Health financing in fragile and conflict-affected settings: What do we know, seven years on?

Public health intervention amidst conflict: Violence, politics, and knowledge frames in the 2018-20 Ebola epidemic in Democratic Republic of the Congo

Research, policy, and donor interest in health systems in conflict environments has grown rapidly in recent years. The 2018-20 Ebola outbreak in Democratic Republic of the Congo is a critical case of healthcare militarization. The first-ever such outbreak in an active conflict zone, it grew notorious for violence against response teams, with attacks aggravating the spread of disease. However, while medical responders observed physical attacks, the causes of the violence remained largely unknown. Drawing on interviews and participant observation, we contribute civilian vantages of the way health intervention grew militarized, or associated with conflict. The argument builds in two core steps. A first reconstructs civilian experiences of conflict prior to Ebola to trace how the response took on a political meaning. We find that relationships linking state forces with the health response inadvertently tethered Ebola to what civilians perceived as security threats and that by repeating government statements about conflict, response teams unintentionally endorsed a version of the truth that silenced local voices. A second step addresses a central paradox: residents communicated these concerns directly, repeatedly, and via official response channels, yet healthcare teams failed to apply these insights. We locate this gap in the knowledge structures, or frames, accompanying intervention. Medical emergencies in warzones operate with dual sets of frames casting conflict players as "non-state" and public health resistance as "ignorance." Both frames intersect in ways that amplify invisibilities in each, clouding understandings of the nature of conflict and humanitarians' role in it. We suggest this places intervention teams at heightened risk of mis-stepping on political fault lines-and not understanding why. The study advances work on community engagement by showing that instead of simply providing scientific knowledge, effective engagement requires adjusting socio-political lenses within the response. It contributes to studies on health intervention, humanitarian emergencies, and the limits of medical neutrality.

Implementing and evaluating integrated care models for non-communicable diseases in fragile and humanitarian settings

In this commentary, we advocate for the wider implementation of integrated care models for NCDs within humanitarian preparedness, response, and resilience efforts. Since experience and evidence on integrated NCD care in humanitarian settings is limited, we discuss potential benefits, key lessons learned from other settings, and lessons from the integration of other conditions that may be useful for stakeholders considering an integrated model of NCD care. We also introduce our ongoing project in North Lebanon as a case example currently undergoing parallel tracks of program implementation and process evaluation that aims to strengthen the evidence base on implementing an integrated NCD care model in a crisis setting.

Scoping Review of Health Economics Research on Refugee Health in Sub-Saharan Africa

OBJECTIVES

Most refugees and internally displaced people (IDP) stay in low- and middle-income settings. A substantial proportion are hosted by countries in sub-Saharan African (SSA), which puts significant pressure on limited government healthcare budgets. As health economics may guide more optimal healthcare decision making, we scope the health economics literature on forcibly displaced populations in SSA to identify the nature and range of health economics evidence.

METHODS

We conducted a scoping review of peer-reviewed and gray literature in English published from 2000 to 2021. Our search terms comprised a combination of keywords related to refugees, SSA, and health economics. We followed a stepwise methodology consisting of the identification and selection of studies, extraction and charting of data.

RESULTS

We identified 29 health economics studies on refugees and IDPs in SSA covering different providers, interventions, and delivery platforms. Twenty-one articles studied the determinants of health, followed by 5 on the supply of healthcare and 2 concerned with economic evaluation and the demand for healthcare, respectively. We found an equal division of articles focusing on refugees and IDPs, as well as by settlement type. Mental health was the most frequently studied health area and Uganda was the most studied destination country.

CONCLUSIONS

The health economics literature on refugees in SSA remains limited. Our scoping review encourages future research to study a larger variety of healthcare systems and health economic topics such as economic evaluations, health financing and whole health systems to support resource allocation decisions and sustainable long-term solutions.

Health System Financing and Resource Allocation in Humanitarian Settings: Toward a Collaborative Policy Research Agenda in the Eastern Mediterranean Region

This article discusses key policy questions around health system financing in humanitarian settings, with specific reference to the Eastern Mediterranean region. We discuss key financing functions in the context of different challenges and the potential policy options for addressing these effectively. We also identify areas of collaborative research between academics, policy- and decision-makers and other stakeholders to inform appropriate policy choices that are aligned to universal health coverage in such challenging contexts.

