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The international community increasingly acknowledges the contribution of health systems to climate change and environmental degradation: globally, the health sector contributed approximately 5% to greenhouse gas emissions in 2019. (1) [...]

There is increasing use of machine learning for the health financing functions (revenue raising, pooling and purchasing), yet evidence lacks for its effects on the universal health coverage (UHC) objectives. This paper provides a synopsis of the use cases of machine learning and their potential benefits and risks. The assessment reveals that the various use cases of machine learning for health financing have the potential to affect all the UHC intermediate objectives--the equitable distribution of resources (both positively and negatively); efficiency (primarily positively); and transparency (both positively and negatively). There are also both positive and negative effects on all three UHC final goals, that is, utilization of health services in line with need, financial protection and quality care. When the use of machine learning facilitates or simplifies health financing tasks that are counterproductive to UHC objectives, there are various risks--for instance risk selection, cost reductions at the expense of quality care, reduced financial protection or over-surveillance. Whether the effects of using machine learning are positive or negative depends on how and for which purpose the technology is applied. Therefore, specific health financing guidance and regulations, particularly for (voluntary) health insurance, are needed. To inform the development of specific health financing guidance and regulation, we propose several key policy and research questions. To gain a better understanding of how machine learning affects health financing for UHC objectives, more systematic and rigorous research should accompany the application of machine learning. Alors que l'apprentissage machine connait un usage croissant pour les fonctions de financement de la sante (collecte de revenus, mise en commun et achat), les preuves manquent quant a ses effets sur les objectifs de la couverture sanitaire universelle (CSU). Ce document presente une synthese des cas d'utilisation de l'apprentissage machine et de leurs avantages et risques potentiels. [(evaluation revele que les differents cas d'utilisation de l'apprentissage machine pour le financement de la sante sont susceptibles d'affecter tous les objectifs intermediaires de la CSU: la distribution equitable des ressources (a la fois positivement et negativement), l'efficacite (principalement positivement) et la transparence (a la fois positivement et negativement). Il existe egalement des effets positifs et negatifs sur les trois objectifs finaux de la CSU, a savoir l'utilisation des services de sante en fonction des besoins, la protection financiere et la qualite des soins. Lorsque l'utilisation de l'apprentissage machine facilite ou simplifie des taches de financement de la sante qui vont a lencontre des objectifs de la CSU, differents risques se font jour, comme la selection des risques, la reduction des couts au detriment de la qualite des soins, la reduction de la protection financiere ou la surveillance excessive. Les effets positifs ou negatifs de l'utilisation de l'apprentissage machine dependent de la maniere dont la technologie est appliquee et de l'objectif poursuivi. C'est pourquoi s'imposent des orientations et des reglementations specifiques en matiere de financement de la sante, en particulier pour l'assurance maladie (volontaire). Afin d'eclairer l'elaboration de telles orientations et reglementations, nous proposons plusieurs questions cles en matiere de politique et de recherche. Pour mieux comprendre la facon dont l'apprentissage machine affecte le financement de la sante dans le cadre des objectifs de la CSU, une recherche plus systematique et plus rigoureuse devrait accompagner la mise en oeuvre de l'apprentissage machine. Aunque el uso del aprendizaje automatico para las funciones de financiacion sanitaria (recaudacion de ingresos, mancomunacion y compra) es cada vez mayor, no hay evidencias de sus efectos sobre los objetivos de la cobertura sanitaria universal (CSU). Este documento ofrece una sinopsis de los casos de uso del aprendizaje automatico y sus posibles beneficios y riesgos. La evaluacion revela que los diversos casos de uso del aprendizaje automatico para la financiacion sanitaria tienen el potencial de afectar a todos los objetivos intermedios de la CSU: la distribucion equitativa de los recursos (tanto positiva como negativamente), la eficiencia (principalmente positiva) y la transparencia (tanto positiva como negativamente). Tambien hay efectos positivos y negativos en los tres objetivos finales de la CSU, es decir, la utilizacion de los servicios sanitarios en funcion de las necesidades, la proteccion financiera y la atencion de calidad. El uso del aprendizaje automatico para facilitar o simplificar tareas de financiacion sanitaria contraproducentes para los objetivos de la CSU plantea diversos riesgos, como la seleccion de riesgos, la reduccion de costes a expensas de la calidad de la atencion, la disminucion de la proteccion financiera o el exceso de vigilancia. El caracter positivo o negativo de los efectos del aprendizaje automatico depende de como y con que fin se aplique la tecnologia. Por lo tanto, se necesitan directrices y reglamentos especificos para la financiacion sanitaria, en particular para los seguros de salud (voluntarios). Proponemos varias preguntas clave en materia de politica e investigacion para contribuir a la elaboracion de directrices y reglamentos especificos sobre financiacion sanitaria. A fin de comprender mejor como afecta el aprendizaje automatico al logro de los objetivos de la CSU en el ambito de la financiacion sanitaria, la aplicacion del aprendizaje automatico deberia ir acompanada de una investigacion mas sistematica y rigurosa., Introduction Over the past 10 years, the number of publications on artificial intelligence and machine learning related to health financing tasks has markedly increased, (1) in line with the trend [...]

