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Background: International oral health policy directions led by the World Health Organisation call for the inclusion of oral health within universal health coverage. The aim of this study is to perform a budget impact analysis of a policy option for a more cost-efficient oral health workforce skill-mix (dentists and oral health therapists) to provide public oral healthcare in Victoria, Australia., Methods: Two hypothetical standard care pathways were developed. A dynamic population Markov model in TreeAge software, with a time horizon of 6 years. Two scenarios were modelled to determine: (1) base-case scenario: the threshold the dentist workforce could reduce per year, while achieving the same service delivery outputs, and (2) alternative scenario: the potential cost-savings for utilising an optimally cost-efficient oral health workforce skill-mix., Results: The threshold analysis showed a minimum reduction of 13% of the dentist workforce being replaced with oral health therapists can occur without having any impact on the same service delivery outputs. Under the alternative scenario, the potential cost-savings would be AUD$1,425,037 (standard deviation 58,954)., Conclusions: Governments and policy-decision makers should consider strategies in training, attracting, and retaining oral health therapists to achieve an optimally cost-efficient oral health workforce skill-mix when delivering public oral healthcare., (© 2024 The Author(s). The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Background: Burkina Faso joined the Global Financing Facility for Women, Children and Adolescents (GFF) in 2017 to address persistent gaps in funding for reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). Few empirical papers deal with how global funding mechanisms, and specifically GFF, support resource mobilisation for health nationally., Objective: This study describes the policy processes of developing the GFF planning documents (the Investment Case and Project Appraisal Document) in Burkina Faso., Methods: We conducted an exploratory qualitative policy analysis. Data collection included document review ( N  = 74) and in-depth semi-structured interviews ( N  = 23). Data were analysed based on the components of the health policy triangle., Results: There was strong national political support to RMNCAH-N interventions, and the process of drawing up the investment case (IC) and the project appraisal document was inclusive and multi-sectoral. Despite high-level policy commitments, subsequent implementation of the World Bank project, including the GFF contribution, was perceived by respondents as challenging, even after the project restructuring process occurred. These challenges were due to ongoing policy fragmentation for RMNCAH-N, navigation of differing procedures and perspectives between stakeholders in the setting up of the work, overcoming misunderstandings about the nature of the GFF, and weak institutional anchoring of the IC. Insecurity and political instability also contributed to observed delays and difficulties in implementing the commitments agreed upon. To tackle these issues, transformational and distributive leaderships should be promoted and made effective., Conclusions: Few studies have examined national policy processes linked to the GFF or other global health initiatives. This kind of research is needed to better understand the range of challenges in aligning donor and national priorities encountered across diverse health systems contexts. This study may stimulate others to ensure that the GFF and other global health initiatives respond to local needs and policy environments for better implementation.

Over the last decade, Singapore has grappled with substantial healthcare challenges, chiefly a bourgeoning aging population and a mounting burden of chronic diseases. The oral health landscape has also changed, with the Ministry of Health placing a greater focus on a life-course approach supported by policies that facilitate Singaporeans to receive dental care appropriately and affordably. A pivotal oral health policy is the National Dental Strategy, a comprehensive framework governing dental services in the public sector. This strategy encompasses aspects such as financing, workforce management, and capacity considerations. To facilitate affordability and accessibility to dental services in the public sector, the government extends subsidies to reduce out-of-pocket costs. Those attending private dental clinics also benefit from the Community Health Assist Scheme, introduced in 2012, which alleviates treatment costs for enrolled Singaporeans. Furthermore, additional age-banded subsidies have been introduced for older Singaporeans born before 1960, enhancing financial support when accessing dental services in both private and public sectors. In 2019, a national adult oral health survey was commissioned to gauge the oral health status of Singaporeans aged 21 and above. The findings reported 34.8% having untreated dental caries, and 15.7% and 41.2% experiencing moderate and severe periodontitis, respectively. While over half (53.9%) of respondents visited the dentist at least annually, about 60% of eligible individuals did not utilize their government dental subsidies. In response, the Ministry of Health is committed to strengthening oral disease prevention, integrating oral health into general healthcare services, expanding dental financing schemes to enhance service utilization, improving the quality and transparency of dental care, and leveraging advancements in tele-dentistry and other modes of dental services. It is imperative to adapt Singapore's oral health policies and service delivery models to meet the evolving needs of the population and ensure a sustainable, equitable and resilient oral healthcare system., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The interplay between devolution, health financing and public financial management processes in health-or the lack of coherence between them-can have profound implications for a country's progress towards universal health coverage. This paper explores this relationship in seven Asian and African countries (Burkina Faso, Kenya, Mozambique, Nigeria, Uganda, Indonesia and the Philippines), highlighting challenges and suggesting policy solutions. First, subnational governments rely heavily on transfers from central governments, and most are not required to allocate a minimum share of their budget to health. Central governments channelling more funds to subnational governments through conditional grants is a promising way to increase public financing for health. Second, devolution makes it difficult to pool funding across populations by fragmenting them geographically. Greater fiscal equalisation through improved revenue sharing arrangements and, where applicable, using budgetary funds to subsidise the poor in government-financed health insurance schemes could bridge the gap. Third, weak budget planning across levels could be improved by aligning budget structures, building subnational budgeting capacity and strengthening coordination across levels. Fourth, delays in central transfers and complicated procedures for approvals and disbursements stymie expenditure management at subnational levels. Simplifying processes and enhancing visibility over funding flows, including through digitalised information systems, promise to improve expenditure management and oversight in health. Fifth, subnational governments purchase services primarily through line-item budgets. Shifting to practices that link financial allocations with population health needs and facility performance, combined with reforms to grant commensurate autonomy to facilities, has the potential to enable more strategic purchasing., Competing Interests: Competing interests: None declared., (© World Health Organization 2024. Licensee BMJ.)

