In fragile states, healthcare delivery relies on non-state actors like NGOs and private providers. Short-term donor funding has created fragmented services and weak state capacity. However, donor-driven fragmentation is not only a technical coordination problem; it is also a political economy problem shaped by earmarking, attribution pressures, fiduciary risk aversion, donor-controlled contracts, and upward accountability to funders. We propose shifting from state-as-provider to state-as-steward, not as a choice between two mutually exclusive roles, but as a move toward pluralistic health-system stewardship in which the state may continue to provide some services while stewarding a mixed delivery system. This means integrating the “shadow health system” of non-state services into national health systems through licensing, contracting, and monitoring providers, while unified standards support coordination. Pooled or jointly governed financing, independent verification, shared reporting metrics, and community accountability are needed to align donor incentives with national priorities. Evidence from Afghanistan, Cambodia, Liberia, and other fragile settings demonstrates that contracting and regulation can improve access and oversight. Where governments lack legitimacy, territorial control, or impartiality, stewardship should be adapted through subnational, regional, hybrid, or independently verified mechanisms. Effective stewardship therefore requires rebalancing power, financing, risk, metrics, reporting, and accountability among donors, ministries, non-state actors, and communities.
Public Financial Management (PFM) reforms are being increasingly recognized for their potential to enhance health financing systems and advance progress toward Universal Health Coverage (UHC). Although theoretical frameworks have outlined the pathways through which PFM reforms operate, empirical evidence on their effectiveness in specific low- and middle-income country (LMIC) contexts remains limited. This paper examines the reform of the Single Nodal Agency (SNA) system in India, aimed at improving budget execution in centrally funded schemes, including the flagship health sector scheme, the National Health Mission (NHM). The study analyzes the gains and challenges associated with the reform and highlights the institutional features that are critical to its effectiveness. The study draws on an assessment of SNA implementation in two Indian states, Bihar and Odisha, using qualitative evidence from key informant interviews conducted across multiple administrative levels between February 2023 and February 2024. This was supplemented with data provided by state finance departments and NHM implementing agencies. Results indicate that the reform has achieved its intended gains in cash management, expenditure transparency, and improved alignment of central fund releases with scheme expenditures at the sub-national level. However, weak budget credibility, coupled with constraints in digital connectivity and limited personnel capacity to manage financial transactions, is likely to exacerbate inequities in access to scheme funds. The increased emphasis on spending has heightened compliance pressures on fund utilization, while attention to actual health system outcomes remains limited. In sum, a conducive institutional environment is essential for reaping benefits through PFM reforms in LMICs.
Health policy and systems research (HPSR) is a relatively young and multidisciplinary field of applied and policy-relevant science. It bridges the worlds of research, practice, and advocacy, and is dedicated to producing evidence to improve health policies and systems, while maintaining a focus on equity and social justice. The evidence around HPSR has grown significantly, but there is a paucity of reflections on HPSR as a field in a context of multiple inter-linked crises. This commentary reflects on key thematic, methodological, and value-driven trends in HPSR to underline its utility within the global health discourse and inform its prioritization. Key HPSR trends include increasingly multidisciplinary, participatory, and inclusive approaches and efforts toward decolonization. These reflect national and global societal priorities and respond to shifting burdens of communicable and non-communicable diseases, aging populations, rapid and uncontrolled urbanization, epidemics of infectious diseases, and climate emergency. Improved prioritization of HPSR nationally and globally, including dedicated and diversified funding for research and strengthening of local research and implementation capacities for HPSR, are particularly important in the current context of geopolitical and fiscal changes. Sustaining and growing HPSR can inform strong health systems and, ultimately, contribute to improved health and wellbeing.