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 a ce que l'ensemble de la population ait acces a des services de sante de qualite sans encourir de difficultes financieres. Pour cela, trois fonctions de financement de la sante sont essentielles: le recouvrement des recettes, la mise en commun des fonds et l'achat de services de sante. Cet article s'interesse a la mise en commun, a savoir le recueil et la gestion de ressources financieres prepayees. La mise en commun permet de redistribuer les ressources afin d'offrir un acces equitable aux services necessaires et d'ameliorer la protection financiere meme en cas d'impossibilite de lever des recettes supplementaires pour la CSU. Or, dans de nombreux pays, les mecanismes de mise en commun sont tres fragmentes, ce qui fait obstacle a la redistribution. Cet article entend donner un apergu des possibilites de reforme en ce qui concerne la mise en commun afin d'aider les pays qui cherchent a ameliorer la redistribution des fonds. Nous presentons quatre grands types de reforme concernant la mise en commun et analysons le potentiel ainsi que les difficultes qu'ils presentent pour mettre un terme a la fragmentation du financement de la sante: (i) passage a une couverture obligatoire ou automatique pour tout le monde; (ii) fusion de differentes caisses afin d'augmenter le nombre de membres d'une meme caisse ainsi que la diversite de leurs besoins et de leurs risques; (iii) interfinancement des caisses dont les membres ont des revenus faibles et des risques eleves en matiere de sante; et (iv) harmonisation entre les caisses concernant, par exemple, les avantages, les modes de paiement et les tarifs. Les pays peuvent combiner plusieurs elements de reforme. La realisation du potentiel de redistribution grace a une reforme de la mise en commun depend aussi de l'alignement de la structure de mise en commun sur le recouvrement des recettes et les mecanismes d'achat. Enfin, l'etendue de la reforme est limitee par la faisabilite institutionnelle et politique, et l'economie politique relative a cette reforme de la mise en commun doit etre anticipee et geree. 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 recaudacion de ingresos, la mancomunacion de fondos y la compra de servicios de salud. Este articulo se centra en la mancomunacion: la acumulacion y gestion de recursos financieros prepagados. La mancomunacion crea oportunidades para la redistribucion de recursos que apoyan el acceso equitativo a los servicios necesarios y una mayor proteccion financiera, incluso si no se pueden recaudar ingresos adicionales para la CSU. Sin embargo, en muchos paises los acuerdos de mancomunacion estan muy fragmentados, lo que crea barreras a la redistribucion. El proposito de este articulo es proporcionar una vision general de las opciones de reforma de la mancomunacion para apoyar a los paises que estan explorando formas de mejorar la redistribucion de los fondos. Se describen cuatro grandes tipos de reformas de mancomunacion y se discuten sus potencialidades y desafios para abordar la fragmentacion del financiamiento de la salud: (i) pasar a una cobertura obligatoria o automatica para todos; (ii) fusionar diferentes fondos para aumentar el numero de miembros del fondo y la diversidad de las necesidades y riesgos de salud de los miembros del mismo; (iii) subvencion cruzada de fondos que tienen miembros con menores ingresos y mayores riesgos para la salud; y (iv) armonizacion entre los fondos, tales como beneficios, metodos de pago y tarifas. Los paises pueden combinar varios elementos de reforma. La realizacion efectiva del potencial de redistribucion mediante una reforma de la mancomunacion depende tambien de la alineacion de la estructura de la mancomunacion con los acuerdos de recaudacion de ingresos y compra. Por ultimo, el alcance de la reforma se ve limitado por la viabilidad institucional y politica, y es preciso anticipar y gestionar la economia politica en torno a la reforma de la mancomunacion., Introduction Universal health coverage (UHC) means that all people can access health services of good quality without experiencing financial hardship, with the objectives of equitable access in line with their [...]

