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Many countries that subscribe to the Millennium Development Goals (MDGs) have committed to ensuring access to basic health services for their citizens. Health insurance has been considered and promoted as the major financing mechanism to improve access to health services, as well as to provide financial risk protection. In Africa, several countries have already spent scarce time, money, and effort on health insurance initiatives. Ethiopia, Ghana, Kenya, Nigeria, Rwanda, and Tanzania are just a few of them. However, many of these schemes, both public and private, cover only a small proportion of the population, with the poor less likely to be covered. In fact, unless carefully designed to be pro-poor, health insurance can widen inequity as higher income groups are more likely to be insured and use health care services, taking advantage of their insurance coverage. The purpose of this handbook is to provide policy makers and health insurance designers with practical, action-oriented support that will deepen their understanding of health insurance concepts, help them identify design and implementation challenges, and define realistic steps for the development and scaling up of equitable, efficient, and sustainable health insurance schemes. The handbook takes policy makers and health insurance designers through a step-by-step series of considerations and tasks that need to be achieved. The handbook's philosophy is to not be dogmatic, ideological, or prescriptive. This handbook was prepared to be used in a six-day regional workshop. Clearly, health insurance design is an intensive political and technical process that takes much longer than six days. The expectation for the workshop is that by the end of the week, each team has a clear idea of next steps that they could take back home to engage other stakeholders and move toward scaling up and improving the performance of health insurance in their country.

Unless the concept is clearly understood, \"universal coverage\" (or universal health coverage, UHC) can be used to justify practically any health financing reform or scheme. This paper unpacks the definition of health financing for universal coverage as used in the World Health Organization's World health report 2010 to show how UHC embodies specific health system goals and intermediate objectives and, broadly, how health financing reforms can influence these. All countries seek to improve equity in the use of health services, service quality and financial protection for their populations. Hence, the pursuit of UHC is relevant to every country. Health financing policy is an integral part of efforts to move towards UHC, but for health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the intermediate objectives linked to it, namely, efficiency, equity in health resource distribution and transparency and accountability. The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level.

Background Interest in value-based healthcare, generally defined as providing better care at lower cost, has grown worldwide, and learning health systems (LHSs) have been proposed as a key strategy for improving value in healthcare. LHSs are emerging around the world and aim to leverage advancements in science, technology and practice to improve health system performance at lower cost. However, there remains much uncertainty around the implementation of LHSs and the distinctive features of these systems. This paper presents a conceptual framework that has been developed in Canada to support the implementation of value-creating LHSs. Methods The framework was developed by an interdisciplinary team at the Institut national d’excellence en santé et en services sociaux (INESSS). It was informed by a scoping review of the scientific and grey literature on LHSs, regular team discussions over a 14-month period, and consultations with Canadian and international experts. Results The framework describes four elements that characterise LHSs, namely (1) core values, (2) pillars and accelerators, (3) processes and (4) outcomes. LHSs embody certain core values, including an emphasis on participatory leadership, inclusiveness, scientific rigour and person-centredness. In addition, values such as equity and solidarity should also guide LHSs and are particularly relevant in countries like Canada. LHS pillars are the infrastructure and resources supporting the LHS, whereas accelerators are those specific structures that enable more rapid learning and improvement. For LHSs to create value, such infrastructures must not only exist within the ecosystem but also be connected and aligned with the LHSs’ strategic goals. These pillars support the execution, routinisation and acceleration of learning cycles, which are the fundamental processes of LHSs. The main outcome sought by executing learning cycles is the creation of value, which we define as the striking of a more optimal balance of impacts on patient and provider experience, population health and health system costs. Conclusions Our framework illustrates how the distinctive structures, processes and outcomes of LHSs tie together with the aim of optimising health system performance and delivering greater value in health systems.

Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up. Based on an understanding of CAS behaviours, we describe how phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions can uncover relevant lessons for the design and implementation of health policy and programmes in the context of scaling up health services. The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation. We propose that future efforts to scale up should adapt and apply the models and methodologies which have been used in other fields that study CAS, yet are underused in public health. This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services. The old assumptions have led to disappointed expectations about how to scale up health services, and offer little insight on how to scale up effective interventions in the future. The alternative perspectives offered by CAS may better reflect the complex and changing nature of health systems, and create new opportunities for understanding and scaling up health services.

Background This is the concluding paper of our 11-paper supplement, “Community health workers at the dawn of a new era”. Methods We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes. Results CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness. Conclusion A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.