Political economy analysis (PEA) has been advanced as critical to understanding the political dimensions of policy change processes. However, political economy (PE) is not a theory on its own but draws on several concepts. Nannini et al, in concert with other scholars, emphasise that politics is characterised by conflict, contestation and negotiation over interests, ideas and power as various agents attempt to influence their context. This commentary reflects how Nannini et al wrestled with these PEA concepts - summarised in their conceptual framework used for PEA of the Ugandan case study on financial risk protection reforms. The central premise is that a common understanding of the PEA concepts (mainly structure-agency interactions, ideas, interests, institutions and power) forms a basis for strategies to advance thinking and working politically . Consequently, I generate several insights into how we can promote politically informed approaches to designing, implementing and evaluating policy reforms and development efforts., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Uganda introduced health financing reforms that entailed abolition of user fees, and in due process planned to introduce a National Health Insurance Scheme (NHIS). This paper accentuates a contextual and political-economic analysis that dispels the fears and misconceptions related to introduction of the insurance scheme. The Grindle and Thomas model is used to depict how various factors affect decision making by policy elites concerning a particular policy at a particular time. Drawing lessons from the sub-Sahara region and in particular, Ghana and Rwanda's experience, it is clear that the political will of the executive led by the president in many countries is a key determinant in bringing about health reforms. In this paper, we provide insights based on contextual and political-economic analysis to countries in similar setting that are interested in setting up NHISs., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: As countries health financing policies are expected to support progress towards universal health coverage (UHC), an analysis of these policies is particularly relevant in low- and middle-income countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition., Methods: The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 key informant interviews (KIIs) in the health sector., Results: We find that the current political situation is not yet conducive for implementing a UHC system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship., Conclusion: By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Most sub-Saharan Africa countries adopt global health policies. However, mechanisms with which policy transfers occur have largely been studied amongst developed countries and much less in low- and middle- income countries. The current review sought to contribute to literature in this area by exploring how health policy agendas have been transferred from global to national level in sub-Saharan Africa. This is particularly important in the Sustainable Development Goals (SDGs) era as there are many policy prepositions by global actors to be transferred to national level for example the World Health Organization (WHO) policy principles of health financing reforms that advance Universal Health Coverage (UHC)., Methods: We conducted a critical review of literature following Arksey and O'Malley framework for conducting reviews. We searched EBSCOhost, ProQuest, PubMed, Scopus, Web of Science and Google scholar for articles. We combined the concepts and synonyms of "policy transfer" with those of "sub-Saharan Africa" using Boolean operators in searching databases. Data were analyzed thematically, and results presented narratively., Results: Nine articles satisfied our eligibility criteria. The predominant policy transfer mechanism in the health sector in sub-Saharan Africa is voluntarism. There are cases of coercion, however, even in the face of coercion, there is usually some level of negotiation. Agency, context and nature of the issue are key influencers in policy transfers. The transfer is likely to be smooth if it is mainly technical and changes are within the confines of a given disease programmatic area. Policies with potential implications on bureaucratic and political status quo are more challenging to transfer., Conclusion: Policy transfer, irrespective of the mechanism, requires local alignment and appreciation of context by the principal agents, availability of financial resources, a coordination platform and good working relations amongst stakeholders. Potential effects of the policy on the bureaucratic structure and political status are also important during the policy transfer process., (© 2022. The Author(s).)

In Burkina Faso, Burundi and Niger, the policy to remove user fees for primary care was carried out through significant adjustments in public financial management (PFM). The paper analyzes the PFM adjustments by stage of the budget cycle and describes their importance for health financing. The three countries shifted from input-based to program-based allocation for primary care facility compensation, allowed service providers autonomy to access and manage the funds, and established budget performance monitoring frameworks related to outputs. These PFM changes, in turn, enabled key improvements in health financing, namely, more direct funding of primary care facilities from general budget revenue, and payments to those service providers based on outputs and drawn from noncontributory entitlements. The paper draws on these experiences to provide key lessons on the PFM enabling conditions needed to expand health coverage through public financing mechanisms.

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., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

COVID-19 has shocked all countries' economic and health systems. The combined direct health impact and the current macro-fiscal picture present real and present risks to health financing that facilitate progress toward universal health coverage (UHC). This paper lays out the health financing mechanisms through which the UHC objectives of service coverage and financial protection may be impacted. Macroeconomic, fiscal capacity, and poverty indicators and trends are analyzed in conjunction with health financing indicators to present spending scenarios. The analysis shows that falling or reduced economic growth, combined with rising poverty, is likely to lead to a fall in service use and coverage, while any observed reductions in out-of-pocket spending have to be analyzed carefully to make sure they reflect improved financial protection and not just decreased utilization of services. Potential decreases in out-of-pocket spending will likely be drive by households' financial constraints that lead to less service use. In this way, it is critical to measure and monitor both the service coverage and financial protection indicators of UHC to have a complete picture of downstream effects. The analysis of historical data, including available evidence since the start of the COVID-19 pandemic, lay the foundation for health financing-related policy options that can effectively safeguard UHC progress particularly for the poor and most vulnerable. These targeted policy options are based on documented evidence of effective country responses to previous crises as well as the overall evidence base around health financing for UHC.