Increasing overall fiscal space is important for the health sector due to the centrality of public financing to make progress towards universal health coverage. One strategy is to mobilize additional government revenues through new taxes or increased tax rates on goods and services. We illustrate how countries can assess the feasibility and quantitative potential of different revenue-raising mechanisms. We review and synthesize the processes and results from country assessments in Benin, Mali, Mozambique and Togo. The studies analysed new taxes or increased taxes on airplane tickets, phone calls, alcoholic drinks, tourism services, financial transactions, lottery tickets, vehicles and the extractive industries. Study teams in each country assessed the feasibility of new revenue-raising mechanisms using six qualitative criteria. The quantitative potential of these mechanisms was estimated by defining different scenarios and setting assumptions. Consultations with stakeholders at the start of the process served to select the revenue-raising mechanisms to study and later to discuss findings and options. Exploring feasibility was essential, as this helped rule out options that appeared promising from the quantitative assessment. Stakeholders rated stability and sustainability positive for most mechanisms, but political feasibility was a key issue throughout. The estimated additional revenues through new revenue-raising mechanisms ranged from 0.47-1.62% as a share of general government expenditure in the four countries. Overall, the revenue raised through these mechanisms was small. Countries are advised to consider multiple strategies to expand fiscal space for health. Il est important d'accroitre respace budgetaire global alloue a la sante en raison du caractere crucial du financement public pour accomplir des progres en faveur de la couverture sanitaire universelle. Une strategie consiste a mobiliser des fonds publics supplementaires par le biais de nouvelles taxes ou d'une augmentation des taux d'imposition applicables aux biens et aux services. Nous expliquons comment les pays peuvent evaluer la faisabilite et le potentiel quantitatif de differents mecanismes de mobilisation de fonds. Nous examinons et synthetisons les processus et les resultats devaluations nationales menees au Benin, au Mali, au Mozambique et au Togo. Ces etudes ont analyse la mise en place de nouvelles taxes ou la hausse de taxes sur les billets d'avion, les appels telephoniques, les boissons alcoolisees, les services touristiques, les transactions financieres, les billets de loterie, les vehicules et les industries extractives. Les equipes chargees des etudes au sein de chaque pays ont evalue la faisabilite des nouveaux mecanismes de mobilisation de fonds a l'aide de six criteres qualitatifs. Le potentiel quantitatif de ces mecanismes a ete estime en definissant differents scenarios et en formulant des hypotheses. Des consultations ont ete menees aupres des parties prenantes au debut du processus afin de selectionner les mecanismes de mobilisation de fonds a etudier et de discuter des resultats et des options a un stade ulterieur. Il etait essentiel d'etudier la faisabilite, car cela a permis d'ecarter les options qui semblaient prometteuses a partir de revaluation quantitative. Les parties prenantes ont juge la stabilite et la durability positives pour la plupart des mecanismes, mais la faisabilite politique a ete une question clef tout au long du processus. Nous avons estime que la part des fonds supplementaires generes par les nouveaux mecanismes de mobilisation de fonds dans les depenses generates de l'Etat allait de 0,47 a 1,67% dans les quatre pays. Dans l'ensemble, les fonds generes par ces mecanismes etaient de faible ampleur. Il est conseille aux pays d'envisager plusieurs strategies pour augmenter l'espace budgetaire alloue a la sante. El aumento del espacio fiscal general es importante para el sector de la salud debido al caracter central de la financiacion publica para avanzar hacia una cobertura sanitaria universal. Una estrategia consiste en movilizar fondos publicos adicionales mediante nuevos impuestos