The formal structures in a health system, characterized by the enforcement of rules and regulations, effective human resource management, and adequate funding, are critical contributors to effective governance and optimal health service delivery. Conversely, shortcomings in these domains could lead to poor accountability and corruption within the system. Therefore, this study assesses the state of Nigeria’s subnational governance structures that are conventionally and increasingly responsible for primary healthcare (PHC) delivery. In this qualitative phenomenological study, we conducted and analyzed interviews with senior managers within the PHC system. We found significant informalities and deficiencies in four areas: (a) absence of local interest in strengthening PHC, (b) weak documentation and enforcement of written rules, (c) poor practices and processes of human resource management, and (d) erratic financing of PHC. These deficiencies are seen to encourage the continuation of corruption and weaken institutional capacity to provide effective PHC. We argue that investing in PHC without first addressing these deficiencies as key aspects of subnational governance may result in wasted resources. Based on our findings, we present critical areas to consider for a well-governed PHC system to enhance accountability and address corruption at the healthcare level. The findings of this study are now more important than ever, particularly in light of a Supreme Court ruling on the autonomy of Local Government Areas (LGAs) in Nigeria and the push for state governments to ensure effective PHC services. The study demonstrates critical areas for strengthening the subnational administration of primary healthcare institutions across low- and middle-income countries (LMICs).
The field of planetary health ethics is beginning to emerge. This commentary represents a preliminary effort to articulate ethical principles for planetary health by considering three domains: (1) non-sentient nature, (2) non-human animals, and (3) human beings. The paper gives special attention to Japanese traditions and concepts as a possible basis for broader ethical principles that may be universally applicable to how we relate to nature, other animals, and human beings, in the pursuit of planetary health. Ultimately, the process of defining ethical principles for planetary health challenges us to move away from human-centered ethics and practices. It requires that we think of human beings as essentially part of the planet, spiritually connected to the natural elements and sentient animals around us (rather than viewing ourselves as the owners of the planet's resources, destined to consume nature and animals for our own purposes).
We live in an interdependent world riven by ideology, factions, and rivalries, and we face enormous challenges such as climate disruption, an aging population, and coping with the consequences of technologies such as gene editing and artificial intelligence. This paper considers global mega-challenges: huge problems that are unbounded by national borders; pose profound risk to humanity, often with unequal impact; and are complex, deeply rooted, multi-faceted, and inter-connected. After presenting seven illustrative mega-challenges, the paper introduces a “Ten-C” spectrum of relations between countries. Taking account of the philosophy of the renowned global leader in medicine Dr. Taro Takemi, the paper suggests positive ways that global collaboration in science, education, and health can lead to a more successful and resilient world.
Progress toward Universal Health Coverage (UHC) remains a priority for low- and middle-income countries (LMICs). For countries that have adopted Social Health Insurance (SHI) as a strategy, expanding coverage among informal sector households presents an important pathway to this goal. This scoping review examines strategies and interventions employed in LMICs to improve the enrollment and retention of informal sector households in SHI schemes. The review highlights common barriers, including irregular incomes, limited awareness, administrative challenges, and trust deficits. Potential strategies include designing flexible contribution mechanisms, simplified registration processes, targeted awareness campaigns, leveraging existing community structures, and designing comprehensive benefit packages that balance coverage goals with fiscal sustainability. Our findings emphasize the importance of context-specific and innovative approaches that could include tiered premiums, mobile payment platforms, and partnerships with microfinance institutions to address financial and logistical barriers. However, there is also evidence to suggest that net revenue gains from contributory mechanisms are typically modest, with enrollment expansion often requiring substantial public subsidies and incurring additional administrative costs. For Zambia, integrating some of these lessons into the National Health Insurance Scheme (NHIS) offers a pathway to enhancing coverage among the informal sector and advancing equitable access to healthcare, while acknowledging the fiscal constraints.
Previous studies have shown that facility autonomy, especially control over budget allocation, and management practices can have a modest positive effect on health facility performance, but the evidence is limited and often qualitative. Data from the evaluation of the Nigeria States Health Investment Project (NSHIP), a study that examined the effects of direct facility and performance-based financing, offers a novel opportunity to quantitatively examine these relationships in the context of a lower middle-income country. We utilize non-parametric statistics and regression methods to test the hypothesis that autonomy, supervision, and management affected facility performance. Results show that facilities with greater autonomy, more budget control, and better management practices generally outperform their peers on a range of facility readiness and service delivery measures. For example, regressions show that facilities with high autonomy held an additional 2.1 outreach sessions per month and facilities with a business plan offered 1.8 additional outreach services (p < 0.05). Supervision practices, including visit frequency and a quantitative checklist, are associated with 26% higher productivity and up to a 29% increase in equipment availability (p < 0.05). Sensitivity analyses validated that results are robust. We conclude that facility-level autonomy and especially budget control can improve primary healthcare facility readiness and service availability. Further, management practices that are reinforced through supportive supervision and routine monitoring can maximize the benefits that accrue from even small amounts of incremental financing. This shows that these policies and practices can contribute critically to efficiently achieving the goals of universal healthcare policies in the context of limited resources.
