Health Policy and Planning

Subramonia Pillai, Vasanthi; Favaretti, Caterina; Basenero, Andrew; Ntambara, John Bosco; Wesva, Ivan; Jonathan, Kafeero Martin; Munana, Richard; Cazier, Juliette; Bärnighausen, Till; Schwab, Josephine; Wachinger, Jonas; Kalyesubula, Robert; McMahon, Shannon A; Sudharsanan, Nikkil

doi: 10.1093/heapol/czag044pmid: 41926709

In Uganda, frequent shortages of antihypertensive medications hinder continuity of care, undermining blood pressure management. Building on preliminary ethnographic research, this study evaluates a community-led, mobile-wallet-based pooling intervention—MoPuleesa—designed to improve medication access at a rural clinic in Nakaseke District, Uganda. Over a 7-month period, 183 patients enrolled and were linked to a digital savings platform that required monthly contributions of 5000 UGX (∼USD 1.39) into a communal fund to bulk-purchase medications at a discounted cost. Using survey data, transaction logs, and clinic records, we assessed contribution behavior, risk of adverse selection, equity, changes in medication availability, and patient blood pressure levels. On average, 48% participants contributed each month. Contribution rates showed no significant differences across education levels or medication costs, suggesting minimal equity concerns or adverse selection. Government pharmacies fulfilled only 8% of total prescriptions; however, for contributors, MoPuleesa closed 84% of the remaining medication gap. However, despite improvements in medication supply, we did not observe statistically significant improvements in blood pressure. Our findings demonstrate the feasibility and effectiveness of mobile money pooling in addressing chronic medication shortages. MoPuleesa achieved broad participation and equitable outcomes in a resource-constrained setting and significantly improved medication availability. We conclude that mobile-based fund pooling for medication can significantly improve medication supply and, with improvements in eligibility assessments, could serve as a complementary or intermediate solution to structural barriers in under-resourced health systems.

Dumcheva, Anastasiya; Laatikainen, Tiina; Rakovac, Ivo; Nevalainen, Jaakko; Nuorti, Pekka

doi: 10.1093/heapol/czag055pmid: 41992534

Premature mortality from noncommunicable diseases (NCDs) remains high in twelve Eastern Europe and Central Asia (EECA) countries—Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan. Although WHO-recommended ‘Best Buys’ offer effective strategies to reduce NCDs, their implementation in EECA remains poorly documented. We conducted a cross-country, retrospective analysis of the adoption and implementation of population-level NCD ‘Best Buys’ interventions targeting tobacco, alcohol, diet, and physical activity across EECA from 2010 (or earliest available year) to 2024 (or latest available year), aiming to identify progress, gaps, and priorities for action. Data were sourced from WHO NCD Country Capacity Surveys and other global databases and monitoring reports. A scoring system (0–1) captured implementation status, and spider charts and summary tables visualized trends over time. Tobacco control showed the most progress, with widespread adoption of taxation and graphic warnings. However, the implementation of smoke-free laws, cessation support, and media campaigns was inconsistent. Alcohol policies varied: most countries increased taxes and banned advertising, but gaps persisted in sales restrictions, health warnings, and treatment services. Adoption of nutrition policies remained inconsistent, with substantial gaps in food reformulation, labelling, fiscal tools, and education. Physical activity campaigns were common, but integration into healthcare systems was poorly documented. Disparities in implementation were observed across and within countries, in terms of the number and combination of ‘Best Buys’ strategies adopted. Despite some progress, major gaps remain in the implementation of population-level NCD ‘Best Buys’ across EECA. Greater prioritization of cost-effective tobacco, alcohol, nutrition, and physical activity strategies is needed. Subregional and country-level analyses of NCD ‘Best Buys’ implementation over time can help policymakers identify progress and gaps, guiding targeted, evidence-informed action to address shared behavioural risks and thereby prevent many NCDs and contribute to equitable and sustainable health outcomes.

