The equitable provision of accessible quality health services and the achievement of universal health coverage (UHC) continue to be prominent on the global health agenda, yet remains an elusive target for many low- and middle-income countries (LMIC). In these contexts, the private not-for-profit (PNFP) sector plays a significant role, and in many African countries, faith-based non-profit (FBNP) providers dominate this sector. Robust public-private partnerships are increasingly being recognised as important to building and maintaining strong, resilient health systems. However, there is a lack of evidence on whether collaborations between FBNPs and the public sector are complementary, have achieved their intended aims, or exactly how these relationships developed over time to shape these health systems. Furthermore, reliable information on both the historical and current spatial distribution of services and how this relates to geographic accessibility and the achievement of UHC is limited. This study explores this in Ghana, a country with a large FBNP sector, mostly networked under the Christian Health Association of Ghana (CHAG) which has an influential and now formalised relationship with the government. The following health systems research study utilises a mixed methods approach, synthesising geospatial mapping with varied documentary resources (secondary and primary, current and archival). The evolution of the FBNP sector and the shifts in service footprint are reflected in the geospatial maps, aligned with key historical events and contextualised by a narrative analysis. The study highlights that many faith-based facilities were initially located in rural and remote areas beyond colonial governance control (or boundaries), and many of these facilities still exist, demonstrating resilience to change over time. However, this service footprint has changed and today, public and private health facilities are located in similar areas throughout the country. This trend is in-line with social and political events, changing population dynamics and an increasing population of urban poor. The analysis assesses how the growth of the public sector, and these shifts in presence and profile for the FBNPs has influenced their perceived and measured contribution to UHC - in particular geographic accessibility. This study provides a model for representing the evolution of the relationship between public and a particular type of non-state provider over time, characterising the historical development of the health system, which should be considered in efforts to strengthen and develop the Ghanaian health system, and other relatable LMIC health systems.

The role of the private sector in improving health systems performance in lower to middle income countries is increasingly gaining more recognition. Public-private partnership (PPP) has been suggested as a tool, to assist governments fulfil their responsibilities in the efficient delivery of health services. In Tanzania, although the idea of PPP has existed for many years in the health sector, there has been limited coordination, especially at a district level - which has contributed to limited health gains or systems strengthening obviously seen as a result of PPP. In 2009 a formal PPP policy was introduced in Tanzania, which directs the appropriate allocation of resources, and describes risk and rewards that can be achieved by building on the expertise of each partner. The Health Sector Strategic Plan III (2009-2015) further emphasises the need for service level agreements (SLAs), which are seen as an important indicator of improved PPP. This case study that draws on the decision-space framework, was conducted in the Bagamoyo district of Tanzania, and employed in-depth interviews, document reviews, and observations methods. The study findings reveal several forms of informal partnerships between the local government and non-state actors. The lack of SLAs for facilities that receive subsides from the government is argued to contribute to inappropriate distribution of risk and reward leading to moral hazards. This is evidenced by non-state actors who pursue their own interests, diverting from public social goals. Furthermore, findings highlight weak capacity of governing bodies to exercise oversights and sanctions, which is acerbated by weak accountability linkages and power differences. Moreover, restricted flexibility in spending is seen to deter prompt actions to address evolving population needs, given limited local fiscal space. It is concluded that effective PPP policy implementation at a local level depends on the capacity of local government officials to make choices that would embrace relational elements dynamics in strategic plans. Disempowered Council Health Services Board in relation to engaging non-state actors is shown to impede PPP initiatives that are conceptualized at local and national levels. This study highlights a need to consider initiatives that would foster new social contracts with non-state actors at the local level and in return build a people-centred district health system. This study is intended to improve knowledge on health systems policy interventions, strengthen future policy implementation at the sub-national level, and strengthen the district health systems as a result of PPP in a country with similar contextual elements.