The Governance of Childhood Vaccination Services in Crisis Settings: A Scoping Review

The persistence of inadequate vaccination in crisis-affected settings raises concerns about decision making regarding vaccine selection, timing, location, and recipients. This review aims to describe the key features of childhood vaccination intervention design and planning in crisis-affected settings and investigate how the governance of childhood vaccination is defined, understood, and practised. We performed a scoping review of 193 peer-reviewed articles and grey literature on vaccination governance and service design and planning. We focused on 41 crises between 2010 and 2021. Following screening and data extraction, our analysis involved descriptive statistics and applying the governance analysis framework to code text excerpts, employing deductive and inductive approaches. Most documents related to active outbreaks in conflict-affected settings and to the mass delivery of polio, cholera, and measles vaccines. Information on vaccination modalities, target populations, vaccine sources, and funding was limited. We found various interpretations of governance, often implying hierarchical authority and regulation. Analysis of governance arrangements suggests a multi-actor yet fragmented governance structure, with inequitable actor participation, ineffective actor collaboration, and a lack of a shared strategic vision due to competing priorities and accountabilities. Better documentation of vaccination efforts during emergencies, including vaccination decision making, governance, and planning, is needed. We recommend empirical research within decision-making spaces.

Third party monitoring for health in Afghanistan: the good, the bad and the ugly

Third party monitoring (TPM) is used in development programming to assess deliverables in a contract relationship between purchasers (donors or government) and providers (non-governmental organisations or non-state entities). In this paper, we draw from our experience as public health professionals involved in implementing and monitoring the Basic Package of Health Services (BPHS) and the Essential Package of Hospital Services (EPHS) as part of the SEHAT and Sehatmandi programs in Afghanistan between 2013 and 2021. We analyse our own TPM experience through the lens of the three parties involved: the Ministry of Public Health; the service providers implementing the BPHS/EPHS; and the TPM agency responsible for monitoring the implementation. Despite the highly challenging and fragile context, our findings suggest that the consistent investments and strategic vision of donor programmes in Afghanistan over the past decades have led to a functioning and robust system to monitor the BPHS/EPHS implementation in Afghanistan. To maximise the efficiency, effectiveness and impact of this system, it is important to promote local ownership and use of the data, to balance the need for comprehensive information with the risk of jamming processes, and to address political economy dynamics in pay-for-performance schemes. Our findings are likely to be emblematic of TPM issues in other sectors and other fragile and conflicted affected settings and offer a range of lessons learnt to inform the implementation of TPM schemes.

Ensuring leadership at the operational level of a health system in protracted crisis context: a cross-sectional qualitative study covering 8 health districts in Eastern Democratic Republic of Congo

BACKGROUND

This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC.

METHODS

A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC's health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service's Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes.

RESULTS

The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone's external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership.

CONCLUSIONS

Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings.

An in-depth qualitative study of health care providers' experiences of performance-based financing program as a nation-wide adopted policy in Cameroon: A principal-agent perspective

OBJECTIVES

The study applies the principal-agent approach to explore providers' experiences before and after the introduction of performance-based financing (PBF) in Cameroon, challenges and facilitators in the implementation process, and mechanisms in place to ensure sustainability.

METHODS

The study was an in-depth qualitative study whose goal was to provide multiple descriptions of experiences and insights from a principal-agent analysis perspective. Purposive sampling was used to identify the key characteristics of the participants relevant to the study. A snowballing technique was used to further identify eligible participants. Only healthcare providers who were exposed to the previous system and could reflect on and provide meaningful data that captured the everyday experiences before and after the implementation of PBF were included. Data were collected from three districts in the Southwest region of Cameroon from May 2021 to August 2021. Data were transcribed and analyzed using MaxQDA.

RESULTS

A total of 17 interviews and 3 focus group discussions (24 participants) were conducted with healthcare providers and key stakeholders involved in PBF. The respondents described a range of changes that they had experienced since the introduction of PBF. Each of these changes was categorized as either positive or negative. Positive changes were framed into 14 dominant categories: motivation, negotiations, innovation, resource allocation, autonomy, decentralization, transparency, improved quality of care, separation of function, performance, equity considerations, opportunity to recruit, participation in decision-making, and improved access to and utilization of maternal health services. The main challenges (negative experiences) reported were framed into nine categories: management of change, retention issues, conflict of interest, poor understanding of the PBF concept, resistance to change, verification challenges, delays in payment of PBF incentives, data entry and documentation, and challenges in meeting the equity considerations of the poor and vulnerable. Despite the challenges, providers preferred the decentralized approach to the centralized system.