Context: The Health Information Technology for Economic and Clinical Health (HITECH) Act set ambitious goals for developing electronic health information as one tool to reform health care delivery and improve health outcomes. With HITECH's grant funding now mostly exhausted but statutory authority for standards remaining, this article looks back at HITECH's experience in the first 5 years to assess its implementation, remaining challenges, and lessons learned. Methods: This review derives from a global assessment of the HITECH Act. Earlier, we examined the logic of HITECH and identified interdependencies critical to its ultimate success. In this article, we build on that framework to review what has and has not been accomplished in building the infrastructure authorized by HITECH since it was enacted. The review incorporates quantitative and qualitative evidence of progress from the global assessment and from the evaluations funded by the Office of the National Coordinator for Health Information Technology (ONC) of individual programs authorized by the HITECH Act. Findings: Our review of the evidence provides a mixed picture. Despite HITECH's challenging demands, its complex programs were implemented, and important changes sought by the act are now in place. Electronic health records (EHRs) now exist in some form in most professional practices and hospitals eligible for HITECH incentive payments, more information is being shared electronically, and the focus of attention has shifted from adoption of EHRs toward more fundamental issues associated with using health information technology (health IT) to improve health care delivery and outcomes. In some areas, HITECH's achievements to date have fallen short of the hopes of its proponents as it has proven challenging to move meaningful use beyond the initial low bar set by Meaningful Use Stage 1. EHR products vary in their ability to support more advanced functionalities, such as patient engagement and population-based care management. Many barriers to interoperability persist, limiting electronic commkunication across a diverse set of largely private providers and care settings. Conclusions: Achieving the expansive goals of HITECH required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, some better positioned to move forward than others. To date, it has proven easier to get providers to adopt EHRs, perhaps in response to financial incentives to do so, than to develop a robust infrastructure that allows the information in EHRs to be used effectively and shared not only within clinical practices but also across providers. Effective exchange of data is necessary to drive the kinds of delivery and payment reforms sought nationwide.

Background In 2009, Damschroder et al. developed the Consolidated Framework for Implementation Research (CFIR), which provides a comprehensive listing of constructs thought to influence implementation. This systematic review assesses the extent to which the CFIR’s use in implementation research fulfills goals set forth by Damschroder et al. in terms of breadth of use, depth of application, and contribution to implementation research. Methods We searched Scopus and Web of Science for publications that cited the original CFIR publication by Damschroder et al. (Implement Sci 4:50, 2009) and downloaded each unique result for review. After applying exclusion criteria, the final articles were empirical studies published in peer-review journals that used the CFIR in a meaningful way (i.e., used the CFIR to guide data collection, measurement, coding, analysis, and/or reporting). A framework analysis approach was used to guide abstraction and synthesis of the included articles. Results Twenty-six of 429 unique articles (6 %) met inclusion criteria. We found great breadth in CFIR application; the CFIR was applied across a wide variety of study objectives, settings, and units of analysis. There was also variation in the method of included studies (mixed methods ( n  = 13); qualitative ( n  = 10); quantitative ( n  = 3)). Depth of CFIR application revealed some areas for improvement. Few studies ( n  = 3) reported justification for selection of CFIR constructs used; the majority of studies ( n  = 14) used the CFIR to guide data analysis only; and few studies investigated any outcomes ( n  = 11). Finally, reflections on the contribution of the CFIR to implementation research were scarce. Conclusions Our results indicate that the CFIR has been used across a wide range of studies, though more in-depth use of the CFIR may help advance implementation science. To harness its potential, researchers should consider how to most meaningfully use the CFIR. Specific recommendations for applying the CFIR include explicitly justifying selection of CFIR constructs; integrating the CFIR throughout the research process (in study design, data collection, and analysis); and appropriately using the CFIR given the phase of implementation of the research (e.g., if the research is post-implementation, using the CFIR to link determinants of implementation to outcomes).

[...]the Every Woman Every Child movement attracted more than US$60 billion dollars to women's and children's health between 2010 and 2015, with commitments from over 300 partners.6 The movement has spurred partnership mechanisms to support country-led implementation of the global strategy (2016-2030) - including the Global Financing Facility in support of Every Woman Every Child, the Innovation Marketplace, Unified Accountability Framework and the UN system's health agencies' H6 partnership.1 The global strategy (2016-2030) recognizes that human rights and other fundamental development principles - such as equity, community ownership and development effectiveness - are drivers of transformative change.1 In Peru, principles of equity underpinned a programme of poverty mapping to identify and prioritize reaching poor, rural and indigenous populations with social protection programmes and culturally appropriate, affordable care.7 In Kenya, the institutionalization of human rights principles is benefiting women's health following complaints alleging systematic violation of women's reproductive health rights in health facilities.

Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries. We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories—government, out-of-pocket, and prepaid private health spending—and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to generate more resources for health. Between 1995 and 2016, health spending grew at a rate of 4·00% (95% uncertainty interval 3·89–4·12) annually, although it grew slower in per capita terms (2·72% [2·61–2·84]) and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries (5·55% [5·18–5·95]), mainly due to growth in government health spending, and in lower-middle-income countries (3·71% [3·10–4·34]), mainly from DAH. Health spending globally reached $8·0 trillion (7·8–8·1) in 2016 (comprising 8·6% [8·4–8·7] of the global economy and $10·3 trillion [10·1–10·6] in purchasing-power parity-adjusted dollars), with a per capita spending of US$5252 (5184–5319) in high-income countries, $491 (461–524) in upper-middle-income countries, $81 (74–89) in lower-middle-income countries, and $40 (38–43) in low-income countries. In 2016, 0·4% (0·3–0·4) of health spending globally was in low-income countries, despite these countries comprising 10·0% of the global population. In 2018, the largest proportion of DAH targeted HIV/AIDS ($9·5 billion, 24·3% of total DAH), although spending on other infectious diseases (excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6·27% per year). The leading sources of DAH were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation). For the first time, we included estimates of China's contribution to DAH ($644·7 million in 2018). Globally, health spending is projected to increase to $15·0 trillion (14·0–16·0) by 2050 (reaching 9·4% [7·6–11·3] of the global economy and $21·3 trillion [19·8–23·1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of 1·84% (1·68–2·02) annually, and with continuing disparities in spending between countries. In 2050, we estimate that 0·6% (0·6–0·7) of health spending will occur in currently low-income countries, despite these countries comprising an estimated 15·7% of the global population by 2050. The ratio between per capita health spending in high-income and low-income countries was 130·2 (122·9–136·9) in 2016 and is projected to remain at similar levels in 2050 (125·9 [113·7–138·1]). The decomposition analysis identified governments’ increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending. Financing for global health has increased steadily over the past two decades and is projected to continue increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income countries. Many low-income countries are expected to remain dependent on development assistance, although with greater government spending, larger investments in health are feasible. In the absence of sustained new investments in health, increasing efficiency in health spending is essential to meet global health targets. Bill & Melinda Gates Foundation.