Objectives: This study aimed to review the funding policies of clinical commissioning groups for treatment of obstructive sleep apnoea in England., Methods: Published policies from a randomly selected sample of 60 out of 190 clinical commissioning groups were reviewed., Results: Continuous positive airway pressure was funded based on a clinical assessment or according to criteria that were in line with national guidelines in most clinical commissioning groups (49 of 60), with 11 clinical commissioning groups offering no policy. Mandibular advancement devices, tonsillectomy and nasal surgery were funded based on a clinical assessment or certain criteria in 16, 25 and 16 clinical commissioning groups, respectively. In contrast, only one clinical commissioning group provided funding for soft palate, tongue base or mandibular surgery. Hypoglossal nerve stimulation was not mentioned in any clinical commissioning group's policy., Conclusion: Although most clinical commissioning groups provide funding for the use of continuous positive airway pressure, the availability of funding for other obstructive sleep apnoea treatment modalities is heterogeneous, leaving continuous positive airway pressure intolerant patients with limited therapeutic options in some regions.

This article examines how alternate-level-of-care (ALC) days are funded through the cancer surgery funding model in Ontario and evaluates policy options to better address ALC days. The contribution of ALC days to hospital funding and the impact of removing or reallocating this funding from cancer surgery is measured. Though costs associated with ALC days in cancer surgery are low, this article highlights the need for policy options that would realign funding across the healthcare system in Ontario to better meet the needs of patients waiting for ALC, reduce pressure on inpatient bed capacity and improve value for money., (Copyright © 2020 Longwoods Publishing.)

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This analysis of the Canadian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Life expectancy is high, but it plateaued between 2016 and 2017 due to the opioid crisis. Socioeconomic inequalities in health are significant, and the large and persistent gaps in health outcomes between Indigenous peoples and the rest of Canadians represent a major challenge facing the health system, and society more generally. Canada is a federation: the provinces and territories administer health coverage systems for their residents (‎referred to as "medicare")‎, while the federal government sets national standards, such as through the Canada Health Act, and is responsible for health coverage for specific subpopulations. Health care is predominantly publicly financed, with approximately 70% of health expenditures financed through the general tax revenues. Yet there are major gaps in medicare, such as prescription drugs outside hospital, long-term care, mental health care, dental and vision care, which explains the significant role of employer-based private health insurance and out-of-pocket payments. The supply of physicians and nurses is uneven across the country with chronic shortages in rural and remote areas. Recent reforms include a move towards consolidating health regions into more centralized governance structures at the provincial/ territorial level, and gradually moving towards Indigenous self-governance in health care. There has also been some momentum towards introducing a national programme of prescription drug coverage (‎Pharmacare)‎, though the COVID-19 pandemic of 2020 may shift priorities towards addressing other major health system challenges such as the poor quality and regulatory oversight of the long-term care sector. Health system performance has improved in recent years as measured by in-hospital mortality rates, cancer survival and avoidable hospitalizations. Yet major challenges such as access to non-medicare services, wait times for specialist and elective surgical care, and fragmented and poorly coordinated care will continue to preoccupy governments in pursuit of improved health system performance., (World Health Organization 2020 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).)

There is increasing international consensus that countries need to reduce health system fragmentation in order to achieve universal health coverage (UHC). Yet there is little agreement on what drives fragmentation, in particular the extent to which fragmentation has a political purpose. This study analyses a highly fragmented health financing system through a UHC policy that aims to remove user fees for people aged 60 and over in Senegal. 53 semi-structured interviews (SSIs) and focus group discussions with the target population were conducted in four regions in Senegal over a period of six months during 2012. A further 46 SSIs were conducted with key informants at the national level and in each of the four regions. By analysing explanations of the successes and failures of policies, an understanding of power relations in state institutions, communities and individuals is gained. The concept of governmentality is used to interpret the results. The interviewees' main concern was to implement or resist various techniques of control over the conduct of bureaucrats, health workers, patients and the wider population. These techniques included numeracy and calculation, referral letters, ID cards, data collection, new prudentialism, active citizenship and ethical self-formation through affinities of the community. The techniques sought to make two types of subjects; citizens subjects of rights and obligations; and autonomous subjects of choice and self-identity. A key implication is that in Senegal, and perhaps elsewhere, fragmentation of the health system plays a key role in the formation and control of subjects, in the name of "freedom". As such, fragmentation may be an inherent feature of UHC. Interventions that aim to reduce fragmentation based on evidence of its inefficiency, inequity and ineffectiveness in reducing poverty and ill health may be missing this point., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Health technology assessment (HTA) is an effective tool to support priority setting and generate evidence for decision making especially en route to achieving universal health coverage (UHC). We assessed the capacity needs, policy areas of demand, and perspectives of key stakeholders for evidence-informed decision making in Nigeria where HTA is still new., Methods: We surveyed 31 participants including decision makers, policy makers, academic researchers, civil society organizations, community-based organizations, development partners, health professional organizations. We revised an existing survey to qualitatively examine the need, policy areas of demand, and perspectives of stakeholders on HTA. We then analyzed responses and explored key themes., Results: Most respondents were associated with organizations that generated or facilitated health services research. Research institutes highlighted their ability to provide expertise and skills for HTA research but some respondents noted a lack of human capacity for HTA. HTA was considered an important and valuable priority-setting tool with a key role in the design of health benefits packages, clinical guideline development, and service improvement. Public health programs, medicines and vaccines were the three main technology types that would especially benefit from the application of HTA. The perceived availability and accessibility of suitable local data to support HTA varied widely but was mostly considered inadequate and limited. Respondents needed evidence on health system financing, health service provision, burden of disease and noted a need for training support in research methodology, HTA and data management., Conclusion: The use of HTA by policymakers and communities in Nigeria is very limited mainly due to inadequate and insufficient capacity to produce and use HTA. Developing sustainable and institutionalized HTA systems requires in-country expertise and active participation from a range of stakeholders. Stakeholder participation in identifying HTA topics and conducting relevant research will enhance the use of HTA evidence produced for decision making. Therefore, the identified training needs for HTA and possible research topics should be considered a priority in establishing HTA for evidence-informed policy making for achieving UHC particularly among the most vulnerable people in Nigeria.