As community-based governance structures in the service delivery of primary health care, health committees can promote the quality, accessibility and responsiveness of service delivery. More specifically, health committees provide a platform for community members to advocate for their health needs and meaningfully participate in decision-making, oversight and monitoring of service delivery. Hence, health committees provide a bottom-up strategy to realise the right to health and a people-centred health system. Previous research has found that Health Committees in the Cape Metropole of South Africa face similar challenges as their counterparts globally. In South Africa health committees' role and mandate often seem to be unclear and weak policy frameworks have resulted in wide variations in health committee functionality. Health care providers, particularly health facility managers, have been identified to play a key role in creating a supportive environment for health committees' genuine and effective participation. Particularly, health care providers' misunderstandings of health committees' roles and responsibilities as well as their lack of engagement with health committees can form barriers to health committee's functioning. A gap in understanding exists on the impact training of health care providers could have on health committees' meaningful participation. While many health committee members in the Cape Metropole of the Western Cape Province were already trained, health care providers had not been trained until May 2015. Present realist evaluation sought to describe and explore the immediate and short-term impact of this pilot training on health care providers' responsiveness towards health committees. Pre- and post-training questionnaires, direct observations and semi-structured interviews were employed as research methods. The training evaluation was enriched by participants' diverse professional positions and work environments as well as their various experiences and relationships with health committees. The study reveals that the training played a role in increasing health care providers' responsiveness towards health committees' roles and functions. Health care providers demonstrated understandings and intentions towards building effective working relationships with health committees. However, training is recommended to be followed up on and to be continuous to ensure intentions are translated into practice and to account for the dynamic nature of health facilities, health committees and the health system in which they reside. In this manner, health care providers can increasingly contribute to building sustainable relationships with health committees to promote meaningful and effective community participation, the strengthening of people-centred health systems and the progressive realisation of the right to health.

Health systems resilience is an emerging issue in health policy and systems research, yet limited information exists on how resilient health systems are developed and the different elements that contribute to whole (national) health systems resilience. In this study, resilience is understood from the socio-ecological lens applicable for complex adaptive systems. Resilience therefore is not only the ability of a health system to address disturbances and restore its basic structures and functions, but also the ability of a health system to transform or re-organise in response to a disturbance if the current system is no longer tenable for the context. Along with the rise in the interest in health systems resilience is a renewed focus on partnership with nonstate providers (NSPs) to complement national health systems. The role of NSPs in supporting health systems resilience however has been largely unexplored. This study thus explores the topic of resilience with respect to health systems and focuses on a particular NSP type – namely, faith-based health providers (FBHPs). It describes four country cases of Ghana, Malawi, the Democratic Republic of Congo, and South Sudan - where FBHPs, though their inclusion in the health system and the activities they undertook, appear to have influenced the resilience of national health systems. FBHPs have played critical roles in strengthening health systems, which has been argued to be a key source of resilience. Their presence also diversified the actors in the health system, enabling them to step in as an alternative service provider when government services were unavailable. Historically, FBHPs appeared to be more flexible which allowed them to respond more quickly during times of crises. This flexibility in operations, coupled with their mission to serve marginalized populations, have supported the development of innovations for the poor, which in some instances have been adopted by national governments. As such, FBHPs have not only acted as buffers in times of shocks or stressors, but have also supported the transformation of national health systems for the better. Recent trends of closer integration with governments however are increasing the interdependencies between FBHPs and the public sector, which have potential to make health systems more vulnerable and less resilient.

Increased migration is one of the main challenges impacting on health system performance. The World Health Organisation (WHO) framed responsiveness, fair financing, and equity as the intrinsic goals of a health system. In line with this framework, we attempted to map existing research on migration and health system performance. A qualitative systematic review was conducted. We followed the processes indicated for evidence mapping synthesis reviews, which included choosing the scope and research topic, searching, and selecting evidence, reporting findings, and identifying the evidence. We improved the primary review by first performing a brief scoping review, which served as the analytical basis for the systematic review extraction process. Articles found during the scoping review were evaluated again during the bigger systematic review phase. We refined the study's eligibility criteria as well as the data extraction items. Seventy-two articles were considered for the review. Out of this total (55/72) were published between 2016 and 2021. Our analysis showed fairness in financing, weak governance and leadership, the absence of a universally acceptable definition of migration, limited access of migrants to healthcare, equity, health worker attitude towards migrants, dignity, and health care quality to migrants as key challenges that affect health system performance. The mapping exercise shows more literature on migration and health system performance, but also shows gaps requiring urgent attention, including integration of the health system goals in implementing health interventions. We conclude that countries are recognising the challenges of migration on health system performance. Migration is slowly being included in national health policies in low- and middle- income countries, however challenges to implementation of such policies exist. Migration is recognised as a human right and the ethical obligation of health institutions. More agenda setting and funding for bridging work on migration and health system performance is recommended.

