financing have recently been tested as part of a broader development agenda for humanitarian response. Adopting a system that enables donors to invest in disease outbreaks rather than actors represents an opportunity to deliver a more cost-effective, transparent, and unified global response to infectious disease outbreaks. Achieving this will be challenging, but the World Health Organization (WHO) must play a vital role. New thinking is required to improve emergency response in an increasingly crowded and financially convoluted global health arena.

Performance-based financing (PBF) is being implemented across low- and middle-income countries to improve the availability and quality of health services, including medicines. Although a few studies have examined the effects of PBF on the availability of essential medicines (EMs) in low- and middle-income countries, there is limited knowledge of the mechanisms underlying these effects. Our research aimed to explore how PBF in Cameroon influenced the availability of EMs, and to understand the pathways leading to the experiential dimension related with the observed changes. The design was an exploratory qualitative study. Data were collected through in-depth interviews, using semi-structured questionnaires. Key informants were selected using purposive sampling. The respondents (n = 55) included health services managers, healthcare providers, health authorities, regional drugs store managers and community members. All interviews were recorded, transcribed and analysed using qualitative data analysis software. Thematic analysis was performed. Our findings suggest that the PBF programme improved the perceived availability of EMs in three regions in Cameroon. The change in availability of EMs experienced by stakeholders resulted from several pathways, including the greater autonomy of facilities, the enforced regulation from the district medical team, the greater accountability of the pharmacy attendant and supply system liberalization. However, a sequence of challenges, including delays in PBF payments, limited autonomy, lack of leadership and contextual factors such as remoteness or difficulty in access, was perceived to hinder the capacity to yield optimal changes, resulting in heterogeneity in performance between health facilities. The participants raised concerns regarding the quality control of drugs, the inequalities between facilities and the fragmentation of the drug management system. The study highlights that some specific dimensions of PBF, such as pharmacy autonomy and the liberalization of drugs supply systems, need to be supported by equity interventions, reinforced regulation and measures to ensure the quality of drugs at all levels.

The main aim of this work was to identify and present the situation and changes in the level of expenditure on healthcare in the European Union in the years 2013–2017. This involved an analysis of the available literature on healthcare financing, data from the EUROSTAT database. For this work, the comparative method was used, dynamics indicators were used, the Gini concentration coefficient was calculated, and the degree of concentration was presented using the Lorenz curve. Pearson’s linear correlation coefficients were also used. A descriptive, tabular and graphic method was used to present the test results that were obtained. A high concentration of expenditure on healthcare was found in the EU countries with the largest population and that are the most economically developed. These results also relate to these expenses on a per capita basis. The main factor differentiating the level of healthcare financing was the level of economic development. This regularity was confirmed in the statement of expenditure per capita, the relationship between this expenditure and the value of GDP and the results obtained when calculating the correlation between expenditure and economic development. In addition to the economic situation, an important factor determining the amount of expenditure on healthcare was the percentage of the country’s population that are older people.

Summary In the transition to the post-2015 agenda, many countries are striving towards universal health coverage (UHC). Achieving this, governments need to shift from curative care to promotion and prevention services. This research analyses Thailand's financing system for health promotion and prevention, and assesses policy options for health financing reforms. The study employed a mixed-methods approach and integrates multiple sources of evidence, including scientific and grey literature, expenditure data, and semi-structured interviews with key stakeholders in Thailand. The analysis was underpinned by the use of a well-known health financing framework. In Thailand, three agencies plus local governments share major funding roles for health promotion and prevention services: the Ministry of Public Health (MOPH), the National Health Security Office, the Thai Health Promotion Foundation and Tambon Health Insurance Funds. The total expenditure on prevention and public health in 2010 was 10.8% of the total health expenditure, greater than many middle-income countries that average 7.0–9.2%. MOPH was the largest contributor at 32.9%, the Universal Coverage scheme was the second at 23.1%, followed by the local governments and ThaiHealth at 22.8 and 7.3%, respectively. Thailand's health financing system for promotion and prevention is strategic and innovative due to the three complementary mechanisms in operation. There are several methodological limitations to determine the adequate level of spending. The health financing reforms in Thailand could usefully inform policymakers on ways to increase spending on promotion and prevention. Further comparative policy research is needed to generate evidence to support efforts towards UHC.