Most developing countries with weak economies and low GDPs strive to invest an optimal amount of budget to health sector. Compounding on this state of affairs is their inherent inefficiency to spend even that meager amount on the welfare of the patients, improving service delivery, motivating their workforce and making their health systems responsive to the needs of the people they serve. With weak fiscal base and inelasticity in budget spending, when these countries face a catastrophe like COVID-19, there is a whole situation of havoc and lack of finances emerges as the biggest issue in such crises. Pakistan has been no exception to this kind of situation. Government funds allocated to other public sector development schemes are diverted to deal with the health emergency. Hence, the result is an overall socioeconomic shock that a country has to face. Amid such crises, other international commitments also face a state of uncertainty. With the changing disease patterns all over the world, the public financial management system for health sector needs to be revisited to devise a more sustainable and resilient mechanism not only to absorb shocks like COVID-19 but also to meet the international health commitments., (© 2020 John Wiley & Sons, Ltd.)

This study critically evaluates the adoption of a universal healthcare system recently introduced by the Indonesian government in 2014. Our study is driven by the lack of critical analysis of social and political factors and unintended consequences of New Public Management, which is evident in the healthcare sector reforms in emerging economies. This study not only examines the impact of economic and political forces surrounding the introduction of a universal health insurance programme in the country but also offers insights into the critical challenges and undesirable outcomes of a fundamental reform of the healthcare sector in Indonesia. Through a systematic and detailed review of prior studies, legal sources and reports from government and media organizations about the implementation and progress of an UHC health insurance programme in Indonesia, the authors find that a more democratic political system that emerged in 1998 created the opportunity for politicians and international financial aid agencies to introduce a universal social security administration agency called Badan Penyelenggara Jaminan Sosial (BPJS). Despite the introduction of BPJS to expand the health services' coverage, this effort faces critical challenges and unintended outcomes including: (1) increased financial deficits, (2) resistance from medical professionals and (3) politicians' tendency to blame BPJS's management for failing to pay healthcare services costs. We argue that the adoption of the insurance system was primarily motivated by politicians' own interests and those of international agencies at the expense of a sustainable national healthcare system. This study contributes to the healthcare industry policy literature by showing that a poorly designed UHC system could and will undermine the core values of healthcare services. It will also threaten the sustainability of the medical profession in Indonesia. The authors offer several suggestions for devising better policies in this sector in the developing nations., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The MJA-Lancet Countdown on health and climate change was established in 2017 and produced its first Australian national assessment in 2018. It examined 41 indicators across five broad domains: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. It found that, overall, Australia is vulnerable to the impacts of climate change on health, and that policy inaction in this regard threatens Australian lives. In this report we present the 2019 update. We track progress on health and climate change in Australia across the same five broad domains and many of the same indicators as in 2018. A number of new indicators are introduced this year, including one focused on wildfire exposure, and another on engagement in health and climate change in the corporate sector. Several of the previously reported indicators are not included this year, either due to their discontinuation by the parent project, the Lancet Countdown, or because insufficient new data were available for us to meaningfully provide an update to the indicator. In a year marked by an Australian federal election in which climate change featured prominently, we find mixed progress on health and climate change in this country. There has been progress in renewable energy generation, including substantial employment increases in this sector. There has also been some progress at state and local government level. However, there continues to be no engagement on health and climate change in the Australian federal Parliament, and Australia performs poorly across many of the indicators in comparison to other developed countries; for example, it is one of the world's largest net exporters of coal and its electricity generation from low carbon sources is low. We also find significantly increasing exposure of Australians to heatwaves and, in most states and territories, continuing elevated suicide rates at higher temperatures. We conclude that Australia remains at significant risk of declines in health due to climate change, and that substantial and sustained national action is urgently required in order to prevent this., (© 2019 AMPCo Pty Ltd.)

This analysis of the Serbian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The health of the Serbian population has improved over the last decade. Life expectancy at birth increased slightly in recent years, but it remains, for example, around 5 years below the average across European Union countries. Some favourable trends have been observed in health status and morbidity rates, including a decrease in the incidence of tuberculosis, but population ageing means that chronic conditions and long-standing disability are increasing. The state exercises a strong governance role in Serbia's social health insurance system. Recent efforts have increased centralization by transferring ownership of buildings and equipment to the national level. The health insurance system provides coverage for almost the entire population (98%). Even though the system is comprehensive and universal, with free access to publicly provided health services, there are inequities in access to primary care and certain population groups (such as the most socially and economically disadvantaged, the uninsured, and the Roma) often experience problems in accessing care. The uneven distribution of health professionals across the country and shortages in some specialities also exacerbate accessibility problems. High out-of-pocket payments, amounting to over 40% of total expenditure on health, contribute to relatively high levels of self-reported unmet need for medical care. Health care provision is characterized by the role of the "chosen doctor" in primary health care centres, who acts as a gatekeeper in the system. Recent public health efforts have focused on improving access to preventive health services, in particular, for vulnerable groups. Health system reforms since 2012 have focused on improving infrastructure and technology, and on implementing an integrated health information system. However, the country lacks a transparent and comprehensive system for assessing the benefits of health care investments and determining how to pay for them., (World Health Organization 2019 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).)

