Health Policy And Planning[JOURNAL]
Sun
200 papers
Preferences and perceptions around uptake of different TB preventive therapy regimens: An exploratory study in Gauteng and Limpopo, South Africa.
Moolla A, Galvin M, Coetzee L … +4 more , Musakwa N, Leshabana P, Miot J, Evans D
Health Policy Plan · 2026 Jul · PMID 42400264 · Publisher ↗
TB preventive therapy (TPT) is one of three key interventions for reducing TB in South Africa, but uptake and completion rates remain low. In South Africa, the current TPT options include isoniazid and rifapentine or iso...
TB preventive therapy (TPT) is one of three key interventions for reducing TB in South Africa, but uptake and completion rates remain low. In South Africa, the current TPT options include isoniazid and rifapentine or isoniazid and rifampicin. Evidence and lessons learned from programmatic uses of isoniazid preventative therapy (IPT) could provide operational advice to enhance the implementation of new TPT regimens. We conducted 28 in-depth provider interviews (IDIs) to elicit experiences of and preferences for the different TPT regimens between 04/2022 and 12/2022 in the City of Johannesburg, Gauteng and Greater Tzaneen sub-district, Mopani district, Limpopo Provinces. We used purposive sampling to recruit doctors (n=7), pharmacists (n=8) and nurses (n=13) in high and low volume TB and/or HIV facilities. IDIs were recorded for quality, transcription, and translation purposes. Data analysis was conducted using a thematic approach in NVivo 11. We present provider preferences and perspectives for TPT uptake. The most important attributes relating to preferences for TPT regimens attributes among healthcare providers included medication safety, efficacy and low pill burden. Despite valid preferences for different regimens, healthcare service providers had varied experiences around factors that influence the uptake of the different TPT regimens they offered at their facilities. Many providers indicated that patient booking errors, missing patient records, staff shortages, long queues, medication side effects and limited understanding of the benefits of TPT were reasons for poor patient TPT uptake and adherence. Limited knowledge was attributed to a lack of educational materials and insufficient staff-patient engagement time. Providers noted that increased clinician awareness and patient counselling contribute to a higher rate of TPT prescriptions, as well as improved patient uptake and adherence. Thus counselling, staff training, side-effects management, and improved file documentation are key factors for TPT uptake.
Approximating vaccine delivery costs to reach zero-dose children: a Bayesian meta-regression analysis.
Portnoy A, Clarke-Deelder E, Holroyd TA … +2 more , Hogan DR, Mengistu T
Health Policy Plan · 2026 Jul · PMID 42389927 · Publisher ↗
The Immunization Agenda 2030 calls for reaching all people with immunization services, including 'zero-dose' children-children who have not received any routine vaccines. To plan and finance efforts to fully vaccinate th...
The Immunization Agenda 2030 calls for reaching all people with immunization services, including 'zero-dose' children-children who have not received any routine vaccines. To plan and finance efforts to fully vaccinate these children and improve coverage and equity, decision-makers need reliable cost estimates. However, primary data on the costs of reaching zero-dose children, typically part of disadvantaged and hard-to-reach populations, are scarce. This study approximates these costs using standardized, country-level estimates of vaccine delivery unit costs for outreach delivery in low- and middle-income countries (LMICs). We extracted outreach delivery cost-per-dose estimates for childhood immunization services from the 2024 update of the Immunization Delivery Cost Catalogue. Using these data, we developed a meta-regression model to estimate standardized outreach vaccine delivery unit costs. The generalized linear model assumed a Gamma-distributed outcome with a log link and included both country-level and study-level predictors: study year, economic or financial cost basis, routine or campaign delivery, and full or incremental costing approach. The fitted model was used to estimate 2024 outreach delivery costs per dose for 129 LMICs. The model was estimated using 48 observations from 19 countries focused on outreach or mobile vaccine delivery. The best-fitting specification included diphtheria-tetanus-pertussis (DTP1) coverage, per-capita gross domestic product, and under-five population size as predictors. For 2024, the predicted mean economic cost per dose was $8.65 (95% credible interval $2.33-23.71), averaged across all 129 LMICs. To fully immunize a zero-dose child with 13 recommended vaccinations, the equivalent cost estimate was $112.45 ($30.29-308.23). Reaching zero-dose children is crucial for improving equity in global health, and estimates of the costs of doing so are needed to inform budgeting for immunization programs. These meta-regression-based cost estimates can help countries to improve budgeting, planning, and resource allocation for efforts to reach zero-dose children.