Background In the nearly half century since it began lending for population projects, the World Bank has become one of the largest financiers of global health projects and programs, a powerful voice in shaping health agendas in global governance spaces, and a mass producer of evidentiary knowledge for its preferred global health interventions. How can social scientists interrogate the role of the World Bank in shaping ‘global health’ in the current era? Main body As a group of historians, social scientists, and public health officials with experience studying the effects of the institution’s investment in health, we identify three challenges to this research. First, a future research agenda requires recognizing that the Bank is not a monolith, but rather has distinct inter-organizational groups that have shaped investment and discourse in complicated, and sometimes contradictory, ways. Second, we must consider how its influence on health policy and investment has changed significantly over time. Third, we must analyze its modes of engagement with other institutions within the global health landscape, and with the private sector. The unique relationships between Bank entities and countries that shape health policy, and the Bank’s position as a center of research, permit it to have a formative influence on health economics as applied to international development. Addressing these challenges, we propose a future research agenda for the Bank’s influence on global health through three overlapping objects of and domains for study: knowledge-based (shaping health policy knowledge), governance-based (shaping health governance), and finance-based (shaping health financing). We provide a review of case studies in each of these categories to inform this research agenda. Conclusions As the COVID-19 pandemic continues to rage, and as state and non-state actors work to build more inclusive and robust health systems around the world, it is more important than ever to consider how to best document and analyze the impacts of Bank’s financial and technical investments in the Global South.

The major concern of the study is on healthcare financing and health outcomes in the major oil-producing countries in Africa. We used the data sorted from World Development Indicators (WDI) to identify the effect of four different health expenditures on the rate of mortalities on maternal, under-five, infant, neonatal and life expectancy at birth through random and fixed-effect models. This paper also takes cognizance of the environmental variable (pollution) that is common to the top 10 oil-producing countries in Africa. Our findings showed that high health expenditure from government, private and external sources improved health outcomes, while health expenditure from out of pocket is detrimental to health outcomes. Also, the environmental variable has a negative impact on life expectancy. The outcome of the paper indicated that there is a need to reduce environmental pollution, increase health expenditure from government, private, external sources and reduce out of pocket payments in the selected areas.

Health financing policies are critical policy instruments to achieve Universal Health Coverage, and they constitute a key area in policy analysis literature for the health policy and systems research (HPSR) field. Previous reviews have shown that analyses of policy change in low- and middle-income countries are under-theorised. This study aims to explore which theories and conceptual frameworks have been used in research on policy processes of health financing policy in sub-Saharan Africa and to identify challenges and lessons learned from their use. We conducted a scoping review of literature published in English and French between 2000 and 2017. We analysed 23 papers selected as studies of health financing policies in sub-Saharan African countries using policy process or health policy-related theory or conceptual framework ex ante. Theories and frameworks used alone were from political science (35%), economics (9%) and HPSR field (17%). Thirty-five per cent of authors adopted a ‘do-it-yourself’ (bricolage) approach combining theories and frameworks from within political science or between political science and HPSR. Kingdon’s multiple streams theory (22%), Grindle and Thomas’ arenas of conflict (26%) and Walt and Gilson’s policy triangle (30%) were the most used. Authors select theories for their empirical relevance, methodological rational (e.g. comparison), availability of examples in literature, accessibility and consensus. Authors cite few operational and analytical challenges in using theory. The hybridisation, diversification and expansion of mid-range policy theories and conceptual frameworks used deductively in health financing policy reform research are issues for HPSR to consider. We make three recommendations for researchers in the HPSR field. Future research on health financing policy change processes in sub-Saharan Africa should include reflection on learning and challenges for using policy theories and frameworks in the context of HPSR.