o aumentar los tipos impositivos sobre los bienes y servicios. A continuacion se ilustra como los paises pueden evaluar la viabilidad y el potencial cuantitativo de los diferentes mecanismos de recaudacion de fondos. Se han revisado y sintetizado los procesos y los resultados de las evaluaciones nacionales en Benin, Mali, Mozambique y Togo. Los estudios analizaron nuevos impuestos o la subida de los impuestos sobre los billetes de avion, las llamadas telefonicas, las bebidas alcoholicas, los servicios turisticos, las transacciones financieras, los billetes de loteria, los vehiculos y las industrias de extraccion. Los equipos de estudio de cada pais evaluaron la viabilidad de nuevos mecanismos de recaudacion de fondos mediante seis criterios cualitativos. El potencial cuantitativo de estos mecanismos se estimo mediante la definicion de diferentes escenarios y el establecimiento de supuestos. Las consultas con las partes interesadas al comienzo del proceso sirvieron para seleccionar los mecanismos de recaudacion de fondos que se estudiarian y posteriormente examinar las conclusiones y las opciones. Era esencial explorar la viabilidad, ya que ayudaba a descartar opciones que parecian prometedoras de la evaluacion cuantitativa. Las partes interesadas calificaron la estabilidad y la sostenibilidad como positivas para la mayoria de los mecanismos, pero la viabilidad politica fue una cuestion clave en todo momento. Los fondos adicionales estimados por medio de los nuevos mecanismos de recaudacion oscilaron entre el 0,47 % y el 1,62 % de los gastos de las administraciones publicas de los cuatro paises. En general, los fondos recaudados mediante estos mecanismos fueron reducidos. Se aconseja a los paises que consideren multiples estrategias para ampliar el espacio fiscal para la salud., Introduction Countries may need to raise additional funds to progress towards universal health coverage (UHC). This implies increasing the fiscal space for health. Fiscal space has been defined as 'the [...]

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run. [ABSTRACT FROM AUTHOR]

Objective This paper provides a comprehensive overview of hospital payment systems based on diagnosis-related groups (DRGs) in low-and middle-income countries. It also explores design and implementation issues and the related challenges countries face. Methods A literature research for papers on DRG-based payment systems in low- and middle-income countries was conducted in English, French and Spanish through Pubmed, the Pan American Health Organization's Regional Library of Medicine and Google. Findings Twelve low- and middle-income countries have DRG-based payment systems and another 17 are in the piloting or exploratory stage. Countries have chosen from a wide range of imported and self-developed DRG models and most have adapted such models to their specific contexts. All countries have set expenditure ceilings. In general, systems were piloted before being implemented. The need to meet certain requirements in terms of coding standardization, data availability and information technology made implementation difficult. Private sector providers have not been fully integrated, but most countries have managed to delink hospital financing from public finance budgeting. Conclusion Although more evidence on the impact of DRG-based payment systems is needed, our findings suggest that (i) the greater portion of health-care financing should be public rather than private; (ii) it is advisable to pilot systems first and to establish expenditure ceilings; (iii) countries that import an existing variant of a DRG-based system should be mindful of the need for adaptation; and (iv) countries should promote the cooperation of providers for appropriate data generation and claims management. Objectif Cet article donne un apercu complet des systemes de paiement des hopitaux bases sur les groupes homogenes de diagnostic (DRG) dans les pays a revenu faible et moyen. Il examine egalement les questions de conception et de mise en oeuvre, ainsi que les defis associes auxquels les pays font face. Methodes Une recherche documentaire sur les articles