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Specialist groups have often advised health ministers and other decision makers in developing countries on the use of social health insurance (SHI) as a way of mobilizing revenue for health, reforming health sector performance, and providing universal coverage. This book reviews the specific design and implementation challenges facing SHI in low- and middle-income countries and presents case studies on Ghana, Kenya, Philippines, Colombia, and Thailand.

Despite spending more than any other nation on medical care per person, the United States ranks behind other industrialized nations in key health performance measures. A main cause is the deep disparities in access to care and health outcomes. Federal programs such as the designations of Medically Underserved Areas/Populations and Health Professional Shortage Areas are designed to boost the number of health professionals serving these areas and to help alleviate the access problem. Their effectiveness relies first and foremost on an accurate measure of accessibility so that resources can be allocated to truly needy areas. Various measures of accessibility need to be integrated into one framework for comparison and evaluation. Optimization methods can be used to improve the distribution and supply of health care providers to maximize service coverage, minimize travel needs of patients, limit the number of facilities, and maximize health or access equality. Inequality in health care access comes at a personal and societal price, evidenced in disparities in health outcomes, including late-stage cancer diagnosis. This review surveys recent literature on the three named issues with emphasis on methodological advancements and implications for public policy.

Background The Basic Health Care Provision Fund (BHCPF) is a direct financial investment that funds Primary Healthcare (PHC) to improve the quality of services. This study assessed the influence of the BHCPF in improving PHC services. Methods A descriptive cross-sectional study was conducted among PHC workers in 100 facilities randomly selected from the 484 designated PHCs for implementing the BHCPF project in Kano state. Using multiple sampling methods, 200 healthcare workers in PHC facilities were selected and assisted by trained data collectors to respond to the questionnaires. Chi-square analysis was used to show associated factors, while binary regression analysis was used to determine the relationship between factors influencing the BHCPF implementation in PHC. Result The findings showed healthcare workers had higher awareness (61.7%) and good utilization (57.1%) of BHCPF. Challenges of the BHCPF implementation were insufficiently skilled health professionals (85%), lack of data management capacity (52.6%), low community participation and awareness (52.0%), delay in releasing funds (60.7%), poor infrastructure (87.8%), and weak financial management and accountability system (58.2%). Healthcare professionals having a diploma were four times more likely to have the National Health Management Information System (NHMIS) in their facilities (AOR = 4.955, 95% CI = 1.120–21.036; P-value 0.035) than those without. Primary healthcare facilities were two times more likely to have the NHMIS (AOR = 2.549, 95% CI = 1.167–5.566: P-value 0. 019) than health post. Conclusion The factors that influenced PHC facilities to promote the implementation of BHCPF included: periodic evaluation of the facilities, availability of functional storage facilities, and improving the standard of care in PHC facilities. There is a need for retraining healthcare workers and creating more community awareness of the BHCPF.

Diversity in the lines of public institutions, such as hospitals, schools, and police forces, is thought to improve provision for minority group members. Nonetheless, whether and how diversity in public institutions shapes majority citizens’ prejudice toward minorities are unclear. Building on insights from the intergroup contact literature, I suggest that diversity in public institutions can facilitate positive intergroup contact between majority group members and minorities in elevated social positions. Such unique interactions, which exceed the equal status condition for effective intergroup contact, can serve to reduce prejudice and facilitate more inclusive attitudes among majority group members. To test this expectation, I focus on health care provision—a leading sector with regard to minority representation. Leveraging a natural experiment unfolding in 21 Israeli medical clinics where Jewish patients are haphazardly assigned to receive care from Jewish or Arab doctors and embedding prejudice-related questions in a routine evaluation survey, I demonstrate that brief contact with an Arab doctor reduces prejudice. Specifically, contact with an Arab doctor reduces Jewish patients’ exclusionary preferences toward Arabs by one-sixth of an SD and increases Jewish patients’ optimism about peace by a 10th of an SD. The modest magnitude of these effects is similar to the impact of well-powered interventions recently reviewed in a meta-analysis of prejudice reduction experiments. These findings emphasize how the demographic makeup of public institutions can reduce mass prejudice, even in a context of intractable conflict.

