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Health system governance as an evolving domain of interest In the field of international development, the mainstream view that governance is a determinant of development outcomes follows decades of work developed by the World Bank.7 8 Two WHO reports have been pivotal in establishing a similar view for health systems: the World Health Report 20009 and, 7 years later, the report entitled ‘Everybody’s business: strengthening health systems to improve health outcomes’.10 The core contribution of the World Health Report 2000 was to put forward a proposition on how performance of health systems should be conceptualised and measured. The dominant approach to solve this problem has been to mimic the World Bank’s approach of state governance and define dimensions. For Siddiqi et al, ‘governance comprises the complex mechanisms, processes and institutions through which citizens and groups articulate their interests, mediate their differences and exercise their legal rights and obligations’.13 In 2014, Abimbola et al explored the lessons from the common-pool resources literature to enlighten collective action for primary healthcare.5 To our knowledge, this was the first time that the health system governance literature was connecting with the pioneering work of Elinor Ostrom. The same year, Pyone et al took a similar approach: ‘Governance is defined as the rules (both formal and informal) for collective action and decision making in a system with diverse players and organisations while no formal control mechanism can dictate the relationship among those players and organisations.2 Adopting such broad and less normative definitions reduces the risk of excluding certain variables from the scope of analysis.

From January 2015 to December 2016, the health authorities in Burundi piloted the inclusion of child nutrition services into the pre-existing performance-based financing free health care policy (PBF-FHC). An impact evaluation, focused on health centres, found positive effects both in terms of volume of services and quality of care. To some extent, this result is puzzling given the harshness of the contextual constraints related to the fragile setting. With a multi-methods approach, we explored how contextual and implementation constraints interacted with the pre-identified tracks of effect transmission embodied in the intervention. For our analysis, we used a hypothetical Theory of Change (ToC) that mapped a set of seven tracks through which the intervention might develop positive effects for children suffering from malnutrition. We built our analysis on (1) findings from the facility surveys and (2) extra qualitative data (logbooks, interviews and operational document reviews). Our results suggest that six constraints have weighted upon the intervention: (1) initial low skills of health workers; (2) unavailability of resources (including nutritional dietary inputs and equipment); (3) payment delays; (4) suboptimal information; (5) restrictions on autonomy; and (6) low intensity of supervision. Together, they have affected the intensity of the intervention, especially during its first year. From our analysis of the ToC, we noted that the positive effects largely occurred as a result of the incentive and information tracks. Qualitative data suggests that health centres have circumvented the many constraints by relying on a community-based recruitment strategy and a better management of inputs at the level of the facility and the patient himself. Frontline actors have agency: when incentives are right, they take the initiative and find solutions. However, they cannot perform miracles: Burundi needs a holistic societal strategy to resolve the structural problem of child malnutrition. Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).

Background Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery. Methods A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT). Results We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed. Conclusion Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers. Trial registration PROSPERO registration number CRD42022340059 .

There are substantial issues with the quality of care (QoC) received by persons living with chronic conditions, particularly in low- and middle-income countries (LMICs). One possible channel to improve QoC is through financing, specifically purchasing arrangements for health services. This has been actively explored in high-income country settings, generating a growing body of scientific knowledge. To understand the potential and the constraints of using purchasing arrangements as a way to improve QoC for chronic conditions in resource-constrained settings. A Delphi survey was conducted with 49 international participants with content expertise in chronic care management, health financing, or both, and context expertise in resource-constrained settings including in Small Island Developing States or Fragile and Conflict-Affected States, to assess the possible contribution of purchasing arrangements to QoC for chronic conditions with respect to specific types of care providers (e.g. patients and relatives, community health workers, public health centres), decentralized coordination bodies and purchasing agencies in such settings. There was a high level of consensus among the Delphi panel in favour of considering purchasing arrangements as one of the levers to improve QoC for people living with chronic conditions. Specific directions for action were identified along with their caveats. The challenge of improving the quality of chronic care in resource-constrained settings is extensive and requires immediate attention. Leveraging purchasing arrangements is one promising channel to strengthen quality chronic care in such settings.

Malnutrition is a huge problem in Burundi. In order to improve the health system response, the Ministry of Health piloted the introduction of malnutrition prevention and care indicators within its performance-based financing (PBF) scheme. Paying for units of services and for qualitative indicators is expected to enhance provision and quality of these nutrition services. The objective of this study is to assess the impacts of this intervention, on both child acute malnutrition recovery rates at health centre level and prevalence of chronic and acute malnutrition among children at community level. This study follows a cluster-randomized controlled evaluation design: 90 health centres (HC) were randomly selected for the study, 45 of them were randomly assigned to the intervention and received payment related to their performance in malnutrition activities, while the other 45 constituted the control group and got a simple budget allocation. Data were collected from baseline and follow-up surveys of the 90 health centres and 6,480 households with children aged 6 to 23 months. From the respectively 1,067 and 1,402 moderate and severe acute malnutrition transcribed files and registers, findings suggest that the intervention had a positive impact on moderate acute malnutrition recovery rates (OR: 5.59, p = 0.039 -at the endline, 78% in the control group and 97% in the intervention group) but not on uncomplicated severe acute malnutrition recovery rate (OR: 1.16, p = 0.751 -at the endline, 93% in the control group and 92% in the intervention group). The intervention also had a significant increasing impact on the number of children treated for acute malnutrition. Analyses from the anthropometric data collected among 12,679 children aged 6-23 months suggest improvements at health centre level did not translate into better results at community level: prevalence of both acute and chronic malnutrition remained high, precisely at the endline, acute and chronic malnutrition prevalence were resp. 8.80% and 49.90% in the control group and 8.70% and 52.0% in the intervention group, the differences being non-significant. PBF can contribute to a better management of malnutrition at HC level; yet, to address the huge problem of child malnutrition in Burundi, additional strategies are urgently required.