Impact of Social Health Insurance Reforms on Income Inequality: Evidence from China's Urban-rural Residents' Medical Insurance Integration Scheme.
Yu M, Wan X, Deng Y
Health Policy Plan · 2026 Jun · PMID 42373091 · Publisher ↗
The relationship between social health insurance reforms and income inequality has not been thoroughly examined with the domain of social policy research. This study employs data from the China Family Panel Studies spann...
The relationship between social health insurance reforms and income inequality has not been thoroughly examined with the domain of social policy research. This study employs data from the China Family Panel Studies spanning 2014 to 2020 and employs a staggered difference-in-difference model to examine the association between China's Urban-rural Residents' Medical Insurance Integration reform and the urban-rural income disparity, as well as related changes in household health and income. Our findings indicate that the reform has significantly reduced the income gap, a result that is consistent across multiple robustness checks. Notably, the improvement in the health status and economic conditions of rural households is consistent with the reduction in urban-rural income inequality, while no comparable changes were observed among urban households, which were not directly affected by the reform. Furthermore, the reform's effectiveness was most pronounced among households with lower dependency ratios and those with lower incomes. The impact of the policy was particularly significant in regions characterized by advanced healthcare infrastructure and higher levels of economic development. This study contributes to the literature by providing empirical evidence on the relationship between social health insurance reform and income inequality, while offering suggestive insights into how changes in health and economic conditions may be associated with this relationship.
Prospective policy analysis of healthcare workforce policies for effective non-communicable disease prevention and management in Meghalaya, India.
Nair A, John P, Sadanandan R
Health Policy Plan · 2026 Jun · PMID 42367028 · Full text
This study presents a prospective policy analysis of healthcare workforce (human resources for health, HRH) reforms in Meghalaya, India, a state facing dual challenges of a rising burden of non-communicable diseases (NCD...
This study presents a prospective policy analysis of healthcare workforce (human resources for health, HRH) reforms in Meghalaya, India, a state facing dual challenges of a rising burden of non-communicable diseases (NCDs) and persistent inequities in access to medical and public health specialists. Grounded in a health systems and social justice perspective, this study examines current HRH needs and proposed reforms, evaluating their potential to address the evolving health demands of the population, particularly among poor and marginalized groups vulnerable to NCDs. Using secondary evidence, including national surveys, epidemiological data, and government reports, the study maps workforce gaps, especially in rural and tribal regions, and highlights the physician-centric nature of HRH governance in India. The Walt and Gilson policy triangle, combined with adapted HRH evaluation frameworks, guided the analysis of policy context, content, processes, and actors. This approach identified key gaps in recruitment, rural retention, cadre structures, and specialist training for effective NCD prevention and management. A scenario analysis, using the Intuitive Logic method, developed a best-case trajectory of reform achievable through equity-oriented design, strong political will, and institutional capacity, while recognizing risks of policy stagnation. Findings indicate that achieving a socially accountable HRH system characterized by equitable distribution, transparent governance, and meaningful community engagement is critical for improving NCD outcomes and reducing health inequities, particularly by preventing financial distress among the poor. The study contributes to health policy and systems research by linking institutional design to future health system resilience, underscoring the need to embed justice, participation, and adaptability within HRH governance to effectively address present and future health challenges in low-resource contexts such as Meghalaya.
Advancing justice and sustainability through health system resilience under economic sanctions.
Majdzadeh R, Sajadi HS
Health Policy Plan · 2026 Jun · PMID 42367027 · Full text
Prolonged economic sanctions-often framed as non-military tools-have increasingly harmed health systems, especially where institutional and policy capacities are fragmented. Despite the growing debate on sanctions, docum...
