Increasing health system synergies in low-income settings: Lessons learned from a qualitative case study of Rwanda.

Building synergies is seen as an effective strategy to address and decrease existing fragmentation in health systems of low-and middle-income countries (LMICs). To that end, different programmes, such as the Sector Wide Approach, have been adopted to increase health system synergies. Despite these efforts, fragmentation remains an enduring problem, hampering health system performance in LMICs. This study is part of the Lancet Commission on synergies between Universal Health Coverage, Health Security, and Health Promotion; we aimed to document synergising strategies adopted by Rwanda. Data for this paper came from a qualitative study including in-depth interviews of 15 key informants and a document review. A thematic analysis embracing deductive and inductive approaches was used to analyse the data. We found that Rwanda adopted three main strategies to increase health system synergies: (1) alignment of health programmes with national health policies and strategies, (2) increased coordination across national health institutions, and (3) effective monitoring and evaluation frameworks. Achieving synergies in a low-resource country is challenging but not impossible. To meet the target of global health agendas such as the Sustainable Development Goals and the prevention of future global pandemics, efforts to increase health system synergies in LMICs need to be strengthened.

Universal health coverage and the poor: to what extent are health financing policies making a difference? Evidence from a benefit incidence analysis in Zambia.

BACKGROUND: Zambia has invested in several healthcare financing reforms aimed at achieving universal access to health services. Several evaluations have investigated the effects of these reforms on the utilization of health services. However, only one study has assessed the distributional incidence of health spending across different socioeconomic groups, but without differentiating between public and overall health spending and between curative and maternal health services. Our study aims to fill this gap by undertaking a quasi-longitudinal benefit incidence analysis of public and overall health spending between 2006 and 2014. METHODS: We conducted a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies at three time points. We combined data from household surveys and National Health Accounts. RESULTS: Results showed that public (concentration index of - 0.003; SE 0.027 in 2006 and - 0.207; SE 0.011 in 2014) and overall (0.050; SE 0.033 in 2006 and - 0.169; SE 0.011 in 2014) health spending on curative services tended to benefit the poorer segments of the population while public (0.241; SE 0.018 in 2007 and 0.120; SE 0.007 in 2014) and overall health spending (0.051; SE 0.022 in 2007 and 0.116; SE 0.007 in 2014) on institutional delivery tended to benefit the least-poor. Higher inequalities were observed at higher care levels for both curative and institutional delivery services. CONCLUSION: Our findings suggest that the implementation of UHC policies in Zambia led to a reduction in socioeconomic inequality in health spending, particularly at health centres and for curative care. Further action is needed to address existing barriers for the poor to benefit from health spending on curative services and at higher levels of care.

How equitable is health spending on curative services and institutional delivery in Malawi? Evidence from a quasi-longitudinal benefit incidence analysis.

BACKGROUND: Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016. METHODS: We relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group. RESULTS: Socioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively. CONCLUSIONS: Through its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection.

Does the implementation of UHC reforms foster greater equality in health spending? Evidence from a benefit incidence analysis in Burkina Faso.

INTRODUCTION: Burkina Faso is one among many countries in sub-Saharan Africa having invested in Universal Health Coverage (UHC) policies, with a number of studies have evaluated their impacts and equity impacts. Still, no evidence exists on how the distributional incidence of health spending has changed in relation to their implementation. Our study assesses changes in the distributional incidence of public and overall health spending in Burkina Faso in relation to the implementation of UHC policies. METHODS: We combined National Health Accounts data and household survey data to conduct a series of Benefit Incidence Analyses. We captured the distribution of public and overall health spending at three time points. We conducted separate analyses for maternal and curative services and estimated the distribution of health spending separately for different care levels. RESULTS: Inequalities in the distribution of both public and overall spending decreased significantly over time, following the implementation of UHC policies. Pooling data on curative services across all care levels, the concentration index (CI) for public spending decreased from 0.119 (SE 0.013) in 2009 to -0.024 (SE 0.014) in 2017, while the CI for overall spending decreased from 0.222 (SE 0.032) in 2009 to 0.105 (SE 0.025) in 2017. Pooling data on institutional deliveries across all care levels, the CI for public spending decreased from 0.199 (SE 0.029) in 2003 to 0.013 (SE 0.002) in 2017, while the CI for overall spending decreased from 0.242 (SE 0.032) in 2003 to 0.062 (SE 0.016) in 2017. Persistent inequalities were greater at higher care levels for both curative and institutional delivery services. CONCLUSION: Our findings suggest that the implementation of UHC in Burkina Faso has favoured a more equitable distribution of health spending. Nonetheless, additional action is urgently needed to overcome remaining barriers to access, especially among the very poor, further enhancing equality.