The Universal Health Care (UHC) Act in the Philippines aims to provide equitable access to quality and affordable health care. However, its implementation is hampered by significant financing and resource constraints. This study explores these challenges from the perspectives of various stakeholders, aiming to inform policy and improve the execution of the UHC Act. In this qualitative study, we conducted 17 focus group discussions and 19 key informant interviews between September 2023 and May 2024. Participants included national and local policymakers, public and private healthcare providers, and patients. The data were analyzed using the WHO’s health system financing framework, focusing on revenue raising, pooling, and purchasing. The findings reveal critical issues across all financing functions. Revenue-raising is undermined by a lack of funding for local government units and challenges in PhilHealth premium collection from the informal sector. In terms of pooling, the Special Health Fund is hindered by the absence of clear guidelines and delays in fund transfers. Purchasing is plagued by bureaucratic procurement processes, shortages of suppliers, and significant delays and issues in PhilHealth reimbursements. The optimal implementation of the UHC Act in the Philippines is impeded by interrelated financing and resource challenges. Addressing these challenges requires comprehensive reforms, including strengthening local health system integration, finalizing guidelines for local governments, and reforming procurement and PhilHealth’s payment systems.
Ethnic inequities in the receipt of medicines are influenced by a range of factors including inequities in the social determinants of health, barriers to accessing health care, and differences in quality of care. Policy decisions about medicines funding and eligibility play an important role in contributing to equity in access and equity in outcomes. This policy report analyzes the 2021 policy decision in Aotearoa New Zealand to use ethnicity as an explicit eligibility criterion for access to publicly funded sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists for type 2 diabetes. Advocacy for this policy decision was driven by Indigenous health experts, based on strong evidence of persisting ethnic inequities in diabetes prevalence, access to treatment, and outcomes. The impact this policy has had so far on inequities in receipt of diabetes treatment indicates that using explicit ethnicity-based eligibility criteria may help overcome some barriers to access to diabetes care, even in universal health care systems.
Diabetes and other chronic NCDs pose a major public health threat in Ghana, and where health systems are less developed and there are numerous competing societal priorities. This qualitative study examines the barriers hindering domestic financing and prioritization of diabetes and other NCDs in Ghana. The study applied Kingdon’s multiple stream framework using document reviews and face-to-face interviews with 29 key informants/stakeholders in the diabetes or NCD landscape in Ghana. Data from the document review and key informant interviews were thematically analyzed. The study revealed that at the problem stream level, diabetes and other NCDs are not yet sufficiently perceived by the general population and policy makers as major societal issues. Donors are also focusing on different health priorities. On the policy solution stream, many solutions are being initiated and developed by a rich array of policy entrepreneurs. The recent introduction of an excise tax bill on sugar-sweetened, alcoholic beverages and tobacco products suggests positive developments in the politics stream. The health financing system is advanced institutionally, and the country could rapidly convert a higher prioritization of diabetes into resource allocation if the macro-fiscal context permits it. The study concludes that applying Kingdon’s framework provides a nuanced understanding of the barriers, enablers, and opportunities for prioritizing NCDs in Ghana, and finds that policy prioritization will require political commitment from the upper echelon of government. Higher public awareness on the determinants and costs of NCDs would contribute to broad citizen support and the sustainability of the political commitment across successive governments.