Prolonged economic sanctions-often framed as non-military tools-have increasingly harmed health systems, especially where institutional and policy capacities are fragmented. Despite the growing debate on sanctions, documented analyses of health system responses remain scarce. This study examines Iran to assess how prolonged sanctions shaped its health policy architecture and resilience capacity, with attention to compounded crises such as COVID-19. Phase one synthesized seven empirical studies conducted by the authors-including document reviews, interviews, Delphi, and policy analyses-to assess how resilience principles were embedded across the four stages of the health policy cycle: agenda-setting, policy formulation, implementation, and evaluation. These findings formed the foundation for Phase two, which applied an expanded Theory of Change (ToC) framework to reconstruct policy logics, surface implicit assumptions, and identify institutional breakpoints. After modelling the ToC, a panel of experts reviewed and validated the findings, ensuring methodological rigour and contextual accuracy in mapping resilience under sanctions. The findings indicate that while Iranian health authorities implemented adaptive measures, responses were shaped by fragmented coordination, untested assumptions, and limited structured learning systems. Resilience limitations emerged during implementation and were embedded in early design phases, not fully anticipated or addressed, given the complex and uncertain policy environment. This study offers an analytical framework for mapping resilience in policy systems under long-term constraints. Building on identified governance and design weaknesses, we recommend strengthening international legal safeguards; establishing protected humanitarian corridors; institutionalizing risk-informed planning; routine scenario-based resilience testing; and feedback-driven learning mechanisms within national policy systems. These capacities are essential to absorb shocks and enable adaptive, inclusive, sustainable responses. By clarifying structural domains where resilience can be embedded in advance, the analysis offers guidance for countries under comparable pressures to target strategies in governance, planning, and resource protection. This provides a transferable blueprint for strengthening justice-oriented health systems under long-term constraints.
Hybrid Governance: Negotiating justice for health services in informal urban settlements in Dhaka, Bangladesh.
Aktar B, Ozano K, Rashid SF … +2 more , Waldman L, Theobald S
Health Policy Plan · 2026 Jun · PMID 42367026 · Full text
This paper examines the complex governance landscape of public health service delivery in the informal urban settlements of Dhaka, Bangladesh, through the application of Hybrid Governance and Urban Political Ecology (UPE...
This paper examines the complex governance landscape of public health service delivery in the informal urban settlements of Dhaka, Bangladesh, through the application of Hybrid Governance and Urban Political Ecology (UPE) frameworks. Rapid urbanization and insufficient state capacity have led to the development of informal settlements, where conventional governance structures are absent. In this context, hybrid governance systems emerge, which are characterized by collaborations and conflicts among formal authorities, non-state and informal actors, and local community members. In-depth empirical data were drawn from multi-method qualitative research applying community-based participatory research (CBPR) approaches, conducted between 2021 and 2023, in two informal urban settlements in Dhaka, Bangladesh. This paper introduces a "Multi-layered Hybrid Governance" (MHG) framework that explains the complex governance arrangements of public health service delivery in informal urban settlements. The MHG framework features the fragile yet resilient nature of collaborations between formal authorities (state-level governing bodies), formal governance actors (elected local government representatives) and their informal representatives (community leaders, local elites), private service providers (including NGOs), and community members, revealing how public health services are negotiated and legitimized within these informal contexts. The findings suggest that hybrid governance is a form of community resilience that can enhance service delivery in the absence of effective state intervention. However, it can also reinforce existing inequalities and introduce new challenges to residents, especially to those without political connection or strong social networks. This paper urges policymakers and researchers to look beyond conventional health governance models and recognize the limitations of the existing systems. By presenting the MHG framework as an analytical tool for learning health systems from the perspectives of those on the margins, we advocate for more inclusive, resilient governance approaches for promoting justice and ensuring sustainability within fragmented urban health systems.
Assessment of community health workforce governance in federal Nepal.
Tikkanen RS, Pokhrel S, Ghimire U … +3 more , Neupane B, Closser S, Kumar BN
Health Policy Plan · 2026 Jun · PMID 42367025 · Full text
How Community Health Worker (CHWs) programs are governed shapes their performance. CHW governance can be challenged by CHWs' accountability to both governments and their communities, and the need to coordinate between mu...