CONCLUSION

PBF is a national strategy for achieving universal health coverage in Cameroon, and the experiences of providers provide a vital guide to refine national policy. The introduction of PBF has provided positive changes to providers' quality of care when compared to the previous system. Addressing the delays in PBF payments will help to overcome the challenges to implementation and provide opportunities for health facilities to be more efficient and improve their performance. Despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal).

Profile of health care workers in a context of instability: a cross-sectional study of four rural health zones in eastern DR Congo (lessons learned)

BACKGROUND

The crisis in human resources for health is observed worldwide, particularly in sub-Saharan Africa. Many studies have demonstrated the importance of human resources for health as a major pillar for the proper functioning of the health system, especially in fragile and conflict-affected contexts such as DR Congo. However, the aspects relating to human resources profile in relation to the level of performance of the health districts in a particular context of conflicts and multiform crises have not yet been described.

OBJECTIVE

This study aims to describe the profile of staff working in rural health districts in a context of crisis and conflicts.

METHODS

A cross-sectional study was carried out from May 15, 2017 to May 30, 2019 on 1090 health care workers (HCW) exhaustively chosen from four health districts in Eastern Democratic Republic of Congo (Idjwi, Katana, Mulungu and Walungu). Data were collected using a survey questionnaire. The Chi² test was used for comparison of proportions and the Kruskal-Wallis test for medians. As measures of association, we calculated the odds ratios (OR) along with their 95% confidence interval. The α-error cut-off was set at 5%.

RESULTS

In all the health districts the number of medical doctors was very insufficient with an average of 0.35 medical doctors per 10,000 inhabitants. However, the number of nurses was sufficient, with an average of 3 nurses per 5000 inhabitants; the nursing / medical staff (47%) were less represented than the administrative staff (53%). The median (Min-Max) age of all HCW was 46 (20-84) years and 32% of them were female. This was the same for the registration of staff in the civil service (obtaining a registration number). The mechanism of remuneration and payment of benefits, although a national responsibility, also suffered more in unstable districts. Twenty-one percent of the HCW had a monthly income of 151USD and above in the stable district; 9.2% in the intermediate and 0.9% in the unstable districts. Ninety-six percent of HCW do not receive Government' salary and 64% of them do not receive the Government bonus.

CONCLUSION

The context of instability compromises the performance of the health system by depriving it of competent personnel. This is the consequence of the weakening of the mechanisms for implementing the practices and policies related to its management. DR Congo authorities should develop incentive mechanisms to motivate young and trained HCW to work in unstable and intermediate health districts by improving their living and working conditions.

Conducting rapid research to aid the design of a health systems governance intervention in the Somali Region of Ethiopia

INTRODUCTION

The rapid research described in this chapter was conducted as an assignment for a UN agency in Ethiopia's Somali Region. The agency's aim was support the implementation of an interim citizen engagement intervention, with a view of supporting of the Ethiopian Government's Citizen Score Card at primary healthcare facilities and hospitals in future. Many health facilities in Somali Region struggle with budget shortages related to ineffective budget planning and budget execution at woreda health office levels. In this context, an intervention to first improve budget accountability, through the implementation of citizen audits, was proposed.

METHODOLOGY

The rapid study focused on five woredas (districts) within Somali Region, where interviews were conducted with the heads of woreda health offices. In the same five woredas, directors of healthcare facilities were interviewed and offices and healthcare facilities were observed. The framework of assessment and analysis was based on health systems literature on fragile and conflict affected states guided the questions for the health authorities and health facility management.

FINDINGS

The research yielded five distinct mini case studies covering woreda health office planning and budgeting capacity and support (or lack thereof), and related impressions of challenges regarding healthcare delivery at health facilities in the same five woredas.

RESULTS

The findings demonstrated that the capacity for healthcare planning and budgeting Somali Region at woreda level varied significantly and that little guidance was available from regional level health authorities. Frontline health services clearly suffered from budget shortages as a result.

CONCLUSION

The research provided an evidence base for the delay of the roll-out of the Community Scorecard implementation across Somali Region. In a context whereby health facilities remain under-resourced due to budgeting constraints, a citizen-service provider-focused accountability intervention would have been of limited utility. The rapid case study research, conducted by condensing the usual case study research process, allowed for the production of evidence that was "robust enough" to demonstrate heterogeneity and challenges regarding budgeting quality across the five research sites. This evidence clearly transcended the hitherto anecdotal evidence that woreda-level health budget planning remains an area that faces significant shortcomings.

