The devolution of health systems development to local governments in the Philippines in 1991 brought with it unintended consequences as local chief executives found themselves with new responsibilities for which they were not prepared. These unintended consequences were exacerbated with the implementation of the country's Universal Health Care Act in 2019. To address this problem, the Zuellig Family Foundation, a non-profit and non-government organization based in the Philippines with the aim of improving health outcomes, has designed a local level health governance strengthening intervention: the Bayang Malusog (literally Healthy Communities) Municipal Leadership Development Program (BM-MLDP). The BM-MLDP is a 12-month capacity building intervention for local chief executives and local health officials consisting of deep dive immersions, change management and leadership sessions, sustainability of health reform sessions, and co-design sessions to improve population health outcomes. Its implementation on the municipalities of Balete and New Washington in 2022-2023 contributed to improving and sustaining optimal population health outcomes despite resource constraints. This highlights the potential of health governance and capacity building interventions like the BM-MLDP in improving population health outcomes and advancing the implementation of universal health coverage in resource-constrained, devolved healthcare settings.

This paper focuses on the engagement of persons and groups with diverse interests in the governance of the COVID-19 pandemic. During emergencies, involving diverse perspectives in governance mechanisms can contribute to more equitable and evidence-based policies that address societal needs. Previous literature shows that, even with the intent to include diverse perspectives , there can be gaps in engaging non-governmental entities in epidemic governance. This study sought to analyze participation of two important interest groups: academia and civil society organisations (CSOs) during the COVID-19 response, to identify best practices and strategies for enhancing their roles in future health crisis governance. We adopted a comparative case study design to collect data from six countries: Nigeria, Singapore, South Africa, Bangladesh, Jordan, and the United Kingdom, representing varied political and economic contexts, geographic locations, and response strategies during the pandemic. Data sources included key informant interviews and focus group discussions with a total of 64 stakeholders, including government officials, academic experts, and personnel from CSOs. During the COVID-19 pandemic, CSOs actively participated in response efforts, but in the six countries we analyzed, they largely did so independently of the government, particularly during the initial response phase. In some countries, governments involved CSOs only after reports of clusters of new transmission, primarily for risk communication and service delivery like vaccine distribution, without involving them in governance mechanisms like making pandemic preparedness and response policies. Other governments worked with public universities to gather evidence for decision-making and policy formulation starting from the pre-pandemic phase to the initial phase of the pandemic. Across disciplines, experts in epidemiology, mathematical modelling and infectious diseases were more likely to be consulted, whereas economists, sociologists, ethicists and anthropologists were less involved.

In Malawi, health services are officially free at the point of use, but patients often make informal payments to access services or obtain medicines. These payments undermine equity and trust in the health system. This study examined for the first time the prevalence, types, and determinants of informal payments among Malawians who had recently used health services. We conducted a multi-district cross-sectional household survey in four districts chosen to reflect urban and rural Malawi. Households containing someone who had been hospitalised in the previous six months were interviewed using a structured questionnaire. Descriptive analyses identified the types and prevalence of informal payment, while multivariable logistic regressions identified factors associated with informal payments. Overall, 17% of respondents reported paying for services that are officially free. Informal payments are most often for medicines (52%), consumables (24%) and consultations (24%). Female respondents and those living in urban areas were significantly more likely to report giving informal payments, while those with higher levels of education were less likely. Participants with a good or very good financial situation were more likely to make such payments. Significant geographical variations were observed, with higher probabilities in Mchinji and Mzimba than in the Blantyre district. Nearly one in five Malawians reported making informal payments to access health services, questioning the formal policy that these are free. These findings highlight the need for governance reforms, greater accountability and community awareness to reduce informal payments and promote equitable access to care.