RESUMO Este estudo revisou sistematicamente a literatura sobre ‘necessidades em(de) saúde’. Tratou-se de uma revisão integrativa utilizando o portal Biblioteca Virtual em Saúde. Português, espanhol e inglês foram os idiomas utilizados e recuperaram-se apenas os textos completos e com foco específico no Sistema Único de Saúde. Totalizaram-se 17 artigos incluídos, dos quais 88,8% estavam indexados na base Literatura Latino-Americana e do Caribe em Ciências da Saúde. Há uma variada forma de apropriação das ‘necessidades em(de) saúde’, termo cuja definição não é bem delimitada pelos autores, direcionando- o a três núcleos de sentido: ‘direito social constituído’, ‘conjunto articulado da efetividade dos direitos sociais’ e ‘ajuste entre as condições de vida e trabalho com a diversidade inerente às coletividades’. Diversas implicações para o Sistema Único de Saúde foram apresentadas e puderam ser compiladas em sete blocos: ‘capitalismo e sua crise’, ‘financiamento’, ‘características da formação social brasileira’, ‘problemas da gestão pública na saúde’, ‘mescla público-privado’, ‘problemas terminológicos’ e ‘escassez de recursos’. Por fim, os principais desafios da aplicação das necessidades no Sistema Único de Saúde transitam entre o simbólico, o crítico-político, a coerência entre financiamento-princípios, o Estado, a política macroeconômica, a gestão e as ações locais. Investir na superação dos desafios elencados pode ser um guia para a efetivação das necessidades como o centro da ação sanitária. ABSTRACT This study reviewed systematically the literature on ‘needs in health/health needs’. This was an integrative review using the Virtual Health Library portal. Portuguese, English and Spanish were the languages used and only the full texts were recovered with a specific focus on the Unified Health System. A total of 17 articles were included, of which 88.8% were indexed in the Latin American and Caribbean Health Sciences database. There is a varied form of appropriation of the theme ‘needs in health/health needs’, a very broad concept whose definition is not well delimited by the authors, directing it to three nuclei of meaning: ‘constituted social right’, ‘articulated set of the effectiveness of social rights’ and ‘adjustment between living and working conditions with the inherent diversity of collectivities’. Several implications for the Unified Health System were presented and could be compiled in seven blocks: ‘capitalism and its crisis’, ‘financing’, ‘characteristics of the Brazilian social formation’, ‘problems of public health management’, ‘public-private mix’, ‘terminological problems’ and ‘scarcity of resources’. Finally, the main challenges of applying the needs in the Unified Health System move between the symbolic, the critical-political, the coherence between financing-principles, the State, macroeconomic policy, management and local actions. Investing in overcoming the challenges listed can be a guide in realizing needs as the center of health action.

Resumo À luz da análise comparada de sistemas de saúde (SS), discutimos três fenômenos estratégicos para a universalização do SUS: a) os gastos tributários em saúde; b) o financiamento estatal de planos privados de servidores públicos; c) a demanda sindical por planos privados. Dentre os tipos-ideais de SS, o SUS é universal na lei, mas híbrido na prática: beveridgeano na atenção primária à saúde (APS) e misto no cuidado especializado/hospitalar; sem ser universal na realidade (gastos públicos são só 43% dos gastos totais em saúde). Há grande subsídio estatal ao setor privado, via gastos tributários em saúde (30% do orçamento federal na saúde) e financiamento de planos privados para servidores públicos, o que gera incoerência, segmentação do sistema de saúde e iniquidades. Apesar do apoio genérico ao SUS, os movimentos sindicais vem usando planos de saúde na contratação coletiva (76% deles), reforçando o setor privado. A redução dos gastos tributários em saúde - incluindo o financiamento estatal dos planos privados de servidores - aumentaria significativamente o orçamento do SUS e facilitaria a articulação entre sanitaristas e sindicalistas, aproximando a grande força dos sindicatos da longa luta pela universalidade do SUS e da APS. Abstract In the light of the comparative analysis of health systems, we discuss three strategic phenomena for the SUS universalization, as follows: a) health tax expenditures; b) State funding of private plans for public servants; and c) trade union’s demand for private health plans. Among the ideal types of health systems, SUS is universal in law, but hybrid in practice: Beveridgian in primary health care (PHC) and mixed in specialized/hospital care; without really being universal (public spending is only 43% of total health expenditure). There is a massive state subsidy to the private sector, through health tax expenditures (30% of the federal health budget) and financing of private plans for public servants, which generates incoherence, segmentation of the health system and inequities. Despite the general support to the SUS, the union movements have been using private health plans in collective recruitment (76% of them), reinforcing the private sector. Reducing health tax expenditures - including state funding of servants’ private plans - would significantly increase the SUS budget and facilitate articulation between health workers and trade unionists, bringing the high strength of unions closer to the long struggle for the universality of the SUS and PHC.