Introduction: Improving maternal health remains a health priority at the global and national levels. As part of the global strategy, many low/middle-income countries (LMICs) have implemented free primary healthcare policies for different service packages including maternal health. Free maternal healthcare policies aim to improve maternal health by removing the financial burden of accessing maternal healthcare services. The objective of this scoping review is to assess evaluations of free maternal healthcare policies and the impact on maternal health in LMICs. This will help identify theoretical and methodological approaches (or gaps if any) for evaluating the impact of free maternal healthcare policies to inform future work. It will also provide an evidence base for policymakers and other stakeholder with an interest in planning, funding and implementing evidence based and effective interventions to improving maternal health outcomes., Methods: The scoping review will follow the methodological framework proposed by Arksey and O'Malley and refined by Joanna Briggs Institute. It will involve a literature search of the PubMed, Scopus ScienceDirect, Web of Science and CINAHL databases for peer-reviewed journal articles related to the impact of free maternal health policies in LMICs published from 2000 to the present. Two reviewers will screen and appraise eligible articles using preset criteria based on the 'population-concept-context' framework. A data extraction framework will be used to extract and chart data from the reviewed articles. The results will be analysed using descriptive numerical summary analysis and qualitative thematic analysis., Ethics and Dissemination: Ethical approval is not required as the scoping review will synthesise information from publicly available materials. Dissemination will be through publication in a peer-reviewed journal and presentation at relevant conferences and workshops., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

One of the most important gatherings of the world's economic leaders, the G20 Summit and ministerial meetings, takes place in June, 2019. The Summit presents a valuable opportunity to reflect on the provision and receipt of development assistance for health (DAH) and the role the G20 can have in shaping the future of health financing. The participants at the G20 Summit (ie, the world's largest providers of DAH, emerging donors, and DAH recipients) and this Summit's particular focus on global health and the Sustainable Development Goals offers a unique forum to consider the changing DAH context and its pressing questions. In this Health Policy perspective, we examined trends in DAH and its evolution over time, with a particular focus on G20 countries; pointed to persistent and emerging challenges for discussion at the G20 Summit; and highlighted key questions for G20 leaders to address to put the future of DAH on course to meet the expansive Sustainable Development Goals. Key questions include how to best focus DAH for equitable health gains, how to deliver DAH to strengthen health systems, and how to support domestic resource mobilisation and transformative partnerships for sustainable impact. These issues are discussed in the context of the growing effects of climate change, demographic and epidemiological transitions, and a global political shift towards increasing prioritisation of national interests. Although not all these questions are new, novel approaches to allocating DAH that prioritise equity, efficiency, and sustainability, particularly through domestic resource use and mobilisation are needed. Wrestling with difficult questions in a changing landscape is essential to develop a DAH financing system capable of supporting and sustaining crucial global health goals., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: In former Soviet Union countries, tuberculosis (TB) financing largely relies on a hospital-centered model. The World Health Organization favors transformation to ambulatory treatment since it is cheaper and patient-centered. We explored policy and decision maker's perspectives on: a) enabling factors for transformation in Armenia and b) challenges and ways forward in doing so in Ukraine and Tajikistan., Methodology: Qualitative study of key informants from government, donors and the national TB program., Results: 52 informants with a mean service record of 20 years were involved. Key enablers in Armenia included collaborative partnership and political will, carefully selecting an adapted financing scheme that avoided financial penalization of hospitals and health workers, and use of operational research. The operational challenges in Ukraine and Tajikistan hovered around the lack of technical capacity and guidance on "how to implement" alternative financing. Shortcomings in strategic planning, uncertainty/fear that existing hospital funding would be cut and reluctance to change were highlighted. Suggested ways forwards to change the current paradigm included country-level technical assistance, capacity building, regional exchanges and operational research., Conclusions: the perspectives of "those who decide" on transforming TB financing have been highlighted. Taking these perspectives on-board is vital for achieving the end-TB goals., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2019 Karapet Davtyan, Olga Denisiuk, Azamdzhon Mirzoev, Hayk Davtyan, Seda Aghabekyan, Maryna Piskorska, Anna Tyshkevych, Joshua Jayaraj, Armen Hayrapetyan, Rony Zachariah.)

The Singapore healthcare sector faces a myriad of challenges, including a rapidly ageing population, an increasing burden of chronic disease, and the rising cost of healthcare. The Ministry of Health has called for a restructuring and transformation of the current model of care to one that is more accessible, affordable and of higher quality, by the year 2020. In achieving quality health care, care integration through the Regional Health Systems (RHS) is seen as one approach to improving health and social outcomes, increasing healthcare utilisation and increasing satisfaction with healthcare providers. We conducted a qualitative study involving 31 elites from five policy agent clusters, and analysed organisational documents, to explore how the concepts of policy transfer and policy translation, explain the ways in which integrated care was introduced and developed in Singapore, with a focus on the SingHealth (SGH Campus) Regional Health System (RHS). The findings demonstrate that the development of integrated care is mediated by multi-scalar and multi-site networks and contextual features. The multiple and pluralistic interpretations of 'integrated care' and 'policy' are contested spaces or domains requiring further negotiation and debate. Institutional issues in the SingHealth (SGH Campus) RHS, and in the private and ILTC sectors highlight the need to consider spatial and temporal factors, and the multiplexities in the embedding of integrated care policy., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: To progress towards universal health coverage (UHC), each country will have to develop its systemic learning capacity. This study aims at documenting how, across time, learning can feed into a UHC policy process, and how the latter can itself strengthen (or not) the learning capacity of the health system. It specifically focuses on the development of a major health financing policy aligned with the UHC goal in Morocco, the RAMED, a health financing scheme covering hospital costs for the poorest segment of the population., Methods: We conducted a retrospective analysis of the RAMED policy for the period between 1997 and 2018, along with a case study design. For the data collection and analysis, we developed a framework combining Garvin's learning organisation framework and the heuristic health policy analysis framework. We gathered data from key informants and document reviews., Results: The study confirmed the importance of learning during the different stages of the RAMED policy process. There is evidence of a leadership encouraging learning, the introduction and adoption of knowledge management processes, and the start of a transformation of the administrative culture. Yet, our study also showed some major shortcomings, especially the lack of structure of the learning, and insufficient effort to systemise and sustain a transformation of practices within the health administration. Our study also confirms that the learning changes in nature across the different stages of the policy process., Conclusion: The policy decisions and the implementation strategy create a learning dynamic, though not structured in all cases. Despite the positive interaction between learning and the RAMED policy, the opportunity to push forward a more structural transformation towards a learning system has not been fully seized. Hierarchical logics still largely prevail in the Moroccan health administration. The impact of future health policies for both the target beneficiaries and the health system will be bigger if their design integrates purposeful and structured actions in favour of organisational learning. This recommendation probably applies beyond Morocco.