How Community Health Worker (CHWs) programs are governed shapes their performance. CHW governance can be challenged by CHWs' accountability to both governments and their communities, and the need to coordinate between multiple actors. Furthermore, little is known about how decentralization impacts CHW governance. We examined Nepal's Female community health volunteers (FCHV), where a 2015 constitutional change to federalism-a major governance reform representing one form of decentralization-shifted the responsibility for community health governance to local municipalities. We assessed FCHV governance in the federal landscape and provide preliminary insights into how federalization has impacted FCHV governance in its early years. We identified opportunities and challenges brought by federalization for six actors: federal, provincial and municipal governments, international donors, FCHVs and their representative organizations (unions), and non-governmental organizations. Our qualitative case study comprised 26 semi-structured interviews and five focus groups conducted with FCHVs, health workers, federal and municipal government representatives, researchers, and FCHV union, donor and NGO representatives, across four districts in Bagmati Province, combined with analysis of 259 documents. We analysed these data using a theoretical framework of CHW governance adapted from seven existing frameworks on health workforce and community health governance. We show that FCHV governance was characterized by improved accountability, transparency, participation, and responsiveness to local needs, to some extent. Decentralization remained incomplete, with governance challenged by limited budgetary and administrative decision-space at local levels, in part because of continued central-level control and limited revenue-raising capacity, coordination, and enforcement challenges, as well as lack of role clarity. While donors and NGOs participate in decision-making, FCHVs and their representative organizations are not consistently consulted. The results indicate that strengthening FCHV governance in federal Nepal will require capacity-building of municipalities while loosening the federal grip.
Political economy analysis of health: a scoping review of concepts, definitions, frameworks, outcomes, and applications.
Karuveettil V, Janakiram C, Ramesh S … +5 more , Ramachandran A, Mathur M, Varma B, Green H, John D
Health Policy Plan · 2026 Jun · PMID 42367024 · Full text
This review examined 28 studies to understand how political economy analysis (PEA) is conceptualized and applied in health. Definitions of political economy varied, with only 11 studies offering explicit definitions. Mos...
This review examined 28 studies to understand how political economy analysis (PEA) is conceptualized and applied in health. Definitions of political economy varied, with only 11 studies offering explicit definitions. Most commonly, political economy was framed as the study of power, interests, institutions, and ideas shaping health policy processes and outcomes. Applications ranged from analysing structural determinants of health to understanding stakeholder influence in health reforms. Across studies, 31 distinct frameworks and theories were used. Frequently employed models included Campos and Reich's Political Economy of Health Financing Reform Framework, Harris's Applied PEA, and the DFID and World Bank 'How-to' notes. Theoretical underpinnings were drawn from economics, political science, and sociology-such as historical institutionalism, stakeholder theory, and discursive institutionalism-highlighting the interdisciplinary nature of PEA. Health issues analysed through a political economy lens primarily included health financing, governance, human resources for health, and service delivery. PEA was used to explore challenges such as policy reform feasibility, institutional capacity, health workforce equity, and donor dependency. The rationale for applying PEA included uncovering the influence of actors, navigating complex political contexts, and enhancing policy implementation. Overall, PEA in health is marked by conceptual diversity and methodological pluralism. Its growing application reflects the need to understand the interplay of politics, institutions, and economics in addressing systemic health challenges.
How to do (or not to do) realist evaluations to advance theory, practice, and justice in health systems research.
Aivalli P, Hebbar P, Mbachu C … +3 more , Nuggehalli Srinivas P, Abimbola S, Dada S
Health Policy Plan · 2026 Jun · PMID 42367023 · Full text
The realist approach seeks to understand underlying mechanisms that explain how and why complex interventions, programmes, and policies work in specific contexts, making it particularly valuable in health policy and syst...
The realist approach seeks to understand underlying mechanisms that explain how and why complex interventions, programmes, and policies work in specific contexts, making it particularly valuable in health policy and systems research (HPSR). We draw on reflexive practice of realist evaluations from several realist evaluation practitioners and on insights from an organized session at the Eighth Health Systems Research Symposium in Nagasaki, Japan, in 2024, where we engaged a diverse group of practitioners and researchers on how to use realist approaches in HPSR. Examples from our studies, while situated in distinct contexts, highlight common challenges in applying realist methodologies including identifying and refining context-mechanism-outcome configurations. Building on these examples, we illustrate how realist evaluations, if conducted rigorously and with the purpose of advancing justice in health systems, could do so through exposing structural barriers to health justice, amplifying local voices and fostering epistemic justice in knowledge production.
A river, frontline families, and the double-edged sword of community participation: how nutrition interventions are shaped at the village level in Dhubri, India.
Jith JR, Dash S, Bedamatta R
Health Policy Plan · 2026 Jun · PMID 42367022 · Full text
This paper explores how top-down health interventions engage with and reshape communities at the village level, focusing on nutrition interventions as tracers to examine the functioning of local health systems. Drawing o...