Vaidya, Anju; Simkhada, Padam; van Teijlingen, Edwin; Lee, Andrew Chee Keng

doi: 10.1093/heapol/czag048pmid: 41964417

Few policies have focused specifically on the growing burden of non-communicable diseases (NCDs) in low- and middle-income countries. Health policy formulation plays a vital role in the allocation of resources to implement effective interventions and reforms; hence, a nuanced understanding of the health policy formulation process is essential. However, there is limited evidence about the process through which NCD policies were formulated in Nepal. This study used Kingdon’s multiple streams framework to explore how NCDs were recognized and prioritized, how policy alternatives were decided, how policy windows were opened, and which contextual factors influenced the policy formulation process. A qualitative case study approach was applied to gain a comprehensive understanding of the formulation of major NCD-related policies in Nepal. Semi-structured interviews were conducted with 12 key stakeholders and policy documents were analyzed using framework analysis. The NCDs were gradually recognized and prioritized through the convergence of global and local evidence, sustained advocacy, and international commitments. Policymakers encountered several challenges, such as competing health priorities, the chronic nature of NCDs, donor preferences for communicable diseases, financial constraints, and multisectoral complexities of NCDs. The Package of Essential Non-communicable diseases interventions were adopted as a policy alternative, informed by global evidence, World Health Organization recommendations, and lessons from other countries. While coordinated efforts by stakeholders brought the problem, policy, and politics streams together, the role of policy entrepreneurs was found to be less relevant in Nepal’s context. The findings highlight the need to consider external influences while conducting similar studies in low- and middle-income countries. Further research is needed on strategies to address persistent structural and financial challenges in NCD policy formulation.

Almdal, Kerstin; Said, Ali; Moland, Karen Marie; Melberg, Andrea

doi: 10.1093/heapol/czag053pmid: 42010338

Identifying the causes of maternal deaths and contributing factors is essential for improving care. In 2015, Tanzania began implementing the maternal and perinatal death surveillance and response (MPDSR) system, including facility-based maternal death reviews. While most MPDSR studies highlight implementation and technical barriers, less is known about how systemic and institutional dynamics influence these reviews. This study examined stakeholders’ experiences and perceptions of MPDSR in Tanzania, focusing on how clinical causes of death and contributing factors were identified. The study is based on 5 months of ethnographic fieldwork conducted in a Tanzanian region in 2023–2024. It included 33 days of participatory observation of obstetric care, attending nine facility-based maternal death review meetings and conducting 20 in-depth interviews with health workers and administrative staff. Viewing MPDSR as a travelling model and drawing upon the concept of situated knowledge, we examined how institutional and professional factors influenced these reviews. Reviews were routinized and integrated into the regional health system, offering opportunities for teaching and defining standards of practice. However, participants disagreed on whether the reviews promoted quality improvement or focused on individual fault-finding, on how responsibility should be attributed, and whether reviews could accurately establish the causes of deaths. The facility-based death reviews were influenced by institutional and epistemic hierarchies, with responsibility often placed on individuals at the lowest health system level. While MPDSR aims to promote blame-free learning and quality improvement, the process narrowed attention to individual error, obscured systemic constraints, and hindered understanding of the ‘real cause’ of maternal deaths. To capture contextual complexity without adding reporting burden, we recommend expanding the free-text narrative fields in the official MPDSR maternal death report forms and increasing frontline representation in district- and regional reviews to strengthen links between facility and higher-level reviews.

Katana, Patrick V; Ross, Ian; Kiconco, Barbra Elsa; Tenywa, Patrick; Neuman, Melissa; Ssembajjwe, Wilber; Sekitoleko, Isaac; Katumba, Kenneth Roger; Kinyanda, Eugene; Laurence, Yoko V; Greco, Giulia

doi: 10.1093/heapol/czag054pmid: 41999037

Between 8%–39% of people living with HIV (PLWH) in sub-Saharan Africa have a depressive disorder (DD). Despite considerable gains in the treatment of PLWH, DD is increasingly recognised as a threat to successful treatment and prevention. PLWH incur higher health-related costs than the general population due to chronic care management needs. We aimed to estimate the combined economic burden of DD and HIV amongst PLWH and explore their mechanisms of coping with high-of-pocket health expenditure. This was a cost of illness study nested in a cluster-randomized trial that assessed the effectiveness of integrating treatment of DD into routine HIV care in Uganda (HIV+D trial). The study used cross-sectional data collected from 1115 PLWH across both trial arms at baseline, using the 9-item Patient Health Questionnaire (PHQ-9) to measure DD and a structured cost questionnaire. The mean monthly economic cost of HIV and DD amongst n = 486 participants reporting at least one non-zero cost item was United States Dollars (USD) 11.72 (2022 prices), while the mean across the whole sample (including zeroes) was USD 5.05. Mean monthly out-of-pocket expenditure amongst participants reporting at least one non-zero item was USD 7.22, which is 4% of average monthly household income. It was USD 3.11 in the sample as a whole. Moderate DD symptoms (PHQ-9 between 15–19) and severe symptoms (PHQ-9 ≥ 20) were reported by 30% and 5% of respondents respectively, with the remainder experiencing mild symptoms. Social protection mechanisms combined with the integration of the management of DD into routine HIV care could help alleviate this burden.

