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Noncommunicable diseases (NCDs) are by far the major cause of death in lower-middle, upper-middle, and high-income countries; by 2015, they will also be the leading cause of death in low-income countries.

Low-income and middle-income countries (LMICs) are facing an urgent and complex challenge: how to transition to greater self-sustainability in health financing amid declining donor support. While this shift is inevitable, the policy responses it elicits carry significant implications for health system equity and access. This commentary highlights four policy choices increasingly observed in LMICs that we argue are unacceptable in the pursuit of sustainability. These include: (1) shifting the financial burden to out-of-pocket payments; (2) over-reliance on contributory health insurance schemes; (3) displacement of basic primary healthcare services; and (4) abandoning community-based service delivery in favour of facility-centric models, undermining the integrity of people-centred health systems. We argue that while short-term fiscal pressures may push countries towards these decisions, they ultimately erode health gains, exacerbate inequities and threaten progress towards universal health coverage. We call on policymakers to adopt evidence-informed approaches that enhance efficiency, protect the most vulnerable, prioritise public financing and preserve the core values of inclusive and equitable health systems during this critical transition.

Some analysts have identified systematic and structural challenges within the health sector including transforming the acute-care and “illness treatment” orientation of care models, reversing often top-heavy structures of the service delivery systems, and reducing service fragmentation and siloed management among facilities and service levels [4-6]. Automation, adaptation of proliferations of mobile app, application of data science to supply chain, and use of remote-access technologies for diagnosis and treatment support will enhance the overall performance of service delivery systems. [...]whether such improvements in efficiency come from within the public sector itself, or via integration or leveraging private sector actors, should be matters for empirical work, not ideological preferences. Financing realities The sticker shock for the cost of providing universal health coverage, the latest UHC Global Monitoring Report estimates a shortfall of at least 175 billion dollars just in low and middle income countries, and the realization that out of pocket expenditure, currently estimated at almost half a trillion dollars, is not decreasing, reflects the reality that any efficiency gains are being overwhelmed with the surge in pent up demand for health care.

Many countries have committed to achieving Universal Health Coverage. This paper summarizes selected health financing themes from five middle-income country case studies with incomplete progress towards UHC. The paper focuses on key flagship UHC programs in these countries, which exist along other publicly financed health delivery systems, reviewed through the lens of key health financing functions such as revenue raising, pooling and purchasing as well as governance and institutional arrangements. There is variable progress across countries. Indonesia's Jaminan Kesehatan Nasional (JKN) reforms have made substantial progress in health services coverage and health financing indicators though challenges remain in its implementation. In contrast, Ghana has seen reduced funding levels for health and achieved less than 50% in the UHC service coverage index. In India, despite Ayushman Bharat (PM-JAY) reforms having provided important innovations in purchasing and public-private mix, out of pocket spending remains high and the public health financing level low. Kenya still has a challenge to use public financing to enhance coverage for the informal sector, while South Africa has made little progress in strategic purchasing. Despite variations across countries, therefore, important challenges include inadequate financing, sub-optimal pooling, and unmet expectations in strategic purchasing. While complex federal systems may complicate the path forward for most of these countries, evidence of strong political commitment in some of these countries bodes well for further progress.

Access to quality assured artemisinin-based combination therapy (ACT) has remained very low in most malaria endemic countries. A number of reasons, including unaffordable prices, have contributed to the low accessibility to these life-saving medicines. The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured ACT. The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives: replacing older and increasingly ineffective anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displacing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the likelihood of resistance to artemisinin. Access to medicines frameworks paint a broad picture of dimensions of access to medicines and juxtapose components that enhance or hinder access to medicines. Access requires various activities--funding, institutions, interventions, and thinking--from public and private actors at global, national, and local levels. This paper examines, within access to medicines frameworks, the role of the AMFm across and within each dimension and discusses how the AMFm can help to solve access bottlenecks.

Background Objective of the study was to assess the effects of strategies to integrate targeted priority population, health and nutrition interventions into health systems on patient health outcomes and health system effectiveness and thus to compare integrated and non-integrated health programmes. Methods Systematic review using Cochrane methodology of analysing randomised trials, controlled before-and-after and interrupted time series studies. We defined specific strategies to search PubMed, CENTRAL and the Cochrane Effective Practice and Organisation of Care Group register, considered studies published from January 1998 until September 2008, and tracked references and citations. Two reviewers independently agreed on eligibility, with an additional arbiter as needed, and extracted information on outcomes: primary (improved health, financial protection, and user satisfaction) and secondary (improved population coverage, access to health services, efficiency, and quality) using standardised, pre-piloted forms. Two reviewers in the final stage of selection jointly assessed quality of all selected studies using the GRADE criteria. Results Of 8,274 citations identified 12 studies met inclusion criteria. Four studies compared the benefits of Integrated Management of Childhood Illnesses in Tanzania and Bangladesh, showing improved care management and higher utilisation of health facilities at no additional cost. Eight studies focused on integrated delivery of mental health and substance abuse services in the United Kingdom and United States of America. Integrated service delivery resulted in better clinical outcomes and greater reduction of substance abuse in specific sub-groups of patients, with no significant difference found overall. Quality of care, patient satisfaction, and treatment engagement were higher in integrated delivery models. Conclusions Targeted priority population health interventions we identified led to improved health outcomes, quality of care, patient satisfaction and access to care. Limited evidence with inconsistent findings across varied interventions in different settings means no general conclusions can be drawn on the benefits or disadvantages of integrated service delivery.