There is a lack of conceptual clarity regarding the drivers of midwives’ roles within health systems, which has contributed to the significant variability both within and across countries in whether, to what extent and how midwives are integrated in these systems. This dissertation incorporated a mix of methodological approaches to address this gap. First, a critical interpretive synthesis was used to develop a theoretical framework that identifies the different types of policy levers that would be required to enhance to roles of midwives within any given health system, and an exploratory network analysis was used to analyze relationships among the ‘health system arrangements’ part of the framework and to identify gaps in the literature. Second, a logistic regression was used to examine the correlates of birth-experience satisfaction – as a patient experience component of the health system ‘triple aim’ – among women receiving care from midwives, family physicians and/or obstetricians in Ontario’s health system. Third, an embedded single-case study design and Kingdon’s agenda setting and the 3i+E theoretical frameworks were used to qualitatively assess how and under what conditions the Ontario health system has assigned roles to midwives. The research chapters build on each other and make substantive, methodological and theoretical contributions. Specifically, insights gained from the theoretical framework informed variable selection and definition for the quantitative analysis and were tested in the embedded single-case study. Substantively, the dissertation provides a rich understanding of the roles of midwives in health systems through a mix of qualitative and quantitative research evidence, adding to the evidence base that policymakers can draw from when making decisions regarding midwifery care. v Methodologically, the dissertation introduces a novel combination of a critical interpretive synthesis and exploratory network analysis. Lastly, the dissertation advances the theoretical understanding of the roles of midwives within health systems through a new theoretical framework. / Thesis / Doctor of Philosophy (PhD) / Midwives who are educated and regulated according to international standards can play important roles in the provision of maternal and newborn care. Yet, there is significant variation within and across countries in whether, to what extent and how the profession has been integrated in most health systems. A lack of understanding regarding these roles likely contributes to this variation. This dissertation addresses gaps in understanding through: 1) a framework, which can be used as a tool by policymakers to identify policy levers that would be needed to enhance to roles of midwives within any given health system; 2) supportive quantitative evidence on birth-experience satisfaction among women in Ontario’s health system who received care from midwives; and 3) examining in two reform efforts why many women continue to experience unmet midwifery needs in Ontario’s health system even though the government is generally supportive of the profession.

Control of tuberculosis has often been managed as a simple issue, the belief being that activities to care for people affected by tuberculosis can be uniformly standardised and centred on the diagnosis and treatment of tuberculosis. The DOTS strategy has been the most concrete illustration of this approach. It is undeniable that this has been successful in re-organising unstructured and very inefficient national TB control programmes. Today, many countries’ programmes are better organised and have reached case detection and cure rates close to the targets set by WHO (i.e., 70% of cases effectively detected and 85% of detected cases cured). There are mounting arguments to enlarge the scope of activities to care for people affected by TB beyond the classical standardised strategies for diagnostic and treatment of tuberculosis. Indeed, it has become widely accepted that to increase further coverage of diagnosis and treatment of TB, it is necessary to address the economic and psychosocial problems of the people affected by tuberculosis, particularly for those having the least access to and worse quality of care. This will be possible only if, additionally to the current approaches, customised care can be developed after analysis to capture the complexity of care and interventions that take the specificity of local systems in their context into consideration. In chapter 1-2, we illustrate this through the review of the recent customisation of Directly Observed Treatment (DOT) as its naturally evolve in various contexts world-wide. Developing an analysis that captures complex issues in PATB care means having a proper understanding of the interactions between parts of the local care systems to people affected by TB and identifications of the important patterns of these interactions. That is possible only if information different than the usual quantitative indicators is generated. We illustrate this in the part 2. We took the case of Nicaragua’s TB control programme, which is renowned for its performance in America. In that context, we illustrated the limits of a classical approach to TB control programme evaluation (chapter 2-3) and gave four examples of care process analysis that illustrated the economic and psychosocial problems of people affected by tuberculosis (PATB) (chapter 2-4 to 2-7). Developing customised system-sensitive interventions to improve the care process means recognising that the interventions cannot be isolated from the organisational context and social dynamics during changes. Thinking must therefore move beyond the design of universal, standardised tool kits. We illustrate specifically in the part 3 the importance of combined local, national and international processes in improving the care process for people affected by TB in Nicaragua: lessons from successful and unsuccessful local and customised processes of implementing interventions in four local health systems (chapter 3-4) can be an opportunity for a health system research unit in a public health school to build a strategic process of care improvement at national level (through scaling up and through the building of a conducive environment) (chapter 3-5). As a conclusion of this work, we propose in part 4 a three-level reflection through discussion of patterns emerging from the analysis done in the previous chapters: (1) patterns of care and (2) of organisation of health care system are presented in the form of an analytical framework; (3) patterns of regulation and management to improve care for PATB are presented together with a strategy to work on it.