Background Fragmentation of healthcare delivery can disrupt the maternal care continuum and undermine effective coverage. In Mexico’s segmented health system, institutional discontinuities may exacerbate inequities in access and quality. We examined the prevalence, determinants, and consequences of fragmented healthcare (FHC) for effective maternal healthcare coverage (EMHC) between 2009 and 2023. Methods We conducted a retrospective, repeated cross-sectional analysis using nationally representative data from the 2014, 2018, and 2023 ENADID surveys, including 71,874 women aged 12–54 with a recent live birth. EMHC was defined as a composite indicator encompassing adequate antenatal care (ANC), skilled or institutional delivery, timely postpartum care, and a complication-free puerperium. FHC was defined as receiving ANC and delivery care from different healthcare providers. Pooled multivariable regressions with survey fixed effects assessed the association between FHC and EMHC, adjusting for sociodemographic and contextual characteristics. Results Between 2009 and 2023, roughly one in six women experienced FHC, while only one in three achieved EMHC. Fragmentation was more frequent among women covered by publicly subsidized insurance (Seguro Popular or INSABI), Indigenous women, those living in rural areas, and women with higher obstetric risk. Receiving ANC from private providers tripled the odds of FHC compared with women covered by employment-based social security. Women exposed to FHC had a 4.7 percentage point lower probability of achieving EMHC—equivalent to a 20% reduction in the odds of effective coverage (aOR = 0.80; 95% CI: 0.69–0.91). This adverse effect was consistent across survey waves and most pronounced among Ministry of Health users. Conclusions Fragmented maternal healthcare trajectories substantially reduce the likelihood of effective coverage, disproportionately affecting socioeconomically and ethnically disadvantaged populations. The observed reduction in EMHC underscores that fragmentation is not merely a clinical or operational issue, but a structural challenge that requires reforms to improve the coordination of care. Strengthening integration across maternal care networks, ensuring interoperability of health information systems, and adopting continuity-based financing models are critical to improving coordination. Addressing FHC could prevent incomplete or unsafe care and accelerate progress toward universal health coverage. These findings offer actionable lessons for Mexico and other middle-income countries confronting health system fragmentation.

Background Patient satisfaction is an important measure of healthcare quality as it offers information on the provider’s success at meeting clients’ expectations and is a key determinant of patients’ perspective behavioral intention. The aim of this paper is first to assess the degree of patient satisfaction, and second, to study the relationship between patient satisfaction of healthcare system and a set of socio-economic and healthcare provision indicators. Methods This empirical analysis covers 31 countries for the years 2007, 2008, 2009 and 2012. The dependent variable, the satisfaction index, is defined as the patient satisfaction of their country’s health system. We first construct an index of patient satisfaction and then, at a second stage, this index is related to socio-economic and healthcare provision variables. Results Our findings support that there is a strong positive association between patient satisfaction level and healthcare provision indicators, such as nurses and physicians per 100,000 habitants, with the latter being the most important contributor, and a negative association between patient satisfaction level and number of hospital beds. Among the socio-economic variables, public health expenditures greatly shape and positive relate to patient satisfaction, while private spending on health relates negatively. Finally, the elder a patient is, the more satisfied with a country’s healthcare system appears to be. Conclusions We conclude that there is a strong positive association between patient satisfaction and public health expenditures, number of physicians and nurses, and the age of the patient, while there is a negative evidence for private health spending and number of hospital beds.

Background The COVID-19 pandemic has shaken everyday life causing morbidity and mortality across the globe. While each country has been hit by the pandemic, individual countries have had different infection and health trajectories. Of all welfare state institutions, healthcare has faced the most immense pressure due to the pandemic and hence, we take a comparative perspective to study COVID-19 related health system performance. We study the way in which health system characteristics were associated with COVID-19 excess mortality and case fatality rates before Omicron variant. Methods This study analyses the health system performance during the pandemic in 43 OECD countries and selected non-member economies through three healthcare systems dimensions: (1) healthcare finance, (2) healthcare provision, (3) healthcare performance and health outcomes. Health system characteristics-related data is collected from the Global Health Observatory data repository, the COVID-19 related health outcome indicators from the Our World in Data statistics database, and the country characteristics from the World Bank Open Data and the OECD statistics databases. Results We find that the COVID-19 excess mortality and case fatality rates were systematically associated with healthcare system financing and organizational structures, as well as performance regarding other health outcomes besides COVID-19 health outcomes. Conclusion Investments in public health systems in terms of overall financing, health workforce and facilities are instrumental in reducing COVID-19 related mortality. Countries aiming at improving their pandemic preparedness may develop health systems by strengthening their public health systems.