The effect of performance-based financing on maternal healthcare use in Burundi: a two-wave pooled cross-sectional analysis.

BACKGROUND: Several developing countries, especially in Africa, have implemented performance-based financing (PBF) schemes with the aim of improving healthcare provision. PBF was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. OBJECTIVE: To enrich existing studies on Burundi in three ways. Firstly, by evaluating the effect of PBF on maternal care at primary and hospital levels; secondly, on the possession of maternity logbooks for maternal care records; and thirdly, how the amount of subsidies influences healthcare outputs. DESIGN: We used data from repeated cross-sectional surveys in 500 households (intervention group: 225; control group: 275) conducted in 2006 and 2008. A total of 274 women, aged 15-49, who had recently given birth, were interviewed about the use of maternal healthcare and the possession of maternity logbooks. We performed a difference-in-differences analysis using pooled cross-sectional survey data from 2006 and 2008. RESULTS: We found that PBF is associated with an increased institutional deliveries probability of 39.5 percentage points (p < 0.01) - a relative improvement of 81.8%. Institutional deliveries probability increased significantly only at health centre level by 33.6 percentage points (p < 0.01), a  relative rise of 80.6%. There is an indication of a positive spillover effect of PBF on the possession of maternity logbooks. We found no PBF effect on the number of antenatal care visits and anti-tetanus immunization. CONCLUSIONS: Our findings suggest that institutional delivery highly improved because it came from a low baseline and its unit payment was relatively high, leading health workers to promote its use. The fact that deliveries mainly increased in health centres and not in hospitals may be explained by the context of how health delivery is organized in Burundi. Health policymakers have to determine the appropriate financial incentives that best influence the improvement of each health service.

Physicians' and nurses' attitudes towards performance-based financial incentives in Burundi: a qualitative study in the province of Gitega.

BACKGROUND: Performance-based financing (PBF) was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. PBF is a reform approach to improve the quality, quantity, and equity of health services and aims at achieving universal health coverage. It focuses on how to best motivate health practitioners. OBJECTIVE: To elicit physicians' and nurses' experiences and views on how PBF influenced and helped them in healthcare delivery. METHODS: A qualitative cross-sectional study was carried out among frontline health workers such as physicians and nurses. The data was gathered through individual face-to-face, in-depth, semi-structured interviews with 6 physicians and 30 nurses from February to March 2011 in three hospitals in Gitega Province. A simple framework approach and thematic analysis using a combination of manual technique and MAXQDA software guided the analysis of the interview data. RESULTS: Overall, the interviewees felt that the PBF scheme had provided positive motivation to improve the quality of care, mainly in the structures and process of care. The utilization of health services and the relationship between health practitioners and patients also improved. The salary top-ups were recognized as the most significant impetus to increase effort in improving the quality of care. The small and sometimes delayed financial incentives paid to physicians and nurses were criticized. The findings of this study also indicate that the positive interaction between performance-based incentive schemes and other health policies is crucial in achieving comprehensive improvement in healthcare delivery. CONCLUSIONS: PBF has the potential to motivate medical staff to improve healthcare provision. The views of medical staff and the context of the area of implementation have to be taken into consideration when designing and implementing PBF schemes.

The effect of performance-based financial incentives on improving health care provision in Burundi: a controlled cohort study.

To strengthen the health care delivery, the Burundian Government in collaboration with international NGOs piloted performance-based financing (PBF) in 2006. The health facilities were assigned - by using a simple matching method - to begin PBF scheme or to continue with the traditional input-based funding. Our objective was to analyse the effect of that PBF scheme on the quality of health services between 2006 and 2008. We conducted the analysis in 16 health facilities with PBF scheme and 13 health facilities without PBF scheme. We analysed the PBF effect by using 58 composite quality indicators of eight health services: Care management, outpatient care, maternity care, prenatal care, family planning, laboratory services, medicines management and materials management. The differences in quality improvement in the two groups of health facilities were performed applying descriptive statistics, a paired non-parametric Wilcoxon Signed Ranks test and a simple difference-in-difference approach at a significance level of 5%. We found an improvement of the quality of care in the PBF group and a significant deterioration in the non-PBF group in the same four health services: care management, outpatient care, maternity care, and prenatal care. The findings suggest a PBF effect of between 38 and 66 percentage points (p<0.001) in the quality scores of care management, outpatient care, prenatal care, and maternal care. We found no PBF effect on clinical support services: laboratory services, medicines management, and material management. The PBF scheme in Burundi contributed to the improvement of the health services that were strongly under the control of medical personnel (physicians and nurses) in a short time of two years. The clinical support services that did not significantly improved were strongly under the control of laboratory technicians, pharmacists and non-medical personnel.