Universal health coverage (UHC) means that all people can access health services of good quality without experiencing financial hardship. Three health financing functions - revenue raising, pooling of funds and purchasing health services - are vital for UHC. This article focuses on pooling: the accumulation and management of prepaid financial resources. Pooling creates opportunities for redistribution of resources to support equitable access to needed services and greater financial protection even if additional revenues for UHC cannot be raised. However, in many countries pooling arrangements are very fragmented, which create barriers to redistribution. The purpose of this article is to provide an overview of pooling reform options to support countries who are exploring ways to enhance redistribution of funds. We outline four broad types of pooling reforms and discuss their potential and challenges in addressing fragmentation of health financing: (i) shifting to compulsory or automatic coverage for everybody; (ii) merging different pools to increase the number of pool members and the diversity of pool members' health needs and risks; (iii) cross-subsidization of pools that have members with lower revenues and higher health risks; and (iv) harmonization across pools, such as benefits, payment methods and rates. Countries can combine several reform elements. Whether the potential for redistribution is actually realized through a pooling reform also depends on the alignment of the pooling structure with revenue raising and purchasing arrangements. Finally, the scope for reform is constrained by institutional and political feasibility, and the political economy around pooling reforms needs to be anticipated and managed.La couverture sanitaire universelle (CSU) consiste à ce que l'ensemble de la population ait accès à des services de santé de qualité sans encourir de difficultés financières. Pour cela, trois fonctions de financement de la santé sont essentielles: le recouvrement des recettes, la mise en commun des fonds et l'achat de services de santé. Cet article s'intéresse à la mise en commun, à savoir le recueil et la gestion de ressources financières prépayées. La mise en commun permet de redistribuer les ressources afin d'offrir un accès équitable aux services nécessaires et d'améliorer la protection financière même en cas d'impossibilité de lever des recettes supplémentaires pour la CSU. Or, dans de nombreux pays, les mécanismes de mise en commun sont très fragmentés, ce qui fait obstacle à la redistribution. Cet article entend donner un aperçu des possibilités de réforme en ce qui concerne la mise en commun afin d'aider les pays qui cherchent à améliorer la redistribution des fonds. Nous présentons quatre grands types de réforme concernant la mise en commun et analysons le potentiel ainsi que les difficultés qu'ils présentent pour mettre un terme à la fragmentation du financement de la santé: (i) passage à une couverture obligatoire ou automatique pour tout le monde; (ii) fusion de différentes caisses afin d'augmenter le nombre de membres d'une même caisse ainsi que la diversité de leurs besoins et de leurs risques; (iii) interfinancement des caisses dont les membres ont des revenus faibles et des risques élevés en matière de santé; et (iv) harmonisation entre les caisses concernant, par exemple, les avantages, les modes de paiement et les tarifs. Les pays peuvent combiner plusieurs éléments de réforme. La réalisation du potentiel de redistribution grâce à une réforme de la mise en commun dépend aussi de l'alignement de la structure de mise en commun sur le recouvrement des recettes et les mécanismes d'achat. Enfin, l'étendue de la réforme est limitée par la faisabilité institutionnelle et politique, et l'économie politique relative à cette réforme de la mise en commun doit être anticipée et gérée.La cobertura sanitaria universal (CSU) significa que todas las personas pueden acceder a servicios de salud de buena calidad sin experimentar dificultades financieras. Hay tres funciones de financiamiento de la salud que son fundamentales para la CSU: la recaudación de ingresos, la mancomunación de fondos y la compra de servicios de salud. Este artículo se centra en la mancomunación: la acumulación y gestión de recursos financieros prepagados. La mancomunación crea oportunidades para la redistribución de recursos que apoyan el acceso equitativo a los servicios necesarios y una mayor protección financiera, incluso si no se pueden recaudar ingresos adicionales para la CSU. Sin embargo, en muchos países los acuerdos de mancomunación están muy fragmentados, lo que crea barreras a la redistribución. El propósito de este artículo es proporcionar una visión general de las opciones de reforma de la mancomunación para apoyar a los países que están explorando formas de mejorar la redistribución de los fondos. Se describen cuatro grandes tipos de reformas de mancomunación y se discuten sus potencialidades y desafíos para abordar la fragmentación del financiamiento de la salud: (i) pasar a una cobertura obligatoria o automática para todos; (ii) fusionar diferentes fondos para aumentar el número de miembros del fondo y la diversidad de las necesidades y riesgos de salud de los miembros del mismo; (iii) subvención cruzada de fondos que tienen miembros con menores ingresos y mayores riesgos para la salud; y (iv) armonización entre los fondos, tales como beneficios, métodos de pago y tarifas. Los países pueden combinar varios elementos de reforma. La realización efectiva del potencial de redistribución mediante una reforma de la mancomunación depende también de la alineación de la estructura de la mancomunación con los acuerdos de recaudación de ingresos y compra. Por último, el alcance de la reforma se ve limitado por la viabilidad institucional y política, y es preciso anticipar y gestionar la economía política en torno a la reforma de la mancomunación.تعني التغطية الصحية الشاملة (UHC) أنه يمكن لجميع الأشخاص الحصول على الخدمات الصحية ذات الجودة الجيدة دون مواجهة أزمات مالية. هناك ثلاث وظائف للتمويل الصحي، تعد من الجوانب الحيوية للتغطية الصحية الشاملة، ألا وهي جمع الإيرادات، وتجميع الأموال، وشراء الخدمات الصحية. يركز هذا المقال على التجميع: وهو يعني تجميع الموارد المالية المدفوعة مقدماً وإدارتها. ويؤدي التجميع إلى خلق فرص لإعادة توزيع الموارد لدعم إمكانية الحصول على الخدمات المطلوبة بشكل عادل، مع حماية مالية أكبر حتى لو لم يكن بالإمكان جمع إيرادات إضافية للتغطية الصحية الشاملة. ومع ذلك، فإنه في العديد من البلدان تكون ترتيبات التجميع مجزأة للغاية، وهو ما يؤدي لخلق حواجز في مواجهة إعادة التوزيع. الغرض من هذا المقال هو تقديم نظرة عامة حول خيارات الإصلاح في التجميع، بهدف دعم البلدان التي تستكشف طرقاً لتحسين إعادة توزيع الأموال. سوف نوضح أربعة أنواع عامة لإصلاح التجميع، ونناقش إمكانياتها والتحديات التي تواجه التعامل مع تجزئة التمويل الصحي: (1) التحول إلى التغطية الإجبارية أو التلقائية للجميع؛ و(2) دمج وسائل التجميع المختلفة لزيادة عدد أعضاء هذه الوسائل، وكذلك زيادة التنوع في الاحتياجات والمخاطر الصحية لدى أعضاء التجمع؛ و (3) الدعم المتبادل بين وسائل التجميع التي بها أعضاء من ذوي الإيرادات الأقل والمخاطر الصحية الأعلى؛ و (4) التنسيق بين وسائل التجميع، مثل المزايا وطرق الدفع والمعدلات. يمكن للبلدان الجمع بين عدة عناصر للإصلاح. إن إدراك وجود إمكانية لإعادة التوزيع تتحقق بالفعل من خلال إصلاح التجميع، إنما يعتمد أيضاً على التنسيق بين نظام التجميع، وترتيبات جمع الإيرادات والشراء. وفي النهاية، فإن نطاق الإصلاح يتقيد بالجدوى المؤسسية والسياسية، كما أن الاقتصاد السياسي المرتبط بإصلاح التجميع يحتاج إلى التوقع والإدارة.全民健康覆盖 (UHC) 意味着所有人都可以享受优质医疗服务，同时不会遇到财务困难。三项医疗融资职能——提高收入、统筹资金和购买医疗服务——对于 UHC 至关重要。本文着重于统筹：积累和管理预付资金。统筹能够创造资源再分配的机会，有助于人人都能公平地享有所需的服务并且得到更大的财务保障。即使无法为 UHC 增加收入，依然会有保障。然而，在许多国家中，统筹安排非常分散，从而对再分配造成阻碍。本文的目的旨在简要概述统筹改革方案，以支持正在探索加强资金再分配方法的国家。我们概述四种类型的统筹改革并讨论其潜力以及在解决医疗融资分散问题时遇到的挑战：(i) 转为强制性或自主性全民覆盖；(ii) 合并不同的统筹方案以增加参保会员人数，同时提升参保会员的医疗需求和风险多样性；(iii) 对于收入较低和健康风险较高的会员参加的统筹方案进行交叉补贴；(iv) 协调各种统筹方案，例如福利、支付方式和费率。各国可以结合多种改革要素。是否能够真正通过统筹改革发挥再分配的潜力还取决于协调统筹结构与提高收入和购买安排。最后，改革的范围因体制和政治上的可行性而受到限制,需要围绕统筹改革进行政治经济学方面的预测和管理。.Всеобщий охват услугами здравоохранения (ВОУЗ) означает, что все люди могут получить доступ к качественным медицинским услугам, не испытывая финансовых трудностей. Три функции финансирования здравоохранения (сбор доходов, объединение средств и приобретение медицинских услуг) жизненно необходимы для достижения всеобщего охвата услугами здравоохранения. Данная статья посвящена вопросу объединения средств — накоплению предоплаченных финансовых ресурсов и управлению ими. Объединение средств создает возможность перераспределения ресурсов для обеспечения равноправного доступа к необходимым услугам и дополнительной финансовой защиты, даже если дополнительные доходы для достижения всеобщего охвата услугами здравоохранения не могут быть собраны. Однако во многих странах механизмы объединения средств часто разрознены, что создает барьеры для перераспределения. Цель данной статьи — предоставить обзор вариантов реформы объединения средств с целью оказания поддержки странам, которые ищут возможности совершенствования механизмов перераспределения средств. Авторы выделяют четыре основных типа реформ объединения средств и обсуждают их потенциальные возможности и трудности в решении проблемы разрозненности финансирования здравоохранения: (i) переход на обязательный или автоматический охват услугами для всех категорий населения; (ii) объединение различных финансовых ресурсов для увеличения количества участников пула средств и разнообразия потребностей и рисков для здоровья среди участников пула; (iii) перекрестное субсидирование пулов, участники которых имеют более низкие доходы и более высокие риски для здоровья; (iv) согласование льгот, способов оплаты и ставок во всей системе пулов средств. Страны могут объединять несколько элементов реформ. Реализация потенциальных возможностей перераспределения финансовых средств в результате реформы объединения средств также зависит от согласования структуры пула с механизмами сбора доходов и закупок. Необходимо отметить, что масштабы реформы ограничены институциональными и политическими возможностями, а политико-экономическая ситуация вокруг реформы объединения средств должна быть прогнозируемой и управляемой.