This paper explores how top-down health interventions engage with and reshape communities at the village level, focusing on nutrition interventions as tracers to examine the functioning of local health systems. Drawing on 28 in-depth interviews and 6 focus group discussions conducted in Dhubri district, Assam, the study investigates how such interventions are delivered through a health system constituted of both formal structures and informal arrangements, deeply influenced by the ecology of the Brahmaputra River. Using an exploratory qualitative approach, the study surfaces five key themes. First, seasonal disruptions linked to the river significantly affect service continuity, revealing the inadequacy of existing policies to respond to environmental vulnerability. Second, the creation of 'frontline families'-where the personal lives and unpaid labour of frontline health workers' households are drawn into service delivery-reflects systemic dependence on invisible support. Third, community participation emerges as a double-edged sword, simultaneously enabling programme reach and generating unrealistic demands and burdens on frontline actors. Fourth, informal spaces and interpersonal relationships underpin much of the operational success of interventions, compensating for gaps in formal governance and infrastructure. Finally, symbolic campaigns, detached from local material realities, often foster alienation rather than awareness. The findings call for a rethinking of intervention design and delivery that take account of embedded social, ecological, and institutional realities. The paper argues that building just and sustainable health systems requires recognising and supporting the informal, relational, and contextual dimensions that currently remain overlooked in dominant policy frameworks.
Changing health systems-advancing justice and sustainability through research, policy and practice.
Topp SM, N Srinivas P, Batura N … +2 more , Whyle E, Sheikh K
Health Policy Plan · 2026 Jun · PMID 42367021 · Full text
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Can innovation strengthen resilient, just and sustainable health systems in disaster-prone settings? Insights from HSR2024.
Jalaghonia N, Huque R, Daniels D
Health Policy Plan · 2026 Jun · PMID 42367020 · Full text
Health systems in disaster-prone settings face recurrent shocks that expose and often deepen existing inequities. Increasingly, innovation, particularly digital technologies and artificial intelligence (AI), is positione...
Health systems in disaster-prone settings face recurrent shocks that expose and often deepen existing inequities. Increasingly, innovation, particularly digital technologies and artificial intelligence (AI), is positioned as a pathway to strengthen resilience, responsiveness, and accountability. Drawing on insights from innovation-focused sessions at the 8th Global Symposium on Health Systems Research, this commentary examines whether and under what conditions innovation can contribute to resilient, just and sustainable health systems. We define disaster-prone settings as contexts repeatedly exposed to acute shocks and chronic stressors, such as climate events, outbreaks, and displacement, where service delivery is periodically disrupted and recovery shapes long-term system trajectories. Across diverse examples, including digital dashboards, interoperable data systems, AI-supported decision tools, and community-driven innovations, the symposium highlighted how innovations can improve detection, coordination, and service continuity, particularly during crisis conditions. These approaches can make populations previously invisible to the health system visible, strengthen real-time decision-making, and support anticipatory action. However, the analysis shows that innovation does not inherently produce equitable outcomes. Digital and AI-enabled tools may reproduce or even intensify existing exclusions if they rely on unrepresentative data, lack interoperability, or operate without transparent governance and accountability. Many technologies remain at an early stage, with evolving evidence on effectiveness and equity impacts, placing policymakers in a position of making decisions in uncertainty. In disaster contexts, where rapid decisions and weakened oversight are common, these risks are amplified. We argue that innovation strengthens resilience and justice primarily when accompanied by institutional readiness and governance capacity. This includes clear mandates, regulatory frameworks, ethical safeguards, and mechanisms for iterative learning that translate evidence into practice. Equally important are participatory approaches that ensure communities shape design and decision-making, rather than being passive data sources.
Preference for Supplementary Voluntary Health Insurance and Heterogeneity in China: A Discrete Choice Experiment.
Lizheng X, Lei S, Shunping L … +5 more , Jiaqi Y, Xu S, Dan Z, Stephen J, Chaofan L
Health Policy Plan · 2026 Jun · PMID 42366799 · Publisher ↗
Understanding the population's preferences for health insurance plays an important role in optimizing insurance scheme design and improving enrollment rate. This study aims to quantitatively investigate preference for su...
