Managing change towards universal health coverage service provision in Africa

Managing change towards universal health coverage: service provision in Africa Technical brief November 2023 Managing change towards universal health coverage service provision in Africa ISBN: 978-929031489 © WHO African Region, 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. All photos: ©WHO Designed in Pretoria, South Africa Contents Acknowledgements v Abbreviations vi Executive summary vii Background and scope vii Conceptual model vii Methods vii Findings viii Conclusion x Recommendations x 1. Background 1 1.1 Introduction 2 1.2 Overview of health systems reforms in Africa 4 1.3 Objectives and scope of the literature review 5 1.4 Conceptual model 5 2. Methology 7 2.1 Defining the scope and the search strategy 8 2.2 Searching for and identifying evidence 8 2.3 Appraising and selecting relevant literature 8 2.4 Abstracting data and organizing evidence 9 2.5 Synthesizing evidence and drawing conclusions 10 2.6 Developing a narrative and making recommendations 12 3. Findings 13 3.1 Contextual overview of health system reforms and change programmes 14 3.2 Role and application of the 7S model in implementing health systems 19 change programmes 4. Conclusion and implications 40 4.1 Conclusion 41 4.2 Policy implications 42 5. Recommendations for re-pivoting African health systems 46 6. Limitations 48 References 49 Appendices 56 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 List of figures Figure 1. Areas in which health results are needed to attain good health and 1 well-being for all at all ages. Figure 2. Elements of the health system in the UHC, health security and health 3 determinants approach. Figure 3. The McKinsey 7S model 7 Figure 4. Process of selection of relevant articles. 9 Figure 5. Interactions among the elements of the 7S model. 14 Figure 6. Health system reforms and changes prioritized globally. 15 Figure 7. 7S strategy mechanisms that enable successful change management. 23 Figure 8. 7S structure mechanisms that enable successful change management. 27 Figure 9. 7S systems mechanisms that enable successful change management. 37 Figure 11. 7S staff mechanisms that enable successful change management. 40 Figure 12. 7S style mechanisms that enable successful change management. 45 Figure 13. 7S shared values mechanisms that enable successful change management. 50 List of tables Table 1. Shift in the focus of health delivery 2 Table 2. Emerging thematic areas fostering change along the McKinsey 7S model 11 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Acknowledgements This technical brief was developed under the stewardship of the Assistant Regional Director’s Cluster in the World Health Organization (WHO) Regional Office for Africa, led by Dr Lindiwe Makubalo. The cluster coordinates and stewards cross-cutting technical functions of the Regional Office. Technical oversight was provided by Dr Humphrey Karamagi, Data, Analytics and Knowledge Management Team lead. The assessment was conducted by independent experts from the Member States: Jacinta Nzinga, Andrew Likaka, Gordon Abekah-Nkrumah and Gladwell Gathecha. The internal appraisal was carried out by Dr Rex Gadama Mpazanje, WHO Representative to Seychelles; Dr Martins Ovberedjo, WHO Representative to Eritrea; Dr Kizito Bishikwabo Nsarhaza from the Office of the Regional Director; Dr Geoffrey K. Bisoborwa and Mr Kingsley Addai Frimpong from Universal Health Coverage Life Course; Dr Akpaka A. Kalu from Universal Health Coverage Communicable and Noncommunicable Diseases; and Dr Moredreck Chibi, Aminata Binetou Wahebine Seydi and Thandekile Ntombikayise Moyo from the Assistant Regional Director’s Cluster. Coordination from the Regional Office was provided by Solyana Ngusbrhan Kidane. v Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Abbreviations CHWs Community Health Workers HRH Human Resources For Heath IBRD International Bank for Reconstruction and Development ICT Information And Communications Technology IHR (2005) International Health Regulations (2005) LAC Latin America and the Caribbean LMICs Low- And Middle-Income Countries MDGs Millennium Development Goals NCDs Noncommunicable Diseases NGOs Nongovernmental Organizations OECD Organisation for Economic Co-operation and Development PBF Performance-Based Financing PHC Primary Health Care RBF Results-Based Financing SDGs Sustainable Development Goals TB Tuberculosis UHC Universal Health Coverage UK United Kingdom WHO World Health Organization vi Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Executive summary Background and scope The strive towards the attainment of good health is a high priority globally and is even more urgent for all WHO Member States in the African Region. This can only be realized through the attainment of multiple health and related targets across Sustainable Development Goal (SDG) 3. These targets are brought together under three interconnected themes for which results need to be attained: universal health coverage (UHC), health security and coverage of health determinants. The aim of this review was to generate evidence on the most appropriate manner to re-pivot health system development in countries by exploring current change management practices, identifying the practices needed and eventually making proposals on what needs to be done for effective management of health systems at national and subnational levels. The overall goal was to consolidate the existing evidence on the areas where change was needed in the management approach to facilitate the attainment of the triple results. This included: • Collation of evidence on the current state of management of health services at national, subnational and district levels in Africa, as well as globally, based on the McKinsey 7S framework; • Analysis of the requirements for the management of health services and achievement of the triple results of UHC, health security and coverage of health determinants; • Drawing up of recommendations on what is required to move from the current to the desired management practices across the 7S’s. • Drawing up of recommendations on the standard ways of measuring the results for the 7S management approach for comparison with the findings and for evaluation. Conceptual model The McKinsey 7S model, focusing on the