The role of trust funds in the practice of and the policy discourse on the sustainable financing for health and HIV is growing. However, there is a paucity of political analyses on implementing trust fund arrangements. Drawing on a novel meta-framework - connecting multiple streams and advocacy coalition frameworks to policy cycle models of analysis - to politically analyse HIV financing policy design, adoption and implementation as well as insights from public finance literature, this article critically analyses the politics of the AIDS Trust Fund (ATF) in Uganda. We find that politics was the most fundamental driver for the establishment of the ATF. Whereas HIV financing is inherently both technical and political, enacting the ATF was largely a geopolitical positioning policy instrument that entailed navigating political economy challenges in managing multiple stakeholder groups' politics. With the mandated tax revenues earmarked to capitalise the ATF covering only 0.5% of the annual resource needs, we find a very insignificant potential to contribute to financial sustainability of the national HIV response per se. As good ideas and evidence alone often do not necessarily produce desired results, we conclude that systematic and continuous political analysis can bring meaningful insights to our understanding of political economy dimensions of the ATF as an innovative financing policy instrument, thereby helping drive technically sound health financing policy proposals into practice more effectively. For Uganda, while proponents have invested a considerable amount of hope in the ATF as a source of sustainable domestic funding for the HIV response, substantial work remains to be done to address a number of questions that continue to beguile the current ATF architecture. Regarding global health financing policy, the findings suggest the need to pay attention to the position, power and interests of stakeholders as a powerful lever in health financing policy reforms.