Sub-Saharan Africa (SSA) is experiencing an epidemiological transition where non-communicable diseases are becoming the leading cause of disability and mortality alongside infectious diseases such as HIV/AIDS. Multimorbidity, the coexistence of two or more long-term conditions, is increasing in SSA. However, the cost of managing multimorbidity is largely unknown. This study aimed to estimate the economic cost of public outpatient primary care for adults with multimorbidity (HIV, hypertension, and/or diabetes, and their associated conditions: cardiovascular disease, and TB) in rural South Africa. This study used a cross-sectional, retrospective cost-of-illness approach to estimate the direct and indirect costs of multimorbidity management in Bushbuckridge, Mpumalanga, in 2022. Data were synthesized from patient-level data from eight public primary healthcare facilities within the Agincourt study site-a rapidly transitioning rural South African setting. Additionally, government reports and an existing study on transport costs and productivity losses conducted within the Agincourt study site were used to estimate the costs of managing patients in the primary care facilities. Results showed that patients with multimorbidity had higher average economic costs per patient compared to those with single conditions. Overall, patients with multimorbidity increase costs above the baseline of a patient with a single condition (R4 900/annum) by between 42% and 83%. Patients with multimorbidity also incur slightly higher costs associated with accessing primary care services compared to those with a single condition. However, our model shows that the additive cost of managing multiple conditions in separate consultations is higher than managing all conditions in one visit. This shows that managing patients within an integrated care model seems to have a cost-limiting effect. However, treatment guidelines for managing multimorbidity in South Africa should be developed to ensure standardized care.

Physical activity plays a crucial role in preventing and managing obesity and its related comorbidities, with minimal side effects. Similarly, consuming a balanced diet is essential for maintaining good health and adequate nutrition. However, most adults fail to meet population-based dietary and physical activity guidelines. In this pilot cluster-randomized controlled trial, we aimed to evaluate the effectiveness of a video-based physical activity and dietary intervention among adults aged 30-59 years in Phnom Penh, Cambodia. A total of 63 adults participated in the 12-week program, with 31 assigned to the intervention group and 32 to the control group. The intervention group received a video-based program delivered via Telegram and YouTube, complemented by a 2-hour in-person session focusing on technical orientation and safety training. Standard care was provided to both the intervention and control groups and consisted of a single 60-minute in-person lifestyle education session and a printed booklet commonly used in Cambodian health center settings. The intervention group demonstrated greater improvements in physical activity adherence, healthy eating adherence, exercise self-efficacy, healthy eating self-efficacy, systolic blood pressure, body weight, body mass index, waist circumference, fasting blood glucose, and high-density lipoprotein cholesterol levels compared with the control group (p < 0.05). Given its high accessibility and ease of implementation, video-based content appears to be an effective approach and policy for improving health behaviours, even in resource-limited settings. These findings support the use of video and digital platforms as potential strategies and evidence-based policy for preventing and managing non-communicable diseases in low-resource settings.

The systematic involvement of community health workers (CHWs) in hypertension management can improve outcomes and achieve blood pressure control. However, much of this evidence is from effectiveness trials conducted under ideal conditions, with little evidence from programmes operating in routine conditions. In Kenya, recent policy changes have expanded CHW roles to routinely incorporate non-communicable disease (including hypertension) service delivery. We undertook an exploratory descriptive qualitative study in one county, examining what CHWs now referred to as community health promoters (CHPs) do in relation to hypertension service delivery, influences on their involvement, and considerations for sustainability. We found ad hoc and fragmented CHP involvement in practice despite policy guidance for community-level hypertension service delivery. Drawing on the extended health systems building blocks framework, we identified multiple capacities that can support expanded CHP roles in hypertension care, including the pre-existing community health service structure and societal partnerships, as well as their level of motivation. Policy provisions for CHP professionalization (payment of stipends, provision of CHP kits with varied commodities and training) create an enabling environment. However, sustained adoption of the new CHP roles may be impeded by (i) challenges in meeting the financial and supply chain obligations for stipend payments and commodities, respectively; and (ii) inadequate sensitization of communities and frontline-providers concerning expanded CHP roles and implications for facility-level hypertension care. To effectively implement recent policies, strengthening coordination and communication across all community and health system actors is needed, as well as clarity and deliberation on long-term financing for the community health system.