The study examines the effect of health care reform in Bulgaria in 1999 on the equity of health care financing. It explores the distribution of different types of health care financing by income. Furthermore, it separates the financial and social reasons for these differences, dividing them into economic and social inequalities. It suggests a method of distinguishing between financially based and \"exclusion based\" reasons for having progressive/regressive health care financing. Moreover, it looks at the social factors that shape health expenditure patterns and identifies those social characteristics that lead to exclusion from the health care system.

Background The Nigerian National Health Act proposes a radical shift in health financing in Nigeria through the establishment of a fund – Basic Healthcare Provision Fund, (BHCPF). This Fund is intended to improve the functioning of primary health care in Nigeria. Key stakeholders at national, sub-national and local levels have raised concerns over the management of the BHCPF with respect to the roles of various stakeholders in ensuring accountability for its use, and the readiness of the implementers to manage this fund and achieve its objectives. This study explores the governance and accountability readiness of the different layers of implementation of the Fund; and it contributes to the generation of policy implementation guidelines around governance and accountability for the Fund. Methods National, state and LGA level respondents were interviewed using a semi structured tool. Respondents were purposively selected to reflect the different layers of implementation of primary health care and the levels of accountability. Different accountability layers and key stakeholders expected to implement the BHCPF are the Federal government (Federal Ministry of Health, NPHCDA, NHIS, Federal Ministry of Finance); the State government (State Ministry of Health, SPHCB, State Ministry of Finance, Ministry of Local Government); the Local government (Local Government Health Authorities); Health facilities (Health workers, Health facility committees (HFC) and External actors (Development partners and donors, CSOs, Community members). Results In general, the strategies for accountability encompass planning mechanisms, strong and transparent monitoring and supervision systems, and systematic reporting at different levels of the healthcare system. Non-state actors, particularly communities, must be empowered and engaged as instruments for ensuring external accountability at lower levels of implementation. New accountability strategies such as result-based or performance-based financing could be very valuable. Conclusion The key challenges to accountability identified should be addressed and these included trust, transparency and corruption in the health system, political interference at higher levels of government, poor data management, lack of political commitment from the State in relation to release of funds for health activities, poor motivation, mentorship, monitoring and supervision, weak financial management and accountability systems and weak capacity to implement suggested accountability mechanisms due to political interference with accountability structures.

The Basic Health Care Provision Fund (BHCPF) under Nigeria’s National Health Act (NHA) includes the establishment of a national emergency medical response service. This study evaluated the early implementation process of this service as perceived by key stakeholders, which is essential for sustainability and scalability. This cross-sectional mixed-methods study was conducted among national and state-level stakeholders involved in early implementation. Data collection included a self-designed knowledge assessment of national and international emergency care guidelines and a semi-structured open-ended interview adapted from the Consolidated Framework for Implementation Research (CFIR). Qualitative data were analyzed using a deductive framework approach, with construct ratings assigned by consensus. Inter-rater reliability was assessed using Cohen’s kappa. Associations between knowledge scores and CFIR construct ratings were explored using Spearman’s rank correlation. Eight stakeholders from three states with active implementation participated. Respondents expressed strong agreement regarding the source of innovation, tension for change, and available resources, reflecting broad recognition of the need for innovation. Notable variability was observed in goals and feedback, and in available resources, with narrative differences across states. Knowledge assessment scores varied widely (median 60%). A strong positive association was observed between knowledge scores and ratings of goals and feedback (ρ = 0.743, p  = 0.035), although findings are exploratory given the small sample size. Early implementation of Nigeria’s emergency medical response system is characterized by strong stakeholder motivation but uneven knowledge, resource availability, and goal-feedback mechanisms. Targeted capacity-building, improved communication, and structured feedback processes may strengthen implementation and support future scale-up under the NHA.