Background The World Health Organization states there are three interrelated domains that are fundamental to achieving and maintaining universal access to care - raising sufficient funds for health care, reducing financial barriers to access by pooling funds in a way that prevents out-of-pocket costs, and allocating funds in a way that promotes quality, efficiency and equity. In Australia, a comprehensive account of the mechanisms for financing the health system have not been synthesised elsewhere. Therefore, to understand how the maternal health system is financed, this review aims to examine the mechanisms for funding, pooling and purchasing maternal health care and the influence these financing mechanisms have on the delivery of maternal health services in Australia. Methods We conducted a scoping review and interpretative synthesis of the financing mechanisms and their impact on Australia’s maternal health system. Due to the nature of the study question, the review had a major focus on grey literature. The search was undertaken in three stages including; searching (1) Google search engine (2) targeted websites and (3) academic databases. Executive summaries and table of contents were screened for grey literature documents and Titles and Abstracts were screened for journal articles. Screening of publications’ full-text followed. Data relating to either funding, pooling, or purchasing of maternal health care were extracted for synthesis. Results A total of 69 manuscripts were included in the synthesis, with 52 of those from the Google search engine and targeted website (grey literature) search. A total of 17 articles we included in the synthesis from the database search. Conclusion Our study provides a critical review of the mechanisms by which revenues are raised, funds are pooled and their impact on the way health care services are purchased for mothers and babies in Australia. Australia’s maternal health system is financed via both public and private sources, which consequentially creates a two-tiered system. Mothers who can afford private health insurance – typically wealthier, urban and non-First Nations women - therefore receive additional benefits of private care, which further exacerbates inequity between these groups of mothers and babies. The increasing out of pocket costs associated with obstetric care may create a financial burden for women to access necessary care or it may cause them to skip care altogether if the costs are too great.