Understanding the population's preferences for health insurance plays an important role in optimizing insurance scheme design and improving enrollment rate. This study aims to quantitatively investigate preference for supplementary voluntary health insurance (SVHI) from a multi-site survey and examine its heterogeneity in China. A discrete choice experiment was conducted in Shandong, Henan and Sichuan provinces using multi-stage stratified sampling method. Five SVHI attributes were identified: premium, benefit package, deductible, reimbursement rate, and reimbursement for pre-existing conditions. Choice sets were generated using a D-efficient design, grouped into two blocks randomly assigned to respondents, with each set comprising two SVHI options and an opt-out. Data were collected via face-to-face computer-assisted interviews. Mixed logit models was used to estimate preference weights, willingness-to-pay (WTP) and attribute importance scores. Preference heterogeneity was analyzed by disease-related financial risk awareness, numeracy, and health insurance knowledge, demographic, socioeconomic, and health characteristics. Of the 1326 respondents who completed the questionnaire, 1254 were included in the analysis. Reimbursement rate was the most important attribute (34.26%), followed by premium (25.06%), benefit package (17.60%), deductible (17.50%) and reimbursement for pre-existing conditions (5.58%). Overall, respondents expressed the highest WTP (USD 48.50) for improving the reimbursement rate from 50% to 90%, while they showed lowest WTP (USD 8.60) for decreasing deductible from USD 2777.78 to 1388.89. Heterogeneity analysis revealed stronger enrollment preferences among respondents with risk awareness, higher health insurance knowledge, higher numeracy, higher educational attainment, higher income, and those living in urban areas. In addition, higher levels of risk awareness, insurance knowledge, numeracy, income, and education were associated with increased WTP for SVHI attributes. Preference heterogeneity by risk awareness and insurance knowledge suggests need for targeted risk information communication and education campaign to promote SVHI uptake, and diverse insurance design tailored to socioeconomic differences in preferences for attributes.
Balancing policy ambition and systems reality in expanding access to NCD medicines: lessons from Ghana and Georgia.
Koduah A, Zoidze A, Uchaneishvili M … +5 more , Novignon J, Murphy A, Palafox B, Mirzoev T, Gotsadze G
Health Policy Plan · 2026 Jun · PMID 42348917 · Publisher ↗
Ensuring sustained access to affordable, high-quality medicines is central to achieving universal health coverage (UHC) in low- and middle-income countries (LMICs). This is particularly true for chronic non-communicable...
Ensuring sustained access to affordable, high-quality medicines is central to achieving universal health coverage (UHC) in low- and middle-income countries (LMICs). This is particularly true for chronic non-communicable diseases (NCDs), which require long-term, uninterrupted treatment. Although global guidance recommends expanding pharmaceutical benefits, regulating prices, promoting generics, and strengthening procurement and supply chains, many LMICs continue to face inequities in medicine availability and high out-of-pocket costs. The experiences of Ghana and Georgia, two countries that have invested heavily in UHC reforms, pharmaceutical benefits, centralized procurement, and pricing policies, illustrate gaps between policy ambitions and implementation realities in expanding access to NCD medicines. This paper examines four health-system factors influencing access to NCD medicines: system capacity, provider behaviour, digital enablers, and public trust. In both countries, centralized procurement faces forecasting inaccuracies, procurement delays, supply chain weaknesses, and distribution challenges, leading to stockouts and inconsistent availability. Provider behaviours further influenced access, with reimbursement delays, low payment rates, and administrative burdens contributing to informal fees, off-list prescribing, and suboptimal use of generics. Investments in digital systems such as logistics management information systems and electronic prescribing showed promise but were limited by uneven adoption, data quality issues, and insufficient integration into decision-making processes. Public awareness and trust emerged as critical yet neglected determinants. Limited communication and perceptions of low-quality of state-purchased medicines reduced uptake of benefits in Georgia, while gaps between National Health Insurance Scheme (NHIS) intentions and patient experiences constrained equitable access in Ghana. Strengthening access to NCD medicines requires system-wide readiness, aligned provider-patient incentives, effective digital integration, and sustained community engagement to build trust and support uptake.
Developments in the field of Health Policy Analysis in low- and middle-income countries: A review of published literature 2008-2023.
Whyle EB, Gilson L, Shroff ZC
Health Policy Plan · 2026 Jun · PMID 42348916 · Publisher ↗
This review maps the development of Health Policy Analysis (HPA) in low- and middle-income countries (LMICs) since 2008, when Gilson and Raphaely (2008) published a review clarifying the state of the field and tracing it...