Following the global health challenge of Ebola, the World Health Organization (WHO) developed a new approach to prioritizing health policy actions when both markets and government fail. The new approach, Common Goods for Health (CGH), is applied in this paper to identify priority actions to tackle failures in addressing the increasing prevalence of type 2 diabetes globally. National governments could realistically implement these actions to efficiently and equitably reduce the prevalence of type 2 diabetes, a non-communicable disease that is growing in every region of the world. The paper identifies three broad categories of CGH actions: (i) earlier risk identification; (ii) better communication for behavior change; and (iii) reforming tax/subsidy policies on food.
Non-communicable diseases (NCDs) represent the largest burden of disease, even in low-and middle-income countries (LMICs). The long latency period, chronicity, and common environmental, behavioral and genetic etiologies of NCDs-as shown through the example of Type 2 diabetes mellitus (T2DM)-expose health system failures to undertake multi-sectoral public health actions, address early detection, and provide integrated care. Development assistance for health (DAH), with its focus on donor priorities, often exacerbates such health system challenges. DAH has mainly focused on infectious diseases along with conditions related to reproductive health. Some programs show how DAH could help LMICs reorient health systems by focusing on neglected areas like economic and social policies, along with environmental and behavioral drivers of diseases like T2DM. Furthermore, in an era of declining resources for DAH, external support needs to be catalytic, supporting reforms more than financing services. Orienting limited DAH to address NCDs could support the necessary transformation of service organization, financial allocation criteria, data generation and use, health promotion, and training of care providers. DAH could also strengthen the public institutions and policies that prevent NCDs like T2DM through economic policies, environmental regulation, and health promotion interventions that address social and behavioral risk factors. Four broad categories of actions can guide DAH to better orient health systems to address NCDs: "First, do no harm," help transform health systems, think outside the box, and match tools to needs. Several existing assistance modalities are also presented to show specific ways that this reorientation can be implemented.
This commentary traces the origins of Japan's special education system and explores the need to equip preschool teachers with the specific knowledge and skills necessary to care for children under the age of six with disabilities during disasters in Japan. Japan's slow implementation of inclusive education, in which children with and without disabilities are educated together, was noted by the UN Committee on the Rights of Persons with Disabilities in 2022. The Committee also recommended improved care for persons with disabilities in disaster situations and humanitarian emergencies. Historically, Japan has promoted policies that segregate children with disabilities from children without disabilities. Integrated childcare began in the 1970s, but there continues to be a lack of suitable systems and practical guidelines for disaster management in inclusive childcare. The curricula of institutions that train childcare professionals were reviewed. As of April 1, 2023, there were 666 designated childcare teacher training institutions in Japan. Of these, 498 training institutions offered courses to obtain both kindergarten and nursery teaching licenses. Thirty-seven of the institutions were national and public schools, of which the present study included 36 schools whose syllabus was available online and whose course content could be confirmed. Only one school (2.8%) was found to include "disaster and childcare" in its curriculum, and three schools (8.3%) included "safety of children with disabilities" in their curriculum. Specialist disaster preparedness training to enable teachers to care for preschool children with disabilities in the event of a disaster is critical in the context of inclusive childcare.
The related overweight, obesity and diabetes epidemics are more than five decades old and have progressed inexorably. A billion people in the world are now obese, and nearly a billion are diabetic. The belief that diabetes is caused by overweight and obesity has led to public health advice focused on lifestyle change as the main preventive approach. This advice has shifted over time, and some parts of the public health community have started to switch from a lifestyle to an environmental perspective. There is a growing but not yet conclusive evidence base that rather than diabetes being caused by overweight and obesity, the three conditions have a common third cause, and difficulties in controlling weight and blood glucose emerge in tandem. New classes of medications, including semaglutides and tirzepatides, effectively address these processes. They are in the early stages of development but have accumulated a safety record over the last decade. They are largely currently available only to those who can afford their relatively high cost, but new generations of related medications are capable of becoming lower cost, and wider access to them could transform the overweight, obesity and diabetes pandemics. There is a marked absence of enthusiasm for their potential role in the public health community. This appears to reflect stigmatized attitudes to overweight and obesity, which contrast with attitudes to diabetes. A successful medical treatment may be the key to resolving that stigma and reversing the three pandemics.