Zambia has been using output-based approaches for over two decades to finance whole or part of the public health system. Between 1996 and 2006, performance-based contracting (PBC) was implemented countrywide with the Central Board of Health (CBoH) as the provider of health services. This study reviews the association between PBC and equity of access to maternal health services in Zambia between 1996 and 2006. A comprehensive document review was undertaken to evaluate the implementation process, followed by a trend analysis of health expenditure at district level, and a segmented regression analysis of data on antenatal care (ANC) and deliveries at health facilities that was obtained from five demographic and health survey datasets (1992, 1996, 2002, 2007 and 2014). The results show that PBC was anchored by high-level political support, an overarching policy and legal framework, and collective planning and implementation with all key stakeholders. Decentralization of health service provision was also an enabling factor. ANC coverage increased in both the lower and upper wealth quintiles during the PBC era, followed by a declining trend after the PBC era in both quintiles. Further, the percentage of women delivering at health facilities increased during the PBC era, particularly in rural areas and among the poor. The positive trend continued after the PBC era with similar patterns in both lower and upper wealth quintiles. Despite these gains, per capita health expenditure at district level declined during the PBC era, with the situation worsening after the PBC era. The study concludes that a nationwide PBC approach can contribute to improved equity of access to maternal health services and that PBC is a cost-efficient and sustainable policy reform. The study calls for policymakers to comprehensively evaluate the impact of health system reforms before terminating them.

Collective financing, in the form of either public domestic revenues or pooled donor funding, at the country level is necessary to finance common goods for health, which are population-based functions or interventions that contribute to health and have the characteristics of public goods. Financing of common goods for health is an important part of policy efforts to move towards Universal Health Coverage (UHC). This paper builds from country experiences and budget documents to provide an evidence-based argument about how government and donor financing can be reorganized to enable more efficient delivery of common goods for health. Issues related to fragmentation of financing-within the health sector, across sectors, and across levels of government-emerge as key constraints. Effectively addressing fragmentation issues requires: (i) pooling funding and consolidating governance structures to repackage functions across programs; (ii) aligning budgets with efficient delivery strategies to enable intersectoral approaches and related accountability structures; and (iii) coordinating and incentivizing investments across levels of government. This policy response is both technical in nature and also highly political as it requires realigning budgets and organizational structures.

West Africa’s Ebola epidemic of 2014–2016 exposed, among other problems, the under-funding of transnational global health activities known as global common goods for health (CGH), global functions such as pandemic preparedness and research and development (R&D) for neglected diseases. To mobilize sustainable funding for global CGH, it is critical first to understand existing financing flowing to different types of global CGH. In this study, we estimate trends in international spending for global CGH in 2013, 2015, and 2017, encompassing the era before and after the Ebola epidemic. We use a measure of international funding that combines official development assistance (ODA) for health with additional international spending on R&D for diseases of poverty, a measure called ODA+. We classify ODA+ into funding for three global functions—provision of global public goods, management of cross-border externalities, and fostering of global health leadership and stewardship—and country-specific aid. International funding for global functions increased between 2013 and 2015 by $1.4 billion to a total of $7.3 billion in 2015. It then declined to $7.0 billion in 2017, accounting for 24% of all ODA+ in 2017. These findings provide empirical evidence of the reactive nature of international funders for global CGH. While international funders increased funding for global functions in response to the Ebola outbreak, they failed to sustain that funding. To meet future global health challenges proactively, international funders should allocate more funding for global functions.

A series of studies developed in Mexico in the late 1990s identified disturbing rates of catastrophic health expenditures as a result of the fact that approximately half of the Mexican population, ...