elements of strategy, structure, systems, skills, shared values, style and staff, was used to explore how to deliver change in the management of health services. Although various models have been used to understand change management in organizations, the McKinsey 7S model’s strength in the way it looks at change as a complex interactive action that commences with the identification of misalignments and weaknesses within organizations was the reason for its choice. This model suggests that the performance of an organization is based on the level of alignment and mutually reinforcing nature of seven key internal elements, that is strategy, structure, systems, shared values, style, staff and skills. The premise is that all the seven elements are interconnected and mutually reinforcing, and thus a change in one will require a change in the others for the organization to function effectively. To deliver the triple results of UHC, health security and coverage of health determinants, managers, particularly at the subnational level, require modifications in their approach to managing health service delivery. This review explored the current management practices, comparing them with McKinsey’s 7S’s to identify the mechanisms and practices needed for the effective management of health services. Methods Literature search scope, definition and strategy The literature search focused on change management initiatives from all the six WHO regions that leveraged the 7S model to improve the effectiveness of health services, and particularly in Africa. The first step of the search was the identification of grey literature, that is policies, protocols and practice guidelines on the application the 7S model in implementing change programmes. This was followed by a systematic search of recognized public health-related databases and health journal publishers, that is BMC journals, BMJ Open, SAGE Open Medicine, Elsevier, Oxford, PubMed, African Journals Online and Global Health Archives, plus Google Scholar, using agreed search terms. vii Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Appraisal and selection of relevant data The relevant literature retrieved during the search was assessed for data quality and relevance for inclusion to be analysed for the main review. This quality check ensured that the evidence presented also contributed to the understanding and refinement of how change management can be accomplished. Data abstraction and organization of evidence A data abstraction template was developed in Microsoft Excel and used to collate the relevant content from each paper included in the analysis. The template was iteratively recalibrated to reorganize the information, based on whether the change initiative was successful or not, on the WHO region and on level of implementation of the change initiative. A total of 136 articles were included in the synthesis among which 108 focused on strategy, 93 on structure, 102 on systems, 73 on staff, 76 on style and 69 on shared values. All papers on successful change cases were isolated and further examined to appreciate the context within which the interventions they covered were implemented and the mechanisms of action through which key internal elements of the 7S model explained the success of the change. Narrative development and recommendations The findings from the synthesis were reviewed to identify the patterns and interactions that could provide a plausible explanation for what enabled the change and how the change happened or failed to happen. From this we developed guidance on how change management can be instituted by countries, paying attention to the required enabling factors, the process and the options of the change that can be adapted. Findings There was little or no focus on change management in health within the African Region, and the available literature tended to address certain aspects of change but not comprehensively. While clinical management was adequately explored, there is need to also look at the contribution of management to the overall performance of a health care system, especially systems undergoing transition. We found the McKinsey 7S model to be a useful framework for conceptualizing and planning change and providing guidance on implementing and managing health system change processes. A summary of cases on the successful application of the 7S model around the globe is provided below. Strategy For successful change implementation, having a group of experts to promote a supporting and positive culture for change was found to be valuable. In addition, the importance of leveraging existing policies and guidelines to reduce dissatisfaction with and resistance to the change and for its successful management was highlighted. Furthermore, personal initiatives of local leaders and health managers in the implementation process were seen as strategic ways of ensuring the success of the initiative. Structure An alignment between structure and the other elements of the 7S model was seen to be essential in generating the appropriate linkages for organizations to pursue and achieve their objectives. Integration of organizational processes was reported to be key in successful reforms. The review suggested that structure had been used as a mechanism for promoting inclusive governance and accountability in the successful change programmes and that it was seen as a mechanism for regulation, where relevant policies and procedures are developed to guide and elicit compliance from stakeholders and ensure that change implementation happens as planned. Systems The literature indicated that robust financial management systems that facilitate critical investments were crucial in the successful implementation of change programmes. Additionally, critical investments in the lower levels of the health system, for example in public health services, including adequate infrastructure, equipment, drugs and supplies and supporting staff, proved to be essential in the success of reforms. Robust and agile information systems viii Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 for providing data were also seen to be important not only for monitoring the progress of programmes but also in making evidence-based decisions. Success was noted in change reforms that prioritized effective bottom-up and top-down