This commentary examines Qatar's proactive approach to addressing the rising prevalence of Type 2 diabetes mellitus and associated non-communicable diseases within the Gulf Cooperation Council region. Following the 2012 STEPwise survey, which revealed a T2DM prevalence of 16.7%, Qatar launched the National Diabetes Strategy (2016-2022), focusing on six strategic pillars. Recent data from the 2023 STEPwise survey indicates a stabilization in diabetes (18.1%) and obesity (33.4%) rates, alongside other lifestyle factors, necessitating ongoing public health interventions. Qatar leverages innovative technologies and digital health initiatives to enhance diabetes care and disease surveillance. The establishment of national taskforces for obesity and childhood diabetes further exemplifies Qatar's commitment to a coordinated response. Future directions include the National Health Strategy (NHS-3): Action Plan 2024-2030, on Obesity, Diabetes, and Modifiable Risk Factors for Atherosclerotic Cardiovascular Diseases, which aims to strengthen screening and management activities. By fostering partnerships and prioritizing research, Qatar aspires to improve health outcomes and serve as a model for other nations facing similar health challenges.
Sri Lanka has one of the highest prevalence rates of diabetes, and improving diabetes control is a national priority. The care cascade framework, a tool for evaluating diabetes control and identifying system gaps, has not been assessed nationally in Sri Lanka. This study addresses this gap using data from a nationally representative longitudinal cohort. Using 2018-2019 data from the Sri Lanka Health and Ageing Study (SLHAS), we evaluated the diabetes care cascade, estimating levels of (i) prevalence, (ii) testing, (iii) diagnosis, (iv) awareness, (v) treatment, (vi) medication adherence, and (vii) control. Logistic regression assessed factors associated with step performance, and concentration indices quantified socioeconomic inequalities. Performance was benchmarked against other countries. In 4,827 participants the weighted diabetes prevalence was 23.2%. Of those with diabetes, 86.0% had been tested, 62.3% diagnosed, 58.6% aware, 44.7% treated, and 20.6% (hemoglobin A1c, HbA1c < 8.0%) and 12.4% (HbA1c < 7.0%) controlled. Older adults and those with hypertension achieved higher rates at all steps, while disparities by gender, education, location, and body mass index were minimal. Concentration indices confirmed pro-rich inequity from testing to treatment but revealed no significant inequity in control. Sri Lanka outperforms most low- and middle-income countries (LMICs) in testing, diagnosis, treatment, and disparities in coverage, reflecting underlying system strengths. But only one in five Sri Lankans with diabetes achieve control, with significant losses post-treatment. High diagnosis and treatment rates alone are insufficient; strategy must shift toward understanding the reasons for poor control. and improving treatment outcomes, a lesson with wider relevance.
Health systems worldwide face challenges in managing resource scarcity, necessitating systematic and fair approaches to prioritize essential health services. Practical guidance on structuring transparent and inclusive priority setting processes remains limited. This paper presents a 10-step method for designing fair priority-setting processes, demonstrated through the revision of the Zanzibar Essential Health Care Package (2019-2022). The 10-step method provides pragmatic and context-specific guidance, bridging the gap between global frameworks and local implementation in resource-limited settings. These 10 steps build upon recognized and accepted conditions and principles for health priorities and include: (1) development of a roadmap, (2) establishment of management, (3) selection of criteria for priority setting, (4) identification of candidate interventions, (5) formulation of financing strategies, (6) evidence generation, (7) employment of analytics, (8) setting priorities, (9) implementation arrangement, and (10) monitoring and evaluation to track implementation. The core team guided each step based on three fundamental principles-stakeholder involvement, transparency, and structured deliberation. In Zanzibar, consensus-building workshops were held to determine the criteria for setting priorities: cost-effectiveness, budget impact, disease burden, and equity. Political/public acceptability emerged as an additional criterion due to the challenges associated with including abortion services. Financial risk protection was deemed significant but was instead incorporated into the implementation and health financing plans. The core team offered preliminary training sessions on health priorities to stakeholders. This structured 10-step method encourages participation and inclusivity of marginalized groups usually excluded from such discussions, trust, and legitimacy in Essential Health Care Package processes, thereby providing policymakers with a tool for improvement.