This review maps the development of Health Policy Analysis (HPA) in low- and middle-income countries (LMICs) since 2008, when Gilson and Raphaely (2008) published a review clarifying the state of the field and tracing its evolution. Subsequent years have seen some progress in capacity strengthening for HPA in LMICs, but the extent of development of the field has not been formally assessed since that time. We used a combination of bibliometric, thematic and narrative analysis to better understand the nature of the research being undertaken, identify weaknesses in the evidence base, and gauge maturation of the field. Despite the relatively restrictive focus of this review, we identified 629 articles reporting empirical studies of LMIC policy experiences, revealing substantial growth in the volume of published HPA since 2008. However, significant imbalances in knowledge production remain, with low-income country experiences, and those of North Africa and Central Asia still neglected, and with the dominance of HIC authors persisting despite efforts to strengthen the field in LMICs. At the same time, the review finds evidence of maturation, reflected in deeper theoretical engagement, greater methodological diversity, the use of comparative approaches to enable causal explanation and cross-context learning, and the emergence of robust bodies of work on specific health policy issues. Taken together, the findings point to a field that has grown in scale, scope and analytic sophistication, but still requires deliberate nurturing. Purposeful efforts by researchers, funders, and institutions are needed to ensure that HPA realises its full potential and contributes to progressive policy change. Improving domestic and regional funding, supporting LMIC institutions and researchers, deepening theoretical engagement, and encouraging analytical HPA that enables explanation and cross-context learning are essential to sustaining the development of the field and ensuring that it continues to generate rigorous, relevant insights and contributes to progressive policy change.
Does increasing overall health expenditure reduce inequality in under 5 mortality rates between provinces in Indonesia?
Ochoa-Moreno I, Kreif N, Hidayat T … +3 more , Kurnia S, Hidayat B, Griffin S
Health Policy Plan · 2026 Jun · PMID 42315102 · Publisher ↗
While public health expenditure is widely assumed to reduce health inequalities, empirical evidence from low- and middle-income countries remains limited. This study examines whether increases in public health spending i...
While public health expenditure is widely assumed to reduce health inequalities, empirical evidence from low- and middle-income countries remains limited. This study examines whether increases in public health spending in Indonesia between 2010 and 2017 reduced inequalities in under-five mortality (U5MR). We combined two approaches to assess distributional effects of health spending. First, we used a dynamic panel System-GMM model to estimate the impact of public health expenditure on within-province inequality in U5MR, measured by the concentration index across household wealth quintiles. Second, we applied instrumental variable quantile regression to identify heterogeneous treatment effects across provinces with different baseline mortality burdens. In addition, we estimated the average effect of public health expenditure on U5MR levels and found no statistically significant impact. The results show that higher public health spending increased inequality in U5MR across socioeconomic groups, with wealthier households capturing a disproportionate share of the mortality reductions. By contrast, we find no statistically significant heterogeneity in the impact of spending between high- and low-mortality provinces. These results suggest that increases in spending were not well-targeted to disadvantaged groups or high-mortality regions. Our findings demonstrate that raising overall levels of public spending is not sufficient to reduce health inequalities unless resources are explicitly directed toward disadvantaged groups and underserved areas. This study provides a proof of concept for applying distribution-sensitive methods to assess the equity impact of health financing, offering lessons that remain highly relevant for Indonesia's post-JKN reforms and contributing to global debates on equity-weighted evaluation, benefit incidence, and the distributional consequences of health spending in LMICs.
Health facilities as a lever for Birth Registration in Low- and Middle-Income Countries: A Realist Review.
Wolsink L, Behlriti Z, Slemming W … +2 more , Crone M, Orgill M
Health Policy Plan · 2026 Jun · PMID 42312622 · Publisher ↗
The health system has been identified as a key lever for increasing access to birth registration (BR) directly after birth. BR is critical for upholding human rights and accessing essential services, yet many low- and mi...