Introduction: With the improvement of the survival of acute cardiac events and the increasing age, there is a higher demand for cardiac rehabilitation care., Aim: The aim of our study is to analyse the performance indicators of cardiac inpatient rehabilitation care in Hungary financed by the statutory public health insurance system., Data and Methods: Data were derived from the financial database of the National Health Insurance Fund of Hungary. We analysed the period between 2014 and 2017. We investigated the distribution of cardiac rehabilitation hospital beds, the patient turnover and the rehabilitation rate following acute care., Results: In 2017, there were 1765 publicly financed cardiac rehabilitation hospital beds in Hungary (1.8 beds/10 000 population). We observed the lowest number of hospital bed number in Szabolcs-Szatmár-Bereg (0.27 beds/10 000 population), Hajdú-Bihar (0.28) and Fejér (0.6) counties. We found the highest number of hospital beds in Veszprém (11.47 beds/10 000 population), Győr-Moson-Sopron (4.94) counties and in Budapest (2.27). Between 2014 and 2017, the annual number of patients was between 24 834 and 26 146, while the number of nursing days varied between 510 thousand and 542 thousand. The average length of stay showed a moderate increase from 19.2 days/patient (2014) to 20.2 days/patient (2017). Only 6.6-7.6% of the patients who underwent acute myocardial infarction received cardiac rehabilitation care., Conclusion: We found significant regional inequalities in both the capacities and the access to and utilization of cardiac rehabilitation healthcare services, which should be mitigated by health policy activities. The low proportion (6.6-7.6%) of patients who underwent acute myocardial infarction and received cardiac rehabilitation care, should be increased. Orv Hetil. 2019; 160(Suppl 1): 6-12.

Introduction: With the increasing number of the incidence of neuromusculoskeletal and brain circulation disorders, there is a higher demand for neuromusculoskeletal rehabilitation care., Aims: The aim of our study is to analyse the performance indicators of neuromusculoskeletal rehabilitation care in Hungary financed by the statutory public health insurance system., Methods: Data were derived from the financial database of the National Health Insurance Fund of Hungary. We analysed the period between 2014 and 2017. We investigated the distribution of neuromusculoskeletal rehabilitation hospital beds, the patient turnover and patients' pathways. We analysed the regional inequalities in the access to (hospital beds) and utilization (number of patients) of rehabilitation care., Results: In 2017, there were 6798 publicly financed neuromusculoskeletal rehabilitation hospital beds in Hungary (6.94 beds/10 000 population). We observed the lowest number of hospital bed in Komárom-Esztergom (1.5 beds/10 000 population), Somogy (2.0) and Pest (2.7) counties. We found the highest number of hospital beds in Zala (12.6), Győr-Moson-Sopron (12.2) and Baranya (11.5) counties. The more than 2-fold difference in the utilization (Komárom-Esztergom: 52.3 patients/10 000 population; Győr-Moson-Sopron: 136 patients/10 000 population) confirms regional inequalities. Between 2014 and 2017, the annual number of patients showed an increasing tendency, while the average length of stay varied between 21.8 and 22.4 days/patient. The correlation coefficient between hospitals beds and the number of patients was very high (0.798)., Conclusion: We found significant regional inequalities in the access to and utilization of neuromusculoskeletal rehabilitation. Orv Hetil. 2019; 160(Suppl 1): 13-21.

Background: Many Asia-Pacific countries are experiencing rapid changes in socio-economic and health system development. This study aims to describe the strategies supporting rural health worker attraction and retention in Cambodia, China, and Vietnam and explore the context influencing their outcomes., Methods: This paper is a policy analysis based on key informant interviews with stakeholders about a rural province of Cambodia, China, and Vietnam, coupled with a broad review of the literature., Results: Cambodia, China, and Vietnam have implemented medical education, provided financial incentives, and provided personal and professional support to attract and retain rural health workers. More socio-economic development was related to a wider range of interventions and their scope. The health system context influenced the outcomes. Increased autonomy of public hospitals attracted more health workers from rural primary health facilities in China and Vietnam. Health financing policies for universal health coverage in China and Vietnam have increased the utilization of health services. Subsidies for poor people to access health services in Cambodia have provided financial incentives to retain rural health workers. However, the dismantling of the referral system in China and Vietnam has resulted in a high rate of health workers moving from primary health facilities to higher-level hospitals while clear definition of primary healthcare package in Cambodia guided its planning of primary health workforce. The prosperous private health sector in Cambodia and Vietnam attracted more health workers from rural primary health facilities, impeded implementation and determined effectiveness of financial incentives., Conclusions: Socio-economic and health system reforms including health financing, public hospital autonomy, abolition of referral system and prosperous private sector have both positive and negative impacts on the design, implementation, and effectiveness of interventions to attract and retain rural health workers. Interventions to attract and retain health workers in rural and remote areas need to be considered within overall health system reform.