communication, ensuring regular feedback and using channels that were easily accessible. Staff From the review, the innovative ways of addressing staff shortages and maintaining staff in rural areas in several WHO regions included introducing incentives like allowances for housing, transportation, hardship and education. There were also policies on engaging community health workers (CHWs) to improve access to health services in geographically isolated regions and on training of non-physician clinicians for emergency services. At the subnational level, the health workforce retention strategies included non-financial incentives such as provision of housing and transportation, especially in rural areas. In terms of staff development, the review showed that ensuring adequate capacity at the operational level, including refresher training for skill building, plus digital, managerial, professional/clinical, and data use and analysis skills were key in the success of health system reforms. Skills Some of the factors identified by the review to be supportive of change at the national level included benchmarking skills, collaborative learning, networks within and outside the organization that could be relied on to rally change, enhancement of skills through on-site, off-site and mentorship approaches and possession of leadership and management skills. The reviewed literature suggested that digital health and data use skills among policy- makers at the national level and district managers and supervisors at the subnational level were key drivers of success of health system reforms. Approaches for successful learning beyond formal training included peer support, on-the-job training, coaching and mentorship offered through various health capacity strengthening programmes in Africa and though their implementation for CHWs, with whom participatory approaches and action-training programmes were used. Style A bottom-up approach was shown to be the most successful style and to be essential in situations requiring mobilization of grassroot effort and support to build trust, interest and a shared sense of responsibility in a team. Strengthening collaboration among politicians, religious leaders and nongovernmental organizations (NGOs) was fundamental in instituting governance reforms, while participative management from hospital leaders encouraged teamwork and staff participation in planning for reforms. Effective leaders were found to enhance teamwork among diverse groups, particularly transformational leaders, who typically had the ability to inspire confidence and staff respect. Integration of innovations into existing health care management practices required strong leadership, owing to the technological advancement of such innovations, among other elements. However, to navigate such integrations, a considerable level of financial and administrative authority was required. Shared values The shared values element breathes life into all the 7S’s by ensuring shared commitment for the initiative and for related values through fostering community participation, equity, social justice and patient-centred approaches. The use of a shared language and the sharing of information were highlighted in many of the countries as influential in producing progress through channelling ideas and facilitating the transfer of evidence and learning for health system change. A culture that allowed ready sharing of knowledge and demand for data in decision-making proved to be successful in the implementation of change. Shared values were also seen as important in the adaptation of regional and global best practices to the unique sociocultural and political contexts of stakeholders. ix Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Conclusion This literature review highlights the attempts to generate plausible change management strategies that could help countries to improve the functioning of their health systems and thereby contribute to the attainment of UHC, health security and coverage of health determinants. The review shows that investing in all the building blocks of health system development is crucial in meeting the triple aims. The majority of the health service delivery reforms reported in this review that aimed at achieving UHC focused on strengthening and improving primary health care (PHC) through multiple approaches, including disease prevention and health promotion. Linked to this is investment in the health workforce, which largely involved the use of CHWs to reach rural and remote areas, alongside programmes aimed at linking communities to primary health facilities. Addressing the determinants of health calls for engaging beneficiaries as active participants in the dynamic co-production of health. Health determinants influence access to and effective coverage of health care, and so sectors outside health should be involved and closely collaborate with the health sector, with the stewardship of a mix of public and non-public health care providers. Preparedness for acute health shocks requires having the right information provided via health information systems and strengthening the capacity of the health workforce for data collection, analysis and use. There is also the need to strengthen public health infrastructure, build up health care workforce capacity and, most importantly, recruit, educate and retain more of them. These should be routine investments in the system to better prepare for shocks and disruptions. Strong and facilitative leadership, collaborative decision-making and information sharing among health stakeholders are critical for successful health change management. Recommendations Several implications were identified from the health reform literature review using the McKinsey 7S model. The cross-cutting lessons and guidance for instituting change and reforms that emerged include: • A strategy deliberately aimed at enhancing inclusiveness and engagement of all stakeholders ought to be deployed as a governance tool. • A structure is important in integrating processes into a health system to avoid duplication of efforts and fragmentation of the health system. • Systems that support change such as financial management systems and robust information systems are essential in mobilizing resources and in governing operations. • Skill building through