Background Burundi is one of the poorest countries and is among the four countries with the highest prevalence of stunting (58%) among children aged less than 5 years. This situation undermines the economic growth of the country as undernutrition is strongly associated with less schooling and reduced economic productivity. Identifying the determinants of stunting and severe stunting may help policy-makers to direct the limited Burundian resources to the most vulnerable segments of the population, and thus make it more cost effective. This study aimed to identify predictors of stunting and severe stunting among children aged less than two years in Burundi. Methods The sample is made up of 6199 children aged 6 to 23 months with complete anthropometric measurements from the baseline survey of an impact evaluation study of the Performance-Based financing (PBF) scheme applied to nutrition services in Burundi from 2015 to 2017. Binary and multivariable logistic regression analyses were used to examine stunting and severe stunting against a set of child, parental and household variables such as child’s age or breastfeeding pattern, mother’s age or knowledge of malnutrition, household size or socio-economic status. Results The prevalence of stunting and severe stunting were 53% [95%CI: 51.8-54.3] and 20.9% [95%CI: 19.9-22.0] respectively. Compared to children from 6-11 months, children of 12-17 months and 18-23 months had a higher risk of stunting (AdjOR:2.1; 95% CI: 1.8-2.4 and 3.2; 95% CI: 2.8-3.7). Other predictors for stunting were small babies (AdjOR=1.5; 95% CI: 1.3-1.7 for medium-size babies at birth and AdjOR=2.9; 95% CI: 2.4-3.6 for small-size babies at birth) and male children (AdjOR=1.5, 95% CI: 1.4-1.8). In addition, having no education for mothers (AdjOR=1.6; 95% CI: 1.2-2.1), incorrect mothers’ child nutrition status assessment (AdjOR=3.3; 95% CI: 2.8-4), delivering at home (AdjOR=1.4; 95% CI: 1.2-1.6) were found to be predictors for stunting. More than to 2 under five children in the household (AdjOR=1.45; 95% CI: 1.1-1.9 for stunting and AdjOR= 1.5; 95% CI: 1.2-1.9 for severe stunting) and wealth were found to be predictors for both stunting and severe stunting. The factors associated with stunting were found to be applicable for severe stunting as well. Conclusion Mother’s education level, mother’s knowledge about child nutrition status assessment and health facility delivery were predictors of child stunting. Our study confirms that stunting and severe stunting is in Burundi, as elsewhere, a multi-sectorial problem. Some determinants relate to the general development of Burundi: education of girls, poverty, and food security; will be addressed by a large array of actions. Some others relate to the health sector and its performance – we think in particular of the number of children under five in the household (birth spacing), the relationship with the health center and the knowledge of the mother on malnutrition. Our findings confirm that the Ministry of Health and its partners should strive for better performing and holistic nutrition services: they can contribute to better nutrition outcomes.

Background Several low- and middle-income countries have exempted patients from user fees in certain categories of population or of services. These exemptions are very effective in lifting part of the financial barrier to access to services, but they have been organized within unstable health systems where there are sometimes numerous dysfunctions. The objective of this article is to bring to light the disruptions triggered by exemption policies in health systems of low- and middle-income countries. Methods Scoping review of 23 scientific articles. The data were synthesized according to the six essential functions of health systems. Results The disruptions included specifically: 1) immediate and significant increases in service utilization; 2) perceived heavier workloads for health workers, feelings of being exploited and overworked, and decline in morale; 3) lack of information about free services provided and their reimbursement; 4) unavailability of drugs and delays in the distribution of consumables; 5) unpredictable and insufficient funding, revenue losses for health centres, reimbursement delays; 6) the multiplicity of actors and the difficulty of identifying who is responsible (‘no blame’ game), and deficiencies in planning and communication. Conclusions These disruptive elements give us an idea of what is to be expected if exemption policies do not put in place all the required conditions in terms of preparation, planning and complementary measures. There is a lack of knowledge on the effects of exemptions on all the functions of health systems because so few studies have been carried out from this perspective.

Background To progress towards universal health coverage (UHC), each country will have to develop its systemic learning capacity. This study aims at documenting how, across time, learning can feed into a UHC policy process, and how the latter can itself strengthen (or not) the learning capacity of the health system. It specifically focuses on the development of a major health financing policy aligned with the UHC goal in Morocco, the RAMED, a health financing scheme covering hospital costs for the poorest segment of the population. Methods We conducted a retrospective analysis of the RAMED policy for the period between 1997 and 2018, along with a case study design. For the data collection and analysis, we developed a framework combining Garvin’s learning organisation framework and the heuristic health policy analysis framework. We gathered data from key informants and document reviews. Results The study confirmed the importance of learning during the different stages of the RAMED policy process. There is evidence of a leadership encouraging learning, the introduction and adoption of knowledge management processes, and the start of a transformation of the administrative culture. Yet, our study also showed some major shortcomings, especially the lack of structure of the learning, and insufficient effort to systemise and sustain a transformation of practices within the health administration. Our study also confirms that the learning changes in nature across the different stages of the policy process. Conclusion The policy decisions and the implementation strategy create a learning dynamic, though not structured in all cases. Despite the positive interaction between learning and the RAMED policy, the opportunity to push forward a more structural transformation towards a learning system has not been fully seized. Hierarchical logics still largely prevail in the Moroccan health administration. The impact of future health policies for both the target beneficiaries and the health system will be bigger if their design integrates purposeful and structured actions in favour of organisational learning. This recommendation probably applies beyond Morocco.