Aid and forgetting the enemy: A systematic review of the unintended consequences of international development in fragile and conflict-affected situations

Fragile and conflict-affected situations (FCAS) are a significant focus area of international development efforts, with corresponding sizable investments by global donors. When implementing development assistance programmes in this context, the risk of unintended consequences tends to be higher as the conflict tends to increase complexity, and typically, FCAS development programmes are designed to deliver benefits only to parties on one side of the conflict. Searching for new insights, a systematic review of 121 documents was used to identify specific types of unintended consequences, their frequency and the nature of management strategies used to address them. Examination of these documents identified aggravation of the conflict and unintended support either for the opposing side's military regime or a non-state actor was the most common unintended consequence. As nearly all assessments only considered the nature of consequences from the donor's viewpoint, we conclude that there may be a case for assessing impacts from the alternative viewpoint - that is, of unsupported parties to the conflict. More generally, we conclude that FCAS programme guidelines would benefit from the development and deployment of more rigorous evaluation methods and the codifying of unintended consequences terminology.

Healthcare Management: A Bibliometric Analysis Based on the Citations of Research Articles Published between 1967 and 2020

The purpose of this study is to analyse the trends manifested in research literature from the field of healthcare management, with emphasis on bibliometric features and different influencing factors. For this, a search was conducted of nine academic databases between January and May 2021. Article features were registered in our database after first applying the validation criteria used for their inclusion. Then, data regarding the publication of the included articles were collected. The analysis focused on trends over time, topic, and journals in which they were published. Moreover, the effect of some factors on the citation of articles was analysed. Our results showed that the 250 analysed articles were published in 139 journals, and many of were by researchers affiliated with universities in the United States. Over time, the publication of analysed articles and their number of citations registered a continuous increase. The most common topics of focus were healthcare management systems and their challenges. In our study, we identified factors that significantly affect citation number, such as number of years since publication, the number of words in the title, and the number of authors of an article. In addition, major gaps were identified, as were new unresolved challenges that can trigger new research ideas.

Analysis of health overseas development aid for internally displaced persons in low- and middle-income countries

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First detailed analysis of overseas development aid (ODA) for the health of IDPs.

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Reports low and declining health ODA for IDPs.

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Indicates major inequity in health ODA for IDPs compared to refugees.

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Negligible ODA for IDPs was for non-communicable diseases and mental health.

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Health ODA for IDPs did not appear to be related to IDP health needs.

Background

There are an estimated 55 million internally displaced persons (IDPs) globally. IDPs commonly have worse health outcomes than host populations and other forcibly displaced populations such as refugees. Official development assistance (ODA) is a major source of the global financial response for health in low- and middle-income countries (LMICs), including for populations affected by armed conflict and forced displacement. Analysis of ODA supports efforts to improve donor accountability, transparency and the equitable use of ODA. The aim of this study is to examine international donor support and responsiveness to IDP health needs through analysis of ODA disbursements to LMICs between 2010 and 2019.

Methods

ODA disbursement data to LMICs from 2010 to 2019 were extracted from the Creditor Reporting System (CRS) database and analysed with Stata software using a combination of: (i) text searching for IDP and refugee related terms; and (ii) relevant health and humanitarian CRS purpose codes. Descriptive analysis was used to examine patterns of ODA disbursement, and nonlinear least squared regression analysis was used to examine responsiveness of ODA disbursement to recipient country IDP population size and health system capacity and health characteristics.

Findings

The study highlighted declining per IDP capita health ODA from USD 5.34 in 2010 to USD 3.72 in 2019 (with annual average decline of -38% from the 2010 baseline). In contrast, health ODA for refugees in LMICs increased from USD 18.55 in 2010 to USD 23.31 in 2019 (with an annual average increase of +14%). Certain health topics for IDPs received very low ODA, with only 0.44% of IDP health ODA disbursed for non-communicable diseases (including mental health). There was also weak evidence of IDP health ODA being related to recipient country IDP population size, and health system capacity and health characteristics. The paper highlights the need for increased investment by donors in IDP health ODA and to ensure that it is responsive to their health needs.