on-the-job training and mentorship with a focus on leadership and managerial training, alongside technical training, is important. • Staffing capacity expansion through using mid-level cadres and task shifting supported by professional cadres, coupled with seconding of health workers, would provide the required human capital needed for change. • A bottom-up, facilitative, transformational, collaborative, multifaceted and context-specific leadership style is key for positive change. • The shared values element breathes life into the 7S model by ensuring shared commitment to the success of the programme and that the espoused values are demonstrated through community participation, equity, social justice, patient-centred approaches and cultivation of a learning and knowledge sharing culture. The review identified the interactions among the various elements of the 7S model that often strengthen the mechanisms for and act as drivers of change. It provided a menu of the possible options that countries could consider in managing large changes and reforms following the McKinsey 7S model and that would potentially improve the outputs and outcomes of their health systems. However, the extent to which and how this can be achieved is subject to countries’ prioritization of these options based on their needs, feasibility, cost-effectiveness, equity implications and perceived sustainability. Countries will also need to consider their other enabling factors, including global and regional commitments, intersectoral collaboration, partner coordination and accountability mechanisms. x Background 2 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 1. Background 1.1 Introduction All WHO Member States in the African Region have prioritized the attainment of good health and well-being as a common goal. This commitment is encapsulated in the Agenda for Sustainable Development as SDG 3. Attainment of this goal is only possible through the achievement of multiple health and related targets across the SDGs. These multiple targets are brought together under three interconnected themes around which results need to be attained, that is UHC, health security and coverage of health determinants (see Figure 1). Figure 1. Areas in which health results are needed to attain good health and well-being for all at all ages. UHC is an approach that ensures that health goals are attained by achieving maximum population coverage, health service coverage and financial protection against impoverishing health costs. UHC calls for a fundamental shift in service delivery incorporating multiple approaches, including strengthening PHC. In 2018, the global community came together and declared support for the Astana Declaration on Primary Health, which reaffirmed countries’ commitment to comprehensive PHC for all, as well as prioritizing disease prevention and health promotion throughout the life course. Health security is imperative to ensure that all populations are safe and secure from the danger and impact of acute public health events. The International Health Regulations (IHR (2005)) provide guidance for handling public health threats. Of note is how the COVID-19 pandemic highlighted the need to have a revision of these regulations and also revealed the gaps in access to affordable and quality care. Addressing the determinants of health calls for close collaboration with actors outside the health sector such as those in education, housing, transportation, agriculture and the environment in a manner that ensures that health equity is achieved. As such, all the three result areas are interconnected, and achieving success in one automatically leads to achievement of success in the others. There have been explicit calls recently for a comprehensive systems thinking approach to help African countries address their specific health needs and realign their health systems to facilitate the realization of UHC and the SDGs [1, 2]. The UHC, health security and coverage of health determinants results approach represents a departure from the Millennium Development Goals (MDGs) era where the results focused on specific high burden conditions. The key shifts in health service delivery are shown in Table 1. 3Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Table 1. Shift in the focus of health delivery The range, nature and focus of the systems to deliver on the UHC, health security and health determinants expectations also are different. The current focus of investment in the six building blocks needs to evolve to have complex, dynamic systems that allow for the interplay across the 13 elements, three of which are on hardware, that is staff, medical products and infrastructure; four are on software, that is delivery and governance processes, information, and financial management systems; and six are the intangibles, that is values and norms, beliefs, practices, organizational culture, interests and networks, and relationships and power (see Figure 2]. Figure 2. Elements of the health system in the UHC, health security and health determinants approach. 4 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 A good health system is one where the interplay among the 13 elements allows the operationalization of the shifts needed to attain the expected results. There are multiple correct ways to mix, match and connect these elements to produce results, so intervention planning and monitoring in this environment are complex, as the correct approaches will be many and will be location, time and country specific. The WHO Regional Office for Africa is currently supporting a re-pivot of the health service delivery systems to attain success in the three result areas, but the current management practice is not aligned to this. This review aims to determine which management mechanisms guided by the McKinsey 7S model, can guide the attainment of success in the three result areas. 