Strategic purchasing is one of the key policy instruments to achieve the universal health coverage (UHC) goals of improved and equitable access and financial risk protection. Given favourable outcomes of Universal Coverage Scheme (UCS), this study synthesized strategic purchasing experiences in the National Health Security Office (NHSO) responsible for the UCS in contributing to achieving UHC goals. The UCS applied the purchaser–provider split concept where NHSO, as a purchaser, is in a good position to enforce accountability by public and private providers to the UCS beneficiaries, through active purchasing. A comprehensive benefit package resulted in high level of financial risk protection as reflected by low incidence of catastrophic health spending and impoverished households. The NHSO contracted the District Health System (DHS) network, to provide outpatient, health promotion and disease prevention services to the whole district population, based on an annual age-adjusted capitation payment. In most cases, the DHS was the only provider in a district without competitors. Geographical monopoly hampered the NHSO to introduce a competitive contractual agreement, but a durable, mutually dependent relationship based on trust was gradually evolved, while accreditation is an important channel for quality improvement. Strategic purchasing services from DHS achieved a propoor utilization due to geographical proximity, where travel time and costs were minimal. Inpatient services paid by Diagnostic Related Group within a global budget ceiling, which is estimated based on unit costs, admission rates and admission profiles, contained cost effectively. To prevent potential underprovisions of the services, some high cost interventions were unbundled from closed end payment and paid on an agreed fee schedule. Executing monopsonistic purchasing power by NHSO brought down price of services given assured quality. Cost saving resulted in more patients served within a finite annual budget. L’approvisionnement stratégique est l’un des outils clés des mesures pour arriver à l’objectif de la couverture de santé universelle (CSU) qui est d’améliorer et de donner un accès aux soins équitable et de fournir une protection contre les risques financiers. Au vu des résultats positifs du Programme de couverture universelle (PCU), nous synthétisons dans cette étude les expériences d’approvisionnement stratégique de l’Office National de Sécurité Sociale (ONSS) responsable du PCU contribuant à atteindre la CSU. Le PCU pratique le principe de dissociation entre acheteurs et fournisseurs où l’ONSS, en tant qu’acheteur, est dans une bonne position pour imposer le principe de responsabilité des fournisseurs publics et privés envers les bénéficiaires du PCU grâce à des achats actifs. Un régime complet d’avantages sociaux a abouti à une protection élevée contre le risque financier reflété par le faible impact des dépenses de santé catastrophiques et les ménages qui se paupérisent. L’ONSS a engagé le réseau du système de santé des districts (SSD) pour favoriser les soins ambulatoires des patients, pour faire de la promotion et pour apporter des services de prévention à toute la population d’un district, ceci étant basé sur le paiement annuel par capitation ajusté par rapport à l’âge. Dans la plupart des cas, le SSD est le seul prestataire dans un district. Le monopole géographique a freiné l’ONSS à introduire un accord contractuel compétitif en revanche une relation viable et interdépendante basée sur la confiance s’est doucement développée, bien que l’accréditation reste essentielle pour l’amélioration de la qualité. Les services d’achats stratégiques du SSD ont réussi à attirer les personnes pauvres en raison de leur proximité géographique ce qui fait que les coûts et le temps de transport sont minimes. Les services hospitaliers ont été payés par le Diagnostic Related Group qui se base sur un plafond de budget global, qui est estimé par rapport au coût unitaire, au taux d’admission et aux profils d’admission. Afin d’éviter le manque potentiel de prestation de services, des initiatives coûteuses ont été dégroupées à l’approche du paiement et payées selon un calendrier décidé à l’avance. Le pouvoir d’achat monopolistique de l’ONSS a permis de baisser le prix des services tout en assurant la qualité. Ces économies ont permis de prendre en charge plus de patients dans un budget annuel défini. 战略采购是实现全民健康保险（UHC）目标的一项重要政策 工具，该目标旨在加强接受医疗服务的平等性和金融风险保 护。考虑到全民覆盖计划（UCS）的可喜成果，本研究将负 责全民覆盖计划的国家健康安全办公室（NHSO）的战略采 购经验同步进达成全民健康保险的目标中。全民覆盖计划采 用了一种采购者与供应商分开的概念，国家健康安全办公室 作为采购者，通过主动的采购，能够促进公共和私人供应商 为全民覆盖计划的受益者履行责任。通过降低灾难性医疗支 出和减少贫困家庭可以反映出这一计划提高了金融风险防护 水平，带来了全面的效益。国家健康安全办公室与地区医疗 系统（DHS）网络签订合同，根据每年调整年龄后的论人计 酬制，为整个地区的人口提供门诊、健康促进和疾病预防等 服务。大多数情况下DHS是一个地区唯一的供应商。地理上 的垄断限制了国家健康安全办公室引进竞争性的合同协议， 但是建立了一种在信任基础上的持久的相互依赖的关系，信 赖成为质量提高的重要通道。DHS提供的战略采购服务因为 地域接近有利于贫困人口，旅行的时间和成本达到最小化。 在全球预算控制下，由诊断相关组支付的住院服务是具有成 本效益的，这种支付是基于单位成本、住院率和住院病历。 为预防潜在的服务供给不足的情况，一些高成本的措施从限 额支付中分算，按协议价格来支付。由NHSO垄断购买可以 在保证质量的情况下降低服务价格。成本的降低使更多的病 人在每年有限的预算中享受服务。 La compra estratégica es uno de los instrumentos clave de la política para lograr las metas de la cobertura sanitaria universal (CSU) de acceso mejorado y equitativo y de protección del riesgo financiero. Dados los resultados favorables del Esquema de Cubrimiento Universal (ECU), este estudio sintetizó las experiencias de compras estraté- gicas en la Oficina Nacional de Seguridad de Salud (ONSS) responsable del ECU en contribuir a lograr las metas de la CSU. El ECU aplicó el concepto de la división de compradorproveedor donde la ONSS, como comprador, está en una buena posición para hacer cumplir la responsabilidad de los proveedores públicos y privados hacia los beneficiarios de ECU, a través de compras activas. Un paquete de beneficios exhaustivo resultó en un alto nivel de protección del riesgo financiero que se refleja en la baja incidencia de los gastos catastróficos en salud y en los hogares empobrecidos. La ONSS contrató la red del Sistema de Salud del Distrito (SSD), para proveer los servicios ambulatorios, la promoción de la salud y los servicios de prevención de enfermedades a toda la población del distrito, basándose en un pago anual por cabeza ajustado por edad. En la mayoría de los casos, el SSD fue el único proveedor en un distrito sin competidores. El monopolio geográfico obstaculizó a la ONSS la introducción de un acuerdo contractual competitivo, pero una relación duradera, mutuamente dependiente basada en la confianza, se desarrolló gradualmente, mientras que la acreditación resultó ser un canal importante para la mejora de la calidad. Los servicios de compras estratégicas de SSD logró una utilización a favor de los pobres debido a la proximidad geográfica, donde el tiempo de viaje y los costos fueron mínimos. Los servicios para pacientes hospitalizados fueron pagados por el Grupo Relacionado con Diagnóstico dentro de un límite presupuestario global, cuya estimación se basa en los costos unitarios, tasas de admisión y perfiles de admisión, y contuvieron los costos efectivamente. Para evitar una potencial provisión insuficiente de los servicios, algunas intervenciones de alto costo fueron desagregadas del precio cerrado final, y pagados en un esquema de tarifas convenido. Ejecutar el poder adquisitivo de monopsonio por parte de la ONSS bajó los precios de los servicios de calidad asegurada. El ahorro de los costos resultó en más pacientes atendidos dentro de un presupuesto anual limitado.