The health system has been identified as a key lever for increasing access to birth registration (BR) directly after birth. BR is critical for upholding human rights and accessing essential services, yet many low- and middle-income countries struggle with low BR rates. In this realist synthesis, we reviewed literature on two separate interventions that are designed to increase access to BR services. This included (1) embedding or appointing an official to register births in health facilities and (2) incorporating education on BR in routine perinatal care programmes. This study aimed to support the knowledge base on how these interventions work, why, and for whom, within health facility contexts. We followed the RAMESES I publication guidelines for realist syntheses. Iterative searches were carried out in PubMed, Scopus and Web of Science. The search also included grey literature, policy documents and insights from a key informant in South Africa. We adopted an iterative cycle of searches guided by review team exchanges, stakeholders' insights and sequential snowballing searches for theory and background information. We developed two initial programme theories, presented as ICAMO configurations, that were then refined against empirical evidence from 17 included studies, with publication dates ranging from 1992 to 2021. Our review findings highlight that the interventions improved BR rates by lowering logistical barriers, raising awareness and supporting BR staff, (i.e., personnel responsible for conducting BR within health facilities). Literature from LMICs suggest that the effectiveness of facility-level BR interventions is often affected by access to care, travel distances, transportation costs, as well as by the availability of resources, BR infrastructure, and staff motivation within healthcare facilities. These factors may, in turn, affect BR demand, parents' self-efficacy, and the extent to which BR initiatives align with parents' real-life contexts.
Correction to: Measuring and monitoring child health and well-being-an integral part of the climate change agenda.
Health Policy Plan · 2026 May · PMID 42189217 · Publisher ↗
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An Unintended Complementarity: How the Outpatient Pooling Policy Increases Inpatient Services in China.
Wang J, Zhang M, Yu M
Health Policy Plan · 2026 May · PMID 42178857 · Publisher ↗
This study investigates the relationship between outpatient and inpatient services within China's tiered healthcare system following the implementation of outpatient pooling reform. Data were sourced from official admini...
This study investigates the relationship between outpatient and inpatient services within China's tiered healthcare system following the implementation of outpatient pooling reform. Data were sourced from official administrative healthcare service records across counties in Sichuan Province (2010-2020) and individual survey data from the China Health and Retirement Longitudinal Study (CHARLS) (2011-2018). Using a staggered difference-in-differences (DID) design with an imputation model, we identified an unexpected increase in hospital admissions post-reform, which was contrary to the policy's intent to optimize healthcare resource allocation. We found that increased use of outpatient services was positively associated with demand for inpatient care, demonstrating a complementary effect. Mechanism analysis revealed that the rising hospitalization admissions were partly attributable to two factors: (i) expansion of outpatient service in primary care institutions generating an induced hospitalization effect that contributed to the rise in inpatient volume, and (ii) hospitals improving inpatient service efficiency by shifting selected preoperative tests to the outpatient account. These findings confirm the complex interaction between outpatient and inpatient services, and underscore the need for a more effective design of the medical insurance payment system to enhance the efficiency of China's healthcare services.
A qualitative study of stakeholders' perceptions towards the implementation of the National Health Insurance Scheme in Zambia: Equity and financial sustainability in question.
Kazibwe J, Sundewall J, Masiye F … +5 more , Owusu L, Tran PB, Chama-Chiliba CM, Ekman B, Svensson P
Health Policy Plan · 2026 May · PMID 42178854 · Publisher ↗
Low- and middle-income countries are expanding health insurance to enhance financial protection. However, there is scarcity of evidence on the stakeholder perceptions towards health insurance. This study explores stakeho...
Low- and middle-income countries are expanding health insurance to enhance financial protection. However, there is scarcity of evidence on the stakeholder perceptions towards health insurance. This study explores stakeholders' perceptions towards the implementation of the National Health Insurance Scheme in Zambia. This qualitative study is based on 21 in-depth interviews with key stakeholders involved in the NHIS implementation in Zambia. We used qualitative content analysis to describe and interpret the manifest and latent meaning of transcribed interviews. The analysis yielded three overarching themes: i) Politics can make or break the scheme, ii) Equity in question: winners and losers and iii) Pointing at the need for financial sustainability of the National Health Insurance Scheme. The themes are supported by six subthemes and 18 data categories. Participants perceived the scheme as having contributed to improved quality of care and offering a generous health benefit package. However, implementation is perceived to be hindered by political interference, limited use of empirical evidence, weak institutional coordination, and exclusion of key stakeholders from decision-making processes, low enrolment, operational inefficiencies, inequities and a benefit package misaligned with available resources. The Zambia National Health Insurance Scheme is perceived as a promising initiative for expanding access to health and enhancing financial protection. However, it faces numerous challenges ranging from limited enrolment among the poor, vulnerable and informal sector populations to concerns about financial sustainability. Addressing these issues is essential to realize the scheme's potential benefits.
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