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BACKGROUND: The emergence of Global Health Initiatives (GHIs) has been a major feature of the aid environment of the last decade. This paper seeks to examine in depth the behaviour of two prominent GHIs in the early stages of their operation in Uganda as well as the responses of the government. METHODS: The study adopted a qualitative and case study approach to investigate the governance of aid transactions in Uganda. Data sources included documentary review, in-depth and semi-structured interviews and observation of meetings. Agency theory guided the conceptual framework of the study. RESULTS: The Ugandan government had a stated preference for donor funding to be channelled through the general or sectoral budgets. Despite this preference, two large GHIs opted to allocate resources and deliver activities through projects with a disease-specific approach. The mixed motives of contributor country governments, recipient country governments and GHI executives produced incentive regimes in conflict between different aid mechanisms. CONCLUSION: Notwithstanding attempts to align and harmonize donor activities, the interests and motives of the various actors (GHIs and different parts of the government) undermine such efforts.

AbstractThis paper reviews the current evidence base regarding efforts to overcome constraints to effective health service delivery in low and middle‐income countries. A systematic literature review was chosen as the approach to gather and analyse existing knowledge about how to improve the 'close‐to‐client' health system. We focused on three levels of constraints: community and household, the health services delivery level itself, and health sector policy and strategic management. In total, 116 studies were reviewed and their main findings presented. The results should be interpreted with caution due to the considerable limitations in the existing evidence base. Copyright © 2003 John Wiley & Sons, Ltd.

AbstractA key issue in the expansion of access to priority health services is how best to implement scaling up efforts. In this paper, we explore the relative merits of vertical and horizontal delivery modes; review the literature on the impact of vertical programmes on health systems and on experiences of integrating these programmes; and analyse health interventions in terms of their different modes of delivery within the health system infrastructure. We conclude that expanding access to priority health services requires the concerted use of both modes of delivery, according to the capacity of health systems as it changes over time. Copyright © 2003 John Wiley & Sons, Ltd.

AbstractThe Commission on Macroeconomics and Health recommended a significant expansion in funding for health interventions in poor countries. However, there are a range of constraints to expanding access to health services: as well as an absolute lack of resources, access to health interventions is hindered by problems of demand, weak service delivery systems, policies at the health and cross‐sectoral levels, and constraints related to governance, corruption and geography. This special issue is devoted to analysis of the nature and intensity of these constraints, and how they can best be overcome. Copyright © 2003 John Wiley & Sons, Ltd.

AbstractThis paper adopts three approaches to classifying countries by level of constraint, in order to inform the choice of strategies for expanding access to health interventions in different contexts. We find substantial heterogeneity across the 84 low‐income and (all) sub‐Saharan African countries analysed. Poor sub‐Saharan African countries are the most highly constrained; Asian countries, in general, less constrained; and the two Asian giants, China and India, consistently fall above the median. Former Soviet Union countries rank low in terms of governance, but high for health systems variables. Only 10 per cent of the total population of the countries included lives in countries with the greatest constraints. The potential applications of the analysis are discussed, as are the limitations of the cross‐sectional, macro level approach. Copyright © 2003 John Wiley & Sons, Ltd.

OBJECTIVE: This study aimed to assess the current workload and staffing need of physicians and nurses for delivering optimum healthcare services at the Upazila Health Complexes (UpHCs) in Bangladesh. DESIGN: Mixed-methods, combining qualitative (eg, document reviews, key informant interviews, in-depth interviews, observations) and quantitative methods (time-motion survey). SETTING: Study was conducted in 24 health facilities of Bangladesh. However, UpHCs being the nucleus of primary healthcare in Bangladesh, this manuscript limits itself to reporting the findings from the providers at four UpHCs under this project. PARTICIPANTS: 18 physicians and 51 nurses, males and females. PRIMARY OUTCOME MEASURES: Workload components were defined based on inputs from five experts, refined by nine service providers. Using WHO Workload Indicator of Staffing Need (WISN) software, standard workload, category allowance factor, individual allowance factor, total required number of staff, WISN difference and WISN ratio were calculated. RESULTS: Physicians have very high (WISN ratio 0.43) and nurse high (WISN ratio 0.69) workload pressure. 50% of nurses' time are occupied with support activities, instead of nursing care. There are different workloads among the same staff category in different health facilities. If only the vacant posts are filled, the workload is reduced. In fact, sanctioned number of physicians and nurses is more than actual need. CONCLUSIONS: It is evident that high workload pressures prevail for physicians and nurses at the UpHCs. This reveals high demand for these health workforces in the respective subdistricts. WISN method can aid the policy-makers in optimising utilisation of existing human resources. Therefore, the government should adopt flexible health workforce planning and recruitment policy to manage the patient load and disease burden. WISN should, thus, be incorporated as a planning tool for health managers. There should be a regular review of health workforce management decisions, and these should be ...

Coronavirus 2019 (COVID-19's) impact has gone far beyond its direct effect on morbidity and mortality. In addition to adversely impacting non-COVID health care utilization, the pandemic has resulted in a deep global economic contraction due to lockdown policies and declining demand and supply of goods and services. As a result, most countries are experiencing lower levels of gross domestic product (GDP), rising unemployment, higher levels of impoverishment, and increasing income inequality. Some countries are more vulnerable to the economic contagion resulting from COVID-19, including those implementing more stringent lockdowns and those that are more globally integrated due to their dependence on trade, tourism, and remittances. In addition, countries with preexisting conditions of fiscal weakness due to higher dependence on external grant financing, low tax revenues, and large pre-crisis debt levels are struggling to implement countercyclical mitigative fiscal and monetary policies. In addition to declining economic activity, government revenues have declined, government borrowing is increasing, and public debt levels are projected to skyrocket globally. Higher debt levels will likely imply fiscal tightening for years to come. Implications for health financing are potentially dire, dependent in part on the combination of domestic government, external, and out-of-pocket financing for health that is extant across countries. Tentative projections indicate that, in the absence of reprioritization, growth in public spending for health can decline across most low- and middle-income countries in the region, including becoming negative in some cases, risking reversal of gains made toward expanding universal health coverage in recent years. To reduce the likelihood of such a scenario, and with the caveat that protecting levels of financing will not be effective if resources are not used properly to begin with, ministries of health will need to pay careful attention to planning and budgeting - demonstrating where waste can be reduced and efficiency enhanced - and prioritize within their outlays interventions that are the most cost-effective and equitable. At the same time, ministries of finance should improve the adequacy and predictability of outlays for the sector, taking a multiyear programming perspective and include potential additional resources that will be necessary to procure and deliver a COVID-19 vaccine, once an effective one becomes available. In doing so, they should consider augmenting resources via increasing the scope and breadth of health taxes and proactively seeking out debt relief opportunities, especially if these can be tied to efforts to reprioritize health within overall government budgets where this may be necessary. Whereas there is the perception that the health sector has been flooded with new resources to respond to the pandemic, it remains unclear to what extent these have been additional and not a result of reprogramming of outlays from other areas within health. To the extent COVID-19 presents an opportunity, it is one for removing any doubts that health and the economy are inextricably linked, nudging both ministries of health and finance to reevaluate their priorities, accountabilities, and performance to sustain improvements in both population health, including for ensuring pandemic preparedness, and economic performance.