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out-of-pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all., (© 2018 John Wiley & Sons, Ltd.)

Objective: To analyze the allocation of financial resources in the Brazilian Unified Health System (SUS) in the state of São Paulo by level of care, health region, source of funds and level of government., Methods: This is an exploratory study based on 2014 data extracted from the Public Health Budget Database, presented in absolute terms, relative terms and per capita ., Results: In 2014, R$52.1 bi were spent on public health, 58.0% having corresponded to the expenditures of the municipalities and 42.0% to those of the state government. Regional per capita spending varied from R$561.75 to R$824.85. As for the per capita spending on primary health care, which represented 37.5% of the municipalities' total expenditure, the lowest value was found in the city of São Paulo and the highest, in Araçatuba. Campinas had the highest per capita expenditure on medium and high complexity care, while Presidente Prudente had the lowest. The highest regional percentage of the current net revenue spent on health was verified in Registro, and the lowest, in the city of São Paulo., Conclusions: The paradigm of the health sector's financing in São Paulo revealed that the expenditure on primary health care, level elected by health policy as strategic because it depends on coordination and integral health care in the attention networks, was not considered a priority in relation to the expenditure with the medium and high complexity, exposing the iniquities in the state's regions.

The purpose of this study was to disclose the psychological meaning structure of dentistry as a free market within the context of leading Swedish policymaking. Following the criteria for the descriptive phenomenological psychological method data was collected from leading policy makers about the experiential aspects of dentistry as a free market within the context of a welfare state. The analysis showed that dentistry as a free market was experienced as a complex business relationship between buyers and sellers that transcended the traditional dentist and patient roles. The lived experience of the proposed business transaction was based on two inherently conflicting views: the belief in the individual's ability to make a free choice versus the understanding that all individuals in a society do not have the ability or the means necessary to make a free choice. Dentistry as a free market within a welfare state, such as Sweden, can thus be seen as a persistent attempt to hold on to a compromise between two very distinctive political ideologies.

Background: As performance-based financing (PBF) has been increasingly implemented in low-income countries, a growing literature has developed, assessing its effectiveness and, more recently, focussing on the political dynamics of PBF introduction and implementation. This study contributes to the latter body of literature by exploring decision-making processes on PBF in Sierra Leone during the 2010-2017 period. Sierra Leone presents an interesting case because of the 'start-stop-start' trajectory of PBF., Methods: The qualitative case study is based on a document review and 25 key informant interviews with national stakeholders and international actors. Documents and interviews were analysed based on a political economy framework focusing on actors and structure, but also making use of concepts drawn from interpretive policy analysis to look at frames., Results: Our analysis describes the process of negotiation and re-negotiation of PBF in Sierra Leone, highlighting the role of different players, both internal and external, their ideas, capacity and power relations, and the shifting narratives around PBF. It is shown that external actors driving the debate make use of 'frames', both actual (i.e., defining the timing and pace of the discussions, the funding available, etc.) and metaphorical (i.e., how PBF is interpreted, defined and understood) to fit in and influence the debate. This is facilitated by the lack of capacity and resources in the fragile setting. Other strategies, such as 'venue shopping' are employed, though they may add to fragmentation in the volatile context., Conclusions: The retrospective view of the study has an analytical advantage, but findings are also relevant to guide practice. Although power relations and rent-seeking issues are difficult to overcome in resource and capacity-constrained settings, more attention could be paid to other elements. In particular, adopting shared frames to ensure a common and inclusive understanding of technical concepts such as PBF may be useful to ensure the political sustainability of reforms. Also, the 'actual frames' which define negotiation and implementation should remain flexible, allowing for disrupting events (e.g., the Ebola epidemic in Sierra Leone) as well as for time to develop national capacity and ownership in order to ensure longer-term political support and better health system integration.

Background: Health inequity has mainly been linked to differences in economic status, with the poor facing greater challenges accessing healthcare than the less poor. To extend financial coverage to the poor and vulnerable, Kenya has therefore implemented several pro-poor health policy reforms. However, other social determinants of health such as gender and disability also influence health status and access to care. This study employed an intersectional approach to explore how gender disability and poverty interact to influence how poor women in Kenya benefit from pro-poor financing policies that target them., Methods: We applied a qualitative cross-sectional study approach in two purposively selected counties in Kenya. We collected data using in-depth interviews with women with disabilities living in poverty who were beneficiaries of the health insurance subsidy programme and those in the lowest wealth quintiles residing in the health and demographic surveillance system. We analyzed data using a thematic approach drawing from the study's conceptual framework., Results: Women with disabilities living in poverty often opted to forgo seeking free healthcare services because of their roles as the primary household providers and caregivers. Due to limited mobility, they needed someone to accompany them to health facilities, leading to greater transport costs. The absence of someone to accompany them and unaffordability of the high transport costs, for example, made some women forgo seeking antenatal and skilled delivery services despite the existence of a free maternity programme. The layout and equipment at health facilities offering care under pro-poor health financing policies were disability-unfriendly. The latter in addition to negative healthcare worker attitudes towards women with disabilities discouraged them from seeking care. Negative stereotypes against women with disabilities in the society led to their exclusion from public participation forums thereby limiting their awareness about health services., Conclusions: Intersections of gender, poverty, and disability influenced the experiences of women with disabilities living in poverty with pro-poor health financing policies in Kenya. Addressing the healthcare access barriers they face could entail ensuring availability of disability-friendly health facilities and public transport systems, building cultural competence in health service delivery, and empowering them to engage in public participation.