The community care sector is a major component of social protection systems in South Africa. However, despite considerable investment and policy attention on social protection in South Africa, the community care sector continues to face enormous challenges and pressures. On the one hand, government invests a significant amount in social spending and aims to honour its constitutional responsibilities towards improving the health and social welfare of the country. On the other hand, community-based care workers are socially and economically marginalised, and community care services remain fragmented and often inaccessible to those who need them most. This paper explores how elements of South African policy on the community care sector emerged historically out of policy responses to parallel social crises of HIV/AIDS and unemployment in the period 2000-10. We draw on the theories of John Kingdon (agenda setting) and Nancy Fraser (needs interpretation) as the lenses to analyse data from policy documents, published literature, and key informant interviews. We show the convergence and consolidation of policies across sectors in the study period into a community care sector characterised by competing and unresolved tensions: between constitutional promises of social and economic rights and enduring conceptualisations of social reproductive labour as feminised, devalued, and 'invisibilised' within the private, domestic sphere. This results in a community care sector that has limited effectiveness as an arm of the social protection system, and which continues to be plagued by the structural inequalities that characterise South African society.

Globally, an estimated 22.7 million children are unimmunized or 'zero-dose' (ZD), with 3.1 million in Nigeria. The political and economic environment plays a critical role in influencing the number of ZD and under-immunized children. We explored stakeholder perceptions of the political and economic context of vaccination services in Kano and Lagos States, two Nigerian States with a high number of ZD children. We conducted stakeholder mapping, followed by key informant interviews with 84 State, local, and community informants responsible for or influential in immunization. Transcripts were analyzed using a reflective thematic framework approach. We describe the multi-level network of domestic and international actors characterizing Nigeria's immunization policymaking and implementation landscape. Respondents perceived a strong and mutual political commitment by all actors involved in routine immunization. The pivotal role of local influencers further reinforced this commitment, from traditional to religious leaders, to improving uptake in challenging settings. Knowledge of national policies, and thus, perception of their adequacy in addressing under-immunization, was weakest among participants working at the local and community levels. Other reported barriers to policy implementation included bureaucratic delays in fund disbursement, outdated policies, slow dissemination of policies to local levels, and inadequate policy provisions for funding and staffing at the local level. To enhance equitable immunization coverage in Kano and Lagos, our findings suggest a need for meaningful engagement of community actors in policy development, timely policy revisions, and the establishment of mechanisms for expediting fund disbursements and addressing funding shortfalls at the local levels.

Universal health coverage (UHC) provides a platform for attaining 'Health for All'. Attaining UHC requires substantial investment and resources in the health sector. This can be challenging for many sub-Saharan African (SSA) countries. Public-private partnerships (PPPs) could be a potential solution. The implementation of healthcare PPPs for developing health system capacities for UHC presents both significant opportunities and notable challenges. This scoping review, part of a broader review on PPPs, examines the facilitators and barriers of healthcare PPPs and their impact on UHC. The review was guided by Arksey and O'Malley's guidelines for conducting a scoping review. PubMed, Medline (Ovid), Global Health (Ovid), Web of Science, Scopus, and EconLit were searched for peer-reviewed English language publications from January 2013 to December 2023. Nineteen studies were eligible for the final analysis following screening of 944 studies. Identified key facilitators of PPPs for UHC included well-established institutional structures, robust accreditation systems, accountability mechanisms, and political will and support. These factors contributed to improving primary healthcare delivery, which is a critical dimension for UHC. Key barriers identified were limited capacity of implementing partners, regulatory inadequacies, and insufficient funds. These barriers negatively affected the performance of healthcare PPPs, which translates into systemic inequities in access to essential health services, impeding progress towards achieving UHC. Considering contract management capacity of implementers, sources and flow of funds, and regulatory frameworks are highly recommended for UHC to be realized using PPPs.