Nas últimas décadas inúmeras experiências alternativas na área de organização de serviços de saúde tem se desenvolvido no Brasil e países Latino Americanos. O autor considerando as atuais modificações do Sistema de Saúde no Brasil, a partir da criação do Sistema Único de Saúde, estuda a experiência realizada no município de Cotia, existente há mais de 20 anos, tendo como objetivo central analisar seu processo de implementação e os resultados obtidos, dentro da ótica de um Sistema Local de Saúde. O estudo de caso é desenvolvido em dois eixos básicos, um de contextualização da experiência, reconstituindo as diferentes políticas nas esferas federal, estadual e municipal e ainda suas bases conceituais, e outro a partir da experiência em si, recuperando os processos através dos aspectos institucionais, organizacionais, padrões de financiamento e modelo assistencial, avaliando ainda seus resultados e impactos na saúde da comunidade. As conclusões a partir do estudo de caso ressaltam alguns aspectos centrais. Em relação ao desenvolvimento institucional a particularidade da experiência de Cotia, é ter como instituição hegemônica uma entidade privada de caráter filantrópico, a Associação Hospital de Cotia. Essa Associação, desenvolve uma estrutura de participação local, mas predominantemente é orientada a partir de lideranças técnicas fora do município e ligada à Universidade (Faculdade de Saúde Pública). Sua organização contempla como base doutrinária a integração das ações preventivas e curativas e a conformação de uma direção única para o sistema, hospital e rede básica de saúde. Outro aspecto refere-se a formação de recursos humanos incorporada e desenvolvida desde o inicio da experiência. Em relação aos aspectos financeiros do sistema, durante todo período de sua existência a receita operacional tem forte dependência aos orgãos públicos, gerando deficits operacionais cobertos por doações e convênios com instituições internacionais. Em relação ao investimento, essa mesma dependência é observada. Os custos unitários de procedimentos obtidos pelo sistema podem ser considerados baixos, tendo em vista os aspectos qualitativos da prestação de serviço pelo mesmo. Quanto ao modelo assistencial, a experiência de Cotia obedeceu a critérios de racionalização de recursos adotando uma regionalização local, uma hierarquização da rede de serviços e uma articulação intra e intersetorial, desenvolvendo programas, respeitando a integralidade das ações de saúde, criando um sistema de referência e contra-referência efetivo tendo como base na sua priorização a realidade epidemiológico social da comunidade. O componente da participação comunitária do modelo, gerou experiências completas de gerência conjunta de unidades sanitárias e um grau de participação foi considerado satisfatório dada a realidade socio cultural do município. Quanto a área de recursos humanos a experiência desenvolve linhas de formação de recursos humanos de amplo espetro desde o nivel elementar até o nivel universitário, criando um sistema de formação de médicos gerais comunitários adaptados a realidade local. Quanto a dinâmica dos serviços e seus resultados, o sistema atingiu altos graus de cobertura nas populações de maior risco; interferindo de maneira efetiva na melhoria de alguns indicadores de saúde do município principalmente na área Materno-Infantil e de controle das doenças transmissíveis. O autor também vê no atual quradro de organização do Sistema Único, a partir da experiência estudada, a possibilidade de extensão do modelo tendo como base na área hospitalar as Santas Casas. Ainda recomenda o reestudo das formas de financiamento, para o desenvolvimento dos Sistemas Locais, e a criação de uma unidade de gerência neste nivel de intervenção sobre a realidade local. / Some alternative experiences concerning the organization of health services have been developed in Brazil and in other latin americam countries, these late decades. Regarding aspects of the Brazilian Health System imposed through our Constitution, the author studies the experience developed in the Cotia county since twenty years, always having as its main objeetive, the analysis of its implementation process and the achievement obtained within the concept of a Local Health System. The case study is developed focusing two basic points: one, referring the experience already attained by the federal, state and municipal health services, as far as its institutional organization; its financial and health model and final results attained, always dealing with the community health as a whole. The conclusions after the case study point out to some important aspects: dealing with the institutional development of the Cotia Project, it is emphasized a philantropic entity, the Cotia Hospital Association, which has a strong local participation as far its structure is concerned, but also, it is predominantly technical oriented from outside sources of the county, as the school of Public Health of the University of São Paulo. Its organization is based on the philosophy dealing with the integration of preventive and curative health activities, directed towards our existing health system, as far as hospital and health centers services are concerned. Another aspect deals with the development of new human recources, a subject which started at the beginning of the experience. Related to the financial aspects of the project, its