Social health insurance (SHI), one mechanism for achieving universal health coverage, has become increasingly important in low- and middle-income countries (LMICs) as they work to achieve this goal. Although small private providers supply a significant proportion of healthcare in LMICs, integrating these providers into SHI systems is often challenging. Public-private partnerships in health are one way to address these challenges, but we know little about how these collaborations work, how effectively, and why. Drawing on semi-structured interviews conducted with National Health Insurance (NHI) officials in Kenya and Ghana, as well as with staff from several international NGOs (INGOs) representing social franchise networks that are partnering to increase private provider accreditation into the NHIs, this article examines one example of public-private collaboration in practice. We found that interviewees initially had incomplete knowledge about the potential for cross-sector synergy, but both sides were motivated to work together around shared goals and the potential for mutual benefit. The public-private relationship then evolved over time through regular face-to-face interactions, reciprocal feedback, and iterative workplan development. This process led to a collegial relationship that also has given small private providers more voice in the health system. In order to sustain this relationship, we recommend that both public and private sector representatives develop formalized protocols for working together, as well as less formal open channels for communication. Models for aggregating small private providers and delivering them to government programmes as a package have potential to facilitate public-private partnerships as well, but there is little evidence on how these models work in LMICs thus far.

Health technology assessment (HTA) has previously been implemented only in a fragmented manner in the Ethiopian health sector decision-making cycle, and the sector has been hampered by limited institutional capacity and skilled human resources to inform evidence-based decision making. The country is in the midst of widescale implementation of a community-based health insurance scheme and is preparing for the launch of a social health insurance scheme. The country continues to face a limited financial resource envelope, undergoing an epidemiological transition, and is facing a much greater burden of noncommunicable diseases, for which the essential health benefit package, defined 12 years ago, may no longer be suitable. This has called for an in-depth review of the application of HTA in the context of the current health needs and institutional settings. To meet the increasing need for HTA, the Health Economics and Financing Analysis (HEFA) team was established within the Finance Resource Mobilization Department under the Ministry of Health. The HEFA team is tasked with spearheading the application of evidence-based health care decision making in Ethiopia by organizing available evidence, costing interventions, and defining effectiveness measures of the different health programs and then supporting policymakers at the national and regional levels. Improving and harmonizing the institutional approach to HTA, including staffing the HEFA team with the appropriate mix of expertise, and networking with relevant sector organizations will improve Ethiopia's ability to tackle the current health sector challenges as well as protect fledgling insurance schemes' progress toward universal health coverage., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Singapore and Hong Kong, two high-income "Tiger economies" in Asia, were ranked as the top two most efficient health systems in the world. Despite remarkable similarities in history and socioeconomic development, both economies embraced rather different paths in health care reforms in the past decades, which reflect their respective sociopolitical dynamics. Rapidly ageing populations and the anxiety about future funding of health care have prompted them to embark on major health financing reforms in the recent three years. While Singapore has transitioned to universal health coverage with the implementation of MediShield Life (MSL), Hong Kong is about to introduce the Voluntary Health Insurance Scheme (VHIS) to supplement its health care financing. Based on secondary materials including policy documents, press releases, and anecdotal reports, this essay compares these two recent reforms on their political context, drivers of reforms, and policy contents, and assesses their prospects in terms of coverage, financial protection, and major implementation challenges. The preliminary assessment suggests that while both programs are associated with certain drawbacks, those of the VHIS may be more fatal and warrant close attention. This essay concludes with a central caveat that underscores the pivotal role of the state in managing health care reforms., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Over past decades Activity Based Funding has been an attractive tool for hospital funding and governance, but there has been growing frustration especially with its unintended effects. There are numerous examples of alternative models, but there is little in-depth knowledge about how these models came about. The aim of our study was to analyse how the discourse of Activity Based Funding was successfully challenged. This contributes insights into how international/national debates are translated into concrete alternative models through specific discursive mechanisms. The analysis used a discursive policy approach and was based on a case study from Denmark ('New Governance'). The data consisted of project and policy documents as well as qualitative interviews with regional and national experts. The analysis identified four discursive mechanisms: the problem definitions underlying 'New Governance' were clear and simple; the underlying assumptions both accepted and challenged the premises of Activity Based Funding; the alternative of 'New Governance' was defined in rather broad terms; and it was produced, disseminated and defended as part of interweaving processes regionally but also nationally. Our study showed that new models of hospital funding and governance need to be carefully engineered and that they draw on a mix of governance logics. Future research needs to study more examples from a broad range of institutional contexts and points in time., (Copyright © 2018 Elsevier B.V. All rights reserved.)

This article reflects on the future of the Brazilian Unified Health System (SUS, acronym in Portuguese), based on the foresight exercises conducted by the Brasil Saúde Amanhã initiative of the Oswaldo Cruz Foundation. The text briefly reviews some paths followed by the SUS as referred to in the Federal Constitution of 1988. It highlights the movement towards the decentralization of care and the constraint of health financial resources that reduced policies of increasing public expenditures. It examines the public and private arrangements for financing and provision of services that have resulted in sectoral privatization, mainly from economic policies articulated with concession of fiscal benefits. It analyzes the changes in the public sector financing through successive constitutional amendments that resulted in the weakening of established social protection policies, particularly of the health sector. For the future, the text considers population aging and analyzes trends in the epidemiological profile, with consequent changes in the health care paradigm. The article concludes by pointing out the consequences of fiscal strangling in the organization of the healthcare system and the need to reverse legal provisions that hamper the fulfillment of the constitutional mandate for equity and universality.