Women's empowerment and fertility preferences of married women: analysis of demographic and health survey’2016 in Timor-Leste

A recently independent state, Timor-Leste, is progressing towards socioeconomic development, prioritizing women empowerment while its increased fertility rate (4.1) could hinder the growth due to an uncontrolled population. Currently, limited evidence shows that indicators of women's empowerment are associated with fertility preferences and rates. The objective of this study was to assess the association between women empowerment and fertility preferences of married women aged 15 to 49 years in Timor-Leste using nationally representative survey data. The study was conducted using the data of the latest Timor-Leste Demographic and Health Survey 2016. The study included 4040 rural residents and 1810 urban residents of Timor-Leste. Multinomial logistic regression has been performed to assess the strength of association between the exposures indicating women's empowerment and outcome (fertility preference). After adjusting the selected covariates, the findings showed that exposures that indicate women empowerment in DHS, namely, the employment status of women, house and land ownership, ownership of the mobile phone, and independent bank account status, contraceptive use, and the attitude of women towards negotiating sexual relations are significantly associated with fertility preferences. The study shows higher the level of education, the less likely were the women to want more children, and unemployed women were with a higher number of children. Our study also found that the attitude of violence of spouses significantly influenced women's reproductive choice. However, employment had no significant correlation with decision-making opportunities and contraceptive selection due to a lack of substantial data. Also, no meaningful data was available regarding decision-making and fertility preferences. Our findings suggest that women's empowerment governs decision-making in fertility preferences, causing a decline in the fertility rate.

[Contrat unique, une approche innovante de financement du niveau intermédiaire du système de santé en République Démocratique du Congo : processus et défis de mise en œuvre]

Basket fund, an innovative approach for intermediate health system level financing in the Democratic Republic of Congo: Implementation process and challenges.

Health financing for universal health coverage in Sub-Saharan Africa: a systematic review

BACKGROUND

Universal health coverage (UHC) embedded within the United Nations Sustainable Development Goals, is defined by the World Health Organization as all individuals having access to required health services, of sufficient quality, without suffering financial hardship. Effective strategies for financing healthcare are critical in achieving this goal yet remain a challenge in Sub-Saharan Africa (SSA). This systematic review aims to determine reported health financing mechanisms in SSA within the published literature and summarize potential learnings.

METHODS

A systematic review was conducted aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. On 19 to 30 July 2019, MEDLINE, EMBASE, Web of Science, Global Health Database, the Cochrane Library, Scopus and JSTOR were searched for literature published from 2005. Studies describing health financing approaches for UHC in SSA were included. Evidence was synthesised in form of a table and thematic analysis.

RESULTS

Of all records, 39 papers were selected for inclusion. Among the included studies, most studies were conducted in Kenya (n = 7), followed by SSA as a whole (n = 6) and Nigeria (n = 5). More than two thirds of the selected studies reported the importance of equitable national health insurance schemes for UHC. The results indicate that a majority of health care revenue in SSA is from direct out-of-pocket payments. Another common financing mechanism was donor funding, which was reported by most of the studies. The average quality score of all studies was 81.6%, indicating a high appraisal score. The interrater reliability Cohen's kappa score, κ=0.43 (p = 0.002), which showed a moderate level of agreement.

CONCLUSIONS

Appropriate health financing strategies that safeguard financial risk protection underpin sustainable health services and the attainment of UHC. It is evident from the review that innovative health financing strategies in SSA are needed. Some limitations of this review include potentially skewed interpretations due to publication bias and a higher frequency of publications included from two countries in SSA. Establishing evidence-based and multi-sectoral strategies tailored to country contexts remains imperative.

Health-related publications on people living in fragile states in the alert zone: a bibliometric analysis

Background

Fragile states pose a global challenge. Assessing health research activity on people living in these states can help identify neglected health domains in fragile settings. The objective of the current study was to assess and describe health research activity on people living in fragile states in the alert zone.

Method

A bibliometric method was applied using SciVerse Scopus. Research articles published on people in fragile states in the alert zone were retrieved and analyzed. The Fragile State Index (FSI) score was used for selection of states in the alert zone. The analysis was limited to 1 year; 2018.

Results

The search query found 2299 research articles giving an average of 2 research articles per one million population per year in the selected fragile states. The number of research articles per one million population was not significantly correlated (p = 0.053; r = − 0.349) with FSI scores. However, it was significantly correlated with the extent of international research collaboration (p < 0.01, r = 065). Research on communicable diseases was the largest research domain (763 articles; 33.2%) followed by maternal/women’s health (430 articles; 18.7%), non-communicable diseases (291 articles; 12.7%), health system/policy (271 articles; 11.8%) and psychosocial and mental health (89; 3.9%). There were three research themes in the research domain of infectious diseases: HIV/AIDS; water-borne infectious diseases; and miscellaneous infectious diseases such as tuberculosis and malaria. The top ten cited articles were mainly on infectious diseases, particularly on malaria and Lassa fever. Of all the retrieved documents, 727 (31.6%) research articles appeared in national/regional journals while the remaining appeared in international journals. The World Health organization was the most active funding organization for research on fragile states. Top ten active institutions were mainly based in fragile states with the lowest FSI score, specifically Ethiopia, Uganda, Nigeria, and Pakistan.