operational funds since the starting of its activities, it depends on governmental funds and donations from philantropy as well as from agreements between the \"Associação\" and international institutions. The same situation goes on as far as money investment is concerned. Costs out of services offered are not too high, since its quality is always considered excellent. As far as the model of the Cotia experience, it was always directed towards the rationalization of its owm recources, the local regionalization and hierarchilization of health services, its intra and intersectorial articulation, always developing programs concerning the integration of acceptable health actions. This philosophy creates a two-way referencial system based on priorities and the social epidemiological reality of the community, given place to new experiences dealing with the community participation on he administration of the project. This is a very satisfactory achievement, considering the socio cultural reality of the Cotia county. Also, as far as the preparation of new human resources, the project has been. developing courses from the elementary up to the university levels of education, so creating an educational system for the training of the general practitioner, adapted to our local reality. As far as the dynamics of the services and final results, the project has been covering the population standing for high health risk, a fact that effectively attains the betterment of some of the indewes of the Cotia county, mainly concerning to maternal and infant care areas and also to the control of infectioms diseases.

The central tenets of both the National Health Services of Scotland (NHS) and the Unified Health System of Brazil (SUS) are universality and equity of access to services on the basis of need, free at the point of delivery. Redistribution is designed into the Scottish system. This study uses a mixed methods approach to analyse access to health care and the influence of socioeconomic factors using hip arthroplasty as a proxy measure for equity in the public health care systems of Brazil and Scotland. Methods Three studies were conducted to establish the extent to which equity is achieved in each system and the extent to which inequalities in socioeconomic status and health service supply affect equity. First, an ecological study using routine data of hip arthroplasty rates in the public sector by country and geographic region (2009/10 to 2012/13) complemented by an analysis of supply, specifically per capita distribution of beds and staff nationally and by area. Second, inequalities in access due to socioeconomic status were analysed for Scotland using the Scottish Index of Multideprivation (SIMD) in association with standardised rates; in Brazil two socioeconomic indicators (Gini and Human Development Index - HDI) were modelled (Zero Inflated Poisson - ZIP) with standardised municipal rates of arthroplasties (5,565 municipalities); and a Pearson's correlation. Finally, qualitative interviews were undertaken in both countries with civil servants, health workers and policy makers who were invited to comment on the quantitative results from stages I and II based on a script of open ended questions. Results There is an almost eight fold difference in treatment rates between Brazil (7.8-8.3/100,000) and Scotland between 2009/10 to 2012/13 (57.7-61.1/100,000). There are geographic differences within both countries. The health board areas with the lowest and highest regional rates in Scotland were Glasgow & Clyde with rates of 29.2-40.2/100,000 and Ayrshire & Arran with a rate of 60.2-88.5/100,000 respectively; in Brazil the lowest and highest regions were the North Region (2.3-4/100,000) and South Region (15.4-17.9/100,000) respectively. The two least deprived quintiles (4 and 5) in the Scottish population had both a higher utilisation (42.6%) and proportional growth in number of procedures than the two more deprived (1 and 2); quintile 3 had no consistent changes. In Brazil municipal rates showed a negative correlation with Gini (r=- .226) and a positive correlation with HDI (r=.396); the ZIP model demonstrated that for every standard deviation (SD) change in Gini, rates would be 23% higher or lower, for HDI each SD would lower or increase rates by 56%. Three major areas were identified by interviewees as explanatory factors for these quantitative results: equity of access, health systems, evidence based actions/policies. Crucially the interviewees identified GDP spend on public health care, the ability of governments to redistribute and reallocate resources on the basis of need and the distorting effect of the market and private providers including physicians as key factors; and the need for better data collection from the private sector. Conclusion Although both countries aspire to universal health care, Brazil is very far from reaching that goal due to the widespread socioeconomic differences and that the health system does not redistribute resources, staff and beds according to need. Scotland appears to be achieving universal access on the basis of need, nevertheless there are geographic and socioeconomic differences in access that need to be carefully monitored and understood. In Brazil there should be better planning and resource allocation so that public resources are redirected towards those most in need of the North and Northeast regions.