Loha, Eskindir; Somville, Vincent; Borghi, Jo; Binyaruka, Peter; Mæstad, Ottar

doi: 10.1093/heapol/czag058pmid: 42128523

Performance-based financing at health facility level has improved service delivery in many low- and middle-income countries. However, the high costs of implementing such schemes have prompted interest in less complex forms of direct health facility financing. This paper measures the effects of layering a full-blown performance-based financing scheme (results-based financing, RBF) on top of a less comprehensive direct financing scheme in Tanzania. This enables us to assess whether implementing a less comprehensive scheme exhausted the potential for financing reforms to improve service delivery, or whether there are significant gains from adding more resources and incentives to the scheme. We estimated the effects of RBF using a difference-in-differences approach. Over 4 years, we tracked 150 health facilities and more than 3000 households, equally divided between eight districts that implemented both schemes and six districts that implemented only the less comprehensive scheme. Strong positive trends were observed for most outcomes in both groups of districts. At the same time, RBF had positive and statistically significant effects on 14 of 24 directly incentivized outcomes and on 22 of 47 other outcomes, including on service coverage (e.g. prenatal and vaccination services), service quality (e.g. content of care for antenatal and delivery services, drug availability, communication, and responsiveness), and patient satisfaction. A negative effect was estimated for one outcome only (use of family planning method). Statistically significant effects of RBF ranged from −4.3 to 16.2 percentage points (average: 8.7 pp). Analysis of intermediary outcomes revealed that RBF had a positive effect on health worker job satisfaction. We conclude that dosage matters: comprehensive direct financing schemes—with more resources and incentives—can significantly improve service delivery beyond what is achieved by less comprehensive ones.

Yang, Youngran; Yuth, Sreypov; Hwang, Oknam; Koy, Virya

doi: 10.1093/heapol/czag047pmid: 41954907

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-h 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-min 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 < .05). Given its high accessibility and ease of implementation, video-based content appears to be an effective approach and policy for improving health behaviors, 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. Trial registration ISRCTN11839050 (retrospectively registered).

Castro, Arachu; Silva, Martha; Silvestre, Eva

doi: 10.1093/heapol/czag050pmid: 41955572

Racism in healthcare facilities across Latin America systematically affects Indigenous, Afrodescendant, and migrant populations. Yet, no comprehensive synthesis has mapped its scope across different populations, healthcare settings, and countries in the region. This scoping review followed PRISMA guidelines and searched PubMed, EBSCOhost, and EMBASE for peer-reviewed studies published between January 2015 and June 2025. We included studies addressing racism in healthcare facilities where clinical encounters between populations and healthcare workers occur. Data were charted using AI-assisted tools and analyzed thematically. We retained 70 studies from 15 countries, predominantly Brazil (n = 30) and Mexico (n = 14). Racism manifested through three interconnected forms: institutional racism (policies restricting access, absence of data reflecting ethnic identification and racialization processes, resource inequities), personally mediated racism (verbal abuse, physical mistreatment, denial of culturally appropriate care), and internalized racism (self-devaluation, acceptance of mistreatment). These forms of discrimination pervade multiple medical fields, including maternal and reproductive health, mental health services, dental care, chronic disease management, infectious disease treatment, and emergency care. Racialized populations experience delayed diagnoses, inadequate treatment protocols, and systematic exclusion from preventive care. Language barriers, cultural dismissal, and discriminatory triage decisions compound these inequities. Intersectional marginalization based on gender, class, migration status, and sexuality amplifies these effects, producing multiplicative rather than additive health impacts. Achieving health equity requires dismantling institutional racism through meaningful community participation in healthcare governance, mandatory collection of ethno-local data—population descriptors reflecting local ethnic identification and racialization processes—integration of anti-racist and decolonial frameworks in medical education, legal accountability mechanisms, and recognition of racism as a fundamental determinant of health. Interventions targeting only individual bias will fail without addressing structural transformation.

doi: 10.1093/heapol/czag061pmid: 42118814