portant sur les systemes de paiement bases sur les groupes homogenes de diagnostic dans les pays a revenu faible et moyen a ete menee en anglais, francais et espagnol dans Pubmed, la Bibliotheque regionale de l'Organisation panamericaine de la Sante et Google. Resultats Douze pays a revenu faible et moyen ont des systemes de paiement bases sur les groupes homogenes de diagnostic et dix-sept autres pays sont en phase pilote ou exploratoire. Les pays ont fait un choix dans une vaste gamme de modeles de groupes homogenes de diagnostic importes ou developpes par eux-memes, et la plupart des pays ont adapte ces modeles a leurs contextes particuliers. Tous les pays ont defini un plafond de depenses. En general, les systemes ont ete testes en phase pilote avant d'etre mis en oeuvre. La necessite de repondre a certaines exigences en termes de normalisation des codes, de disponibilite des donnees et de technologie des informations a rendu la mise en oeuvre difficile. Les prestataires de service du secteur prive n'ont pas ete pleinement integres mais la majorite des pays ont reussi a dissocier le financement des hopitaux de la budgetisation des finances publiques. Conclusion Bien qu'il soit necessaire d'obtenir davantage de preuves sur l'impact des systemes de paiement bases sur les groupes homogenes de diagnostic, nos resultats suggerent que (i) la plus grande partie du financement des soins de sante devrait provenir du public plutot que du prive; (ii) il est recommande de tester d'abord les systemes en phase pilote et d'etablir des plafonds de depenses; (iii) les pays qui importent un modele existant d'un systeme base sur les groupes homogenes de diagnostic devraient etre conscients de la necessite de les adapter a leurs specificites; et (iv) les pays devraient promouvoir la cooperation de prestataires de service pour la production appropriee des donnees et la gestion des reclamations. Objetivo Este documento ofrece una vision global de los sistemas de pago hospitalario basados en grupos relacionados por el diagnostico (GRD) de paises de ingresos bajos y medianos. Ademas, se analizan los problemas de diseno y ejecucion, asicomo los desafios relacionados a los que se enfrentan los paises. Metodos Se llevo a cabo una investigacion bibliografica en ingles, frances y espanol de tra bajos sobre los sistemas de pago basados en GRD de paises de ingresos bajos y medianos a traves de Pubmed, la Biblioteca Regional de Medicina de la Organizacion Panamericana de la salud y Google. Resultados Doce paises de ingresos bajos y medianos tienen sistemas de pago basados en GRD y otros 17 se encuentran en fase experimental o exploratoria. Los paises han realizado una seleccion de entre un amplio abanico de modelos de GRD importados y de desarrollo propio y la mayoria han adaptado estos modelos a sus contextos locales. Todos los paises han establecido limites de gasto. En general, se pusieron a prueba los sistemas antes de su aplicacion. La aplicacion se ve dificultada por la necesidad de cumplir con ciertos requisitos en terminos de la normalizacion de la codificacion, la disponibilidad, la informacion y la tecnologia de la informacion. Los proveedores del sector privado no se han integrado plenamente, pero la mayoria de los paises han logrado desvincular el financiamiento hospitalario del presupuesto de las finanzas publicas. Conclusion Aunque se necesitan mas pruebas sobre el impacto de los sistemas de pago basados en GRD, nuestros resultados sugieren que (i) la mayor parte del financiamiento sanitario debe ser publico y no privado, (ii) se recomienda poner a prueba los sistemas previamente y establecer limites de gasto, (iii) los paises que importan una variante actual de un sistema basado en GRD deberian tener en cuenta la necesidad de adaptacion, y (iv) los paises deben promover la cooperacion de los proveedores a fin de que la generacion de datos y la gestion de siniestros sean adecuadas., Introduction A key factor for a more rapid move towards universal health coverage is the efficient use of resources, coupled with increased resource mobilization and improved pooling. Substantial efficiency gains [...]