Background: The Human immunodeficiency virus infection (HIV) and Acquired immunodeficiency syndrome (AIDS) epidemic peaked in 1999, which led to an increase in funding by donors and Global Health Initiatives (GHI) to combat the epidemic. This literature review examined how the substantial influx of funding for GHI’s and HIV and AIDS since early 2000 has impacted the health system in Zambia. Method: The method used for the study was a systematic literature review.  Results: There is conflicting views and mixed evidence about whether GHIs and HIV and AIDS initiatives have benefitted the general health system. It is clear that GHIs and HIV and AIDS initiatives have added substantially to the increase in funding for health in Zambia. Furthermore, it seems likely that the special attention put on HIV and AIDS created an exclusive and skewed environment with increased capacity to tackle HIV and AIDS, but with less capacity built for health services in general. In-coming support from Global Health Initiatives and funding for HIV and AIDS in Zambia has to some extent been controlled by and led by the contributing donor, giving the Zambian authorities limited oversight of the resources. Conclusions: The influx of funding for HIV and AIDS has led to increased support for a specific disease, but it has not generated support to the health sector in general. It has also led to a fragmented approach, where HIV and AIDS have fallen outside of the regular coordination of the health sector.   Keywords: Zambia, HIV and AIDS, Health systems, vertical initiatives, strengthening, impact. / Bakgrund: The Human Immunodeficiency Virus Infection (HIV) och Acquired Immunodeficiency Syndrome (AIDS) epidemin var på sin högsta nivå 1999, vilket ledde till en kraftig ökning av resurser från givare och globala hälsoinitiativ för att bekämpa epidemin. Denna genomgång av litteraturen undersökte hur denna tillväxt av resurser sedan början av 2000-talet påverkade hälsosystemet i Zambia. Metod: Den metod som användes för studien var en systematisk litteraturgenomgång. Det finns olika slutsatser och bevis för om insatser för HIV och AIDS och globala hälsoinsatser har gynnat hälsosystemet. Resultat: Det är klart att insatser för HIV och AIDS och globala hälsoinsatser har bidragit substantiellt till finansiering av hälsosektorn i Zambia. Studien visade att det är troligt att det särskilda fokus som HIV och AIDS fick skapade en exklusiv och snedvriden miljö, med ökad kapacitet för att hantera HIV och AIDS, men med mindre kapacitet för hälsosektorn generellt. Det stöd och resurser från globala hälsoinitiativ och för HIV och AIDS som Zambia fick del av, har till en del varit kontrollerat av och letts av bidragsgivaren, vilket ledde till att Zambiska myndigheter hade begränsad kontroll över dessa resurser. Slutsats: De ökade resurser som tillkom för att bekämpa HIV och AIDS innebar en ökad satsning på dessa sjukdomar men det har bevisats att detta inte genererade tillräckligt stöd till hälsosystemet. Detta ledde också till en fragmenterad satsning, där HIV och AIDS har hanterats utanför den vanliga samordningen av hälsosektorn.   Nyckelord: Zambia, HIV och AIDS, Hälsosystem, vertikala initiativ, stärkande, effekt.