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Background: Low-and-middle-income countries, especially in Africa, lack the capacity to adequately invest in health systems to attain universal health coverage (UHC). As such, countries must improve efficiency and provide more services within the available resources. This systematic review synthesised evidence on the efficiency of health systems in the African region and its drivers., Methods: We conducted a systematic literature review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Related studies were grouped and meta-analysed, while others were descriptively analysed. We employed a qualitative content synthesis for synthesising the drivers of efficiency., Results: Overall, 39 studies met a predetermined inclusion criterion and were included from a possible 4 609 records retrieved through a rigorous search and selection process. Using a random effects restricted maximum likelihood method, the pooled efficiency score for the Africa region was estimated to be 0.77, implying that on the flip side, health system inefficiency across countries in the African region was approximately 23%. Across 22 studies that used data envelopment analysis to examine efficiency at the level of health facilities and sub-national entities, the efficiency level was 0.67. Facility-level studies tended to estimate low levels of efficiency compared to health system-level studies. Across the 39 studies, 21 significant drivers of inefficiency were reported, including population density of the catchment area, governance, health facility ownership, health facility staff density, national economic status, type of health facility, education index, hospital size and bed occupancy rate., Conclusion: With approximately 23% of the inefficiency of health systems in Africa, improving efficiency alone will yield an average of 34% improvement in resource availability, assuming all countries are performing similarly to the frontier countries. However, with the low level of health expenditure per capita in Africa, the efficiency gains alone will be insufficient to meet the minimum funding requirement for UHC., Registration: PROSPERO: CRD42022318122., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2023 by the Journal of Global Health. All rights reserved.)

Background and Objectives: The health workforce (HWF) is at the core of ensuring an efficient, effective and functional health system, but it faces chronic underinvestment. This paper presents a fiscal space analysis of 20 countries in East and Southern Africa to generate sustained evidence-based advocacy for significant and smarter investment in the HWF., Methods: We adapted an established empirical framework for fiscal space analysis and applied it to the HWF. Country-specific data were curated and triangulated from publicly available datasets and government reports to model the fiscal space for the HWF for each country. Based on the current knowledge, three scenarios (business as-usual, optimistic and very optimistic) were modelled and compared., Findings: A business-as-usual scenario shows that the cumulative fiscal space across the 20 countries is US$12.179 billion, which would likely increase by 28% to US$15.612 billion by 2026 but varies across countries-the highest proportional increases expected in Seychelles (117%) and Mozambique (69%) but lowest in Zambia (15%). Under optimistic assumptions, allocating an additional 1.5% of gross domestic product (GDP) to health even without further prioritising the proportional allocation to the wage bill could boost the cumulative fiscal space for HWF by US$4.639 billion. In a very optimistic scenario of a 1.5% increase in health expenditure as a proportion of GDP and further prioritisation of HWF within the health expenditure, the cumulative fiscal space for HWF could improve by some 105%-ranging from 24% in Zambia to 330% in Lesotho., Conclusion: Small increments in government health expenditure and increased prioritisation of HWF in funding in tandem with the 57% global average could potentially increase the fiscal space for HWF by at least 32% in 11 countries. Unless the HWF is sufficiently prioritised within the health expenditures, only increasing the overall health expenditure to even recommended levels would still portend severe underinvestment in HWF amid unabating shortages to deliver health services. Thus, HWF strategies and investment plans should include fiscal space analysis to deepen advocacy for sustainable investment in the HWF., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Lessons learned by countries that have successfully implemented coverage schemes for health services may be valuable for other countries, especially low- and middle-income countries (LMICs), which likewise are seeking to provide/expand coverage. The research team surveyed experts in population health management from LMICs for information on characteristics of health care coverage schemes and factors that influenced decision-making processes. The level of coverage provided by the different schemes varied. Nearly all the health care coverage schemes involved various representatives and stakeholders in their decision-making processes. Maternal and child health, cardiovascular diseases, cancer, and HIV were among the highest priorities guiding coverage development decisions. Evidence used to inform coverage decisions included medical literature, regional and global epidemiology, and coverage policies of other coverage schemes. Funding was the most commonly reported reason for restricting coverage. This exploratory study provides an overview of health care coverage schemes from participating LMICs and contributes to the scarce evidence base on coverage decision making. Sharing knowledge and experiences among LMICs can support efforts to establish systems for accessible, affordable, and equitable health care.

Background: The objectives of this study were to assess the patterns of treatment seeking behaviour for children under five with malaria; and to examine the statistical relationship between out-of-pocket expenditure (OOP) on malaria treatment for under-fives and source of treatment, place of residence, education and wealth characteristics of Uganda households. OOP expenditure on health care is now a development concern due to its negative effect on households' ability to finance consumption of other basic needs., Methods: The 2009 Uganda Malaria Indicator Survey was the source of data on treatment seeking behaviour for under-five children with malaria, and patterns and levels of OOP expenditure for malaria treatment. Binomial logit and Log-lin regression models were estimated. In logit model the dependent variable was a dummy (1=incurred some OOP, 0=none incurred) and independent variables were wealth quintiles, rural versus urban, place of treatment, education level, sub-region, and normal duty disruption. The dependent variable in Log-lin model was natural logarithm of OOP and the independent variables were the same as mentioned above., Results: Five key descriptive analysis findings emerge. First, malaria is quite prevalent at 44.7% among children below the age of five. Second, a significant proportion seeks treatment (81.8%). Third, private providers are the preferred option for the under-fives for the treatment of malaria. Fourth, the majority pay about 70.9% for either consultation, medicines, transport or hospitalization but the biggest percent of those who pay, do so for medicines (54.0%). Fifth, hospitalization is the most expensive at an average expenditure of US$7.6 per child, even though only 2.9% of those that seek treatment are hospitalized.The binomial logit model slope coefficients for the variables richest wealth quintile, Private facility as first source of treatment, and sub-regions Central 2, East central, Mid-eastern, Mid-western, and Normal duties disrupted were positive and statistically significant at 99% level of confidence. On the other hand, the Log-lin model slope coefficients for Traditional healer, Sought treatment from one source, Primary educational level, North East, Mid Northern and West Nile variables had a negative sign and were statistically significant at 95% level of confidence., Conclusion: The fact that OOP expenditure is still prevalent and private provider is the preferred choice, increasing public provision may not be the sole answer. Plans to improve malaria treatment should explicitly incorporate efforts to protect households from high OOP expenditures. This calls for provision of subsidies to enable the private sector to reduce prices, regulation of prices of malaria medicines, and reduction/removal of import duties on such medicines.