1.2 Overview of health systems reforms in Africa According to the State of health in the African Region report, although significant challenges exist in African health systems, there have been notable gains in some of the health investment areas. For instance, health service delivery has seen general improvement in the availability of the basic amenities and equipment needed for service provision and emerging opportunities to design public health services around existing infrastructure whilst adhering to service delivery standards. Countries that are doing well in medical products and technologies have regulatory mechanisms at national, regional, subregional and district levels, as well as continental level linkages to ensure product quality, supply chain integrity and counteracting of proliferation of substandard and falsified medicines. Health governance in most African countries is characterized by a legal guiding framework and defined through constitutional provisions impacting health; comprehensive health acts and disease or area specific acts such as human resources for health (HRH) acts, diabetes act etc.; and/or decentralized health laws. Financial reform of the health sector is well under way on the continent, as there are efforts to establish national health insurance schemes to reduce out-of-pocket spending and ensure more sustainable funding for the health sector. These schemes vary in size and scope, and often target a specific demographic or economic group such as civil servants, formal sector employees or the poor. African countries have recognized the need to reorient their health systems to attain the SDGs and have instituted several changes in their health systems such as the financial reforms to achieve UHC and cushion the countries against the effects of withdrawal of donor funding. The reforms include abolishment of user fees, establishment of national health insurance schemes and of an equity fund for the poor, and revision of national health policies and plans [3]. Of note is that the health equity initiative places significant emphasis on closing the gender gaps in all health spheres, promoting maternal and child health, addressing mental health and supporting the elderly and people living with disabilities. In essence, it targets all the vulnerable segments of the population that tended to be sidelined in the drive to achieve the MDGs. Structural adjustments in health services have meant accelerating the decentralization of health services, hence strengthening their access. The delivery of services at health facilities has been an area of concern and is often associated with low productivity and responsiveness. This has resulted in the remodelling of the internal organization of health facilities and has seen a move from verticalization to integration of disease management [4]. The Ebola outbreak in West Africa acted as a learning point in shaping the way countries respond to pandemics. The reforms instituted in the health care systems, including the goal to have strong health leadership and an accountable workforce, have assisted countries to respond to the COVID-19 pandemic [5, 6]. The changes in the African health systems should consider: • Ensuring sustainable health financing, given that no country has achieved the goal of the Abuja Declaration to allocate 15% of its annual budget to health [5]; • Placing emphasis on decentralization of health services; • Introducing national health insurance schemes, community health services and subsidies for services for maternal and child health and key vulnerable populations; • Ensuring quality of care and continuum of care during emergency situations. 5Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 The private sector is playing an increasingly important role in partnerships and collaborations for health financing in Africa. In fact, in sub-Saharan Africa about half of the spending on health in all the economic quintiles comes from the private sector. Yet, dialogue and sharing of information between the private and public sectors are rare. 1.3 Objectives and scope of the literature review The aim of this review was to generate evidence on the most appropriate manner to re-pivot health systems development in African countries by exploring the literature on the current change management practices, identifying the practices needed and eventually making proposals on what needs to be done for effective management of health systems at national and subnational levels in the African Region. The overall goal was to consolidate existing evidence on the areas whose management approach needs change that will facilitate attainment of results in the triple areas of UHC, health security and health determinants. The process involved: • Collating evidence on the current state of the management of health services at the national and subnational levels in Africa and globally; • Analysing the information on the requirements for managing health services to attain results in UHC, health security and coverage of health determinants; • Making recommendations on how to move from the current to the desired management practices and on the ways of measuring the standard results for the 7S management approach for comparison and evaluation across the findings. 1.4 Conceptual model The need to deliver the UHC, health security and health determinants triple results requires changing existing models of managing health services and systems to those that are both effective and also deliver the much needed change. The McKinsey 7S framework is a research tool that considers the multidimensionality of an organization or a system, that is it looks at the organization, team and individual levels. It evokes the notion of an organization’s health, an intangible component that incorporates the management method and the organizational culture. We found the framework useful in understanding change because it is based on the concept of management by objectives and, therefore, it helps in analysing the dysfunctions of the management process. A health system’s performance can be diagnosed using the 7S framework to produce a comprehensive assessment of its functioning and identify the leverage points for implementing and sustaining change processes. We leveraged the framework1 to explore how health services can be made more efficient than they were at the time of the scoping review. The McKinsey 7S model (Figure 3) suggests that the performance of an organization is based on the level of alignment and mutually reinforcing nature of seven key internal elements: strategy, structure, systems, shared values, style, staff and skills. Given that the 7S’s are interconnected and mutually reinforcing, a change in one will require a change in the