In 2005, the Member states of WHO adopted a resolution encouraging countries to develop health financing systems capable of achieving and/or maintaining universal coverage of health services--where all people have access to needed health services without the risk of severe financial consequences. In doing this, a major challenge for many countries will be to move away from out-of-pocket payments, which are often used as an important source of fund collection Prepayment methods will need to be developed or expanded but, in addition to questions of revenue collection, specific attention will also have to be paid to pooling funds to spread risks and to enable their efficient and equitable use. Developing prepayment mechanisms may take time, depending on countries' economic, social and political contexts. Specific rules for health financing policy will need to be developed and implementing organizations will need to be tailored to the level that countries can support and sustain. In this paper we propose a comprehensive framework focusing on health financing rules and organizations that can be used to support countries in developing their health financing systems in the search for universal coverage. Une traduction en francais de ce resume figure a la fin de l'article. Al final del articulo se facilita una traduccion al espanol. En 2005, les Etats Membres de l'OMS ont adopte une resolution encourageant les pays a developper des systemes de financement de la sante capables de mettre en place et/ou de maintenir une couverture universelle des services de sante permettant a toutes les personnes d'avoir acces aux services sanitaires dont elles ont besoin sans risquer des consequences financieres graves. Dans cette voie, l'une des difficultes majeures pour de nombreux pays reside dans l'abandon du systeme des debours directs par les menages, qui sert frequemment de source importante de financement. II faut developper ou elargir des methodes de prepaiement, tout en accordant une attention particuliere non seulement aux questions de collecte des contributions, mais aussi a la mise en commun des fonds pour repartir les risques et permettre un usage efficace et equitable de ces fonds. La mise au point de mecanismes de prepaiement peut prendre du temps en fonction du contexte economique, social et politique qui regne dans les pays. II faut aussi elaborer des regles speciales pour les politiques de financement de la sante et adapter les organisations chargees de la mise en oeuvre de ces politiques en fonction du niveau que les pays sont en mesure de supporter et de maintenir. Nous proposons dans cet article un cadre complet, regissant principalement les regles et les organisations de financement de la sante, utilisable pour aider les pays a developper des systemes de financement de la sante orientes vers la realisation de la couverture universelle. En 2005 los Estados Miembros de la OMS adoptaron una resolucion en la que se alienta a los paises a desarrollar sistemas de financiacion sanitaria capaces de alcanzar o mantener la cobertura universal de servicios de salud: mecanismos para garantizar que toda la poblacion tenga acceso a los servicios de salud necesarios sin arriesgarse a sufrir consecuencias financieras graves. En ese empeno, un reto importante para muchos paises sera el de renunciar a los pagos directos, empleados a menudo como una fuente importante de fondos. Habra que desarrollar o expandir los metodos de prepago, pero, ademas de las cuestiones relativas a la recaudacion de ingresos, se debera prestar especial atencion a la mancomunacion de fondos, para repartir los riesgos y utilizar dichos fondos de formaeficiente y equitativa. El desarrollo de mecanismos de prepago puede requerir tiempo, segun el contexto economico, social y politico de los paises. Sera necesario elaborar normas especificas para las politicas de financiacion sanitaria y habra que adaptar las organizaciones ejecutoras a niveles que los paises puedan apoyar y mantener. En este articulo proponemos un marco integral centrado en las normas y organizaciones de financiacion de la salud que pueden utilizarse para ayudar a los paises a desarrollar sus sistemas de financiacion sanitaria en pro de la cobertura universal., Introduction Out-of-pocket payments create financial barriers that prevent millions of people each year from seeking and receiving needed health services (1,2) In addition, many of those who do seek and [...]

Abstract Background There is a serious human resource crisis in the health sector in developing countries, particularly in Africa. One of the challenges is the low motivation of health workers. Experience and the evidence suggest that any comprehensive strategy to maximize health worker motivation in a developing country context has to involve a mix of financial and non-financial incentives. This study assesses the role of non-financial incentives for motivation in two cases, in Benin and Kenya. Methods The study design entailed semi-structured qualitative interviews with doctors and nurses from public, private and NGO facilities in rural areas. The selection of health professionals was the result of a layered sampling process. In Benin 62 interviews with health professionals were carried out; in Kenya 37 were obtained. Results from individual interviews were backed up with information from focus group discussions. For further contextual information, interviews with civil servants in the Ministry of Health and at the district level were carried out. The interview material was coded and quantitative data was analysed with SPSS software. Results and discussion The study shows that health workers overall are strongly guided by their professional conscience and similar aspects related to professional ethos. In fact, many health workers are demotivated and frustrated precisely because they are unable to satisfy their professional conscience and impeded in pursuing their vocation due to lack of means and supplies and due to inadequate or inappropriately applied human resources management (HRM) tools. The paper also indicates that even some HRM tools that are applied may adversely affect the motivation of health workers. Conclusion The findings confirm the starting hypothesis that non-financial incentives and HRM tools play an important role with respect to increasing motivation of health professionals. Adequate HRM tools can uphold and strengthen the professional ethos of doctors and nurses. This entails acknowledging their professionalism and addressing professional goals such as recognition, career development and further qualification. It must be the aim of human resources management/quality management (HRM/QM) to develop the work environment so that health workers are enabled to meet their personal and the organizational goals.