Conclusion

Research on fragile states was relatively low. Research on mental health and health system/policy should be encouraged. Collaboration and funding might help academic institutions in fragile states to make health problems in these countries more visible.

Bibliometric analysis of scientific publications on "sustainable development goals" with emphasis on "good health and well-being" goal (2015-2019)

BACKGROUND

Global progress in the United Nations' Sustainable Development Goals (SDGs) requires significant national and international research efforts and collaboration. The current study aimed to provide policymakers, academics, and researchers with a snapshot of global SDGs-related research activity.

METHOD

This was a cross-sectional descriptive bibliometric study. SciVerse Scopus was used to retrieve SDGs-related research publications for the period from 2015 to 2019.

RESULTS

In total, 18,696 documents were found. The Sustainability journal ranked first (n = 1008; 5.4%) in the number of SDGs-related publications. The World Health Organization was the most active institution in publishing SDGs-related documents (n = 581; 1.3%). Most of the retrieved documents belonged to SDG 17 (partnership) followed by SDG 13 (climate action), and SDG 12 (responsible consumption and production), while SDG 7 (affordable and clean energy) had the least number of publications. The European region (n = 9756; 52.2%) had the highest research contribution while the Eastern Mediterranean region (n = 1052; 5.6%) had the least contribution. After exclusion of SDG 17, the SDG 3 (good health and well-being) was the top researched SDG for the African region, the Eastern Mediterranean regions, and the South-Eastern Asian region. For the region of the Americas, European region, and the Western Pacific region, the SDG 13 (climate action) was the most researched. The SDG 7 (affordable and clean energy) was the least researched in the African region, the region of the Americas, the European region, and the South-East Asian region. In the Eastern Mediterranean region, SDG 10 (reduced inequality) was the least researched while in the Western Pacific region, SDG 5 (gender inequality) was the least researched. The most researched targets of SDG 3 were targets 7 (sexual and reproductive health services) and 8 (universal health coverage) while the least researched targets were 5 (substance use disorders) and 9 (death from hazardous materials). International research collaboration within SDG 3 between high- and low-income countries was inadequate.

CONCLUSION

The analysis presented in the current study are useful for researchers, institutes, governments, funding agencies, and policy-makers. Countries in Africa, the Middle East, and South-East Asia need to increase their funding and research collaboration in the field of SDGs.

Results-based financing as a strategic purchasing intervention: some progress but much further to go in Zimbabwe?

BACKGROUND

Results-Based Financing (RBF) has proliferated in the health sectors of low and middle income countries, especially those which are fragile or conflict-affected, and has been presented by some as a way of reforming and strengthening strategic purchasing. However, few if any studies have empirically and systematically examined how RBF impacts on health care purchasing. This article examines this question in the context of Zimbabwe's national RBF programme.

METHODS

The article is based on a documentary review, including 60 documents from 2008 to 2018, and 40 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in Zimbabwe. Interviews and analysis of both datasets followed an existing framework for strategic purchasing, adapted to reflect changes over.

RESULTS

We find that some functions, such as assessing service infrastructure gaps, are unaffected by RBF, while others, such as mobilising resources, are partially affected, as RBF has focused on one package of care (maternal and child health services) within the wider essential health care, and has contributed important but marginal costs. Overall purchasing arrangements remain fragmented. Limited improvements have been made to community engagement. The clearest changes to purchasing arrangements relate to providers, at least in relation to the RBF services. Its achievements included enabling flexible resources to reach primary providers, funding supervision and emphasising the importance of reporting.

CONCLUSIONS

Our analysis suggests that RBF in Zimbabwe, at least at this early stage, is mainly functioning as an additional source of funding and as a provider payment mechanism, focussed on the primary care level for MCH services. RBF in this case brought focus to specific outputs but remained one provider payment mechanism amongst many, with limited traction over the main service delivery inputs and programmes. Zimbabwe's economic and political crisis provided an important entry point for RBF, but Zimbabwe did not present a 'blank slate' for RBF to reform: it was a functional health system pre-crisis, which enabled relatively swift scale-up of RBF but also meant that the potential for restructuring of institutional purchasing relationships was limited. This highlights the need for realistic and contextually tailored expectations of RBF.