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.
The REMEDIAR Program, established during Argentina’s 2001–2002 crisis, provides free essential medicines to the uninsured population through direct delivery to more than 8,000 primary healthcare centers. Over two decades, the program has alternated between two financing models: international concessional loans from the Inter-American Development Bank (IDB) and national treasury funding. Using the Nexus Working Group framework linking public financial management to supply chain performance, this longitudinal single-case study (2002–2024) examines how each financing model shaped the program’s funding, procurement, and distribution. This study analyzes the two financing models of the REMEDIAR Program from 2002 to 2024, focusing on budgetary planning, procurement efficiency, and supply chain performance. We combined descriptive time-series analysis of budgetary and operational indicators with a review of normative and administrative documents; no causal effects are estimated. IDB-financed operations showed more stable budget execution, procurement timelines 48% shorter than nationally financed processes, and lower awarded prices, while treasury financing exhibited greater volatility tied to fiscal cycles and currency depreciation. Centralized procurement averaged 25% of market prices versus 46% under a decentralized subnational benchmark, though at the cost of slower formulary adaptation. Per-capita distribution was highest in poorer provinces, and declining household out-of-pocket spending on medicines was associated with periods of higher program intensity. The efficiencies observed under international financing reflect its associated management rules—multi-year budgeting, ring-fenced funds, predictable payments—rather than the source of funds itself. Internalizing these rules under domestic financing emerges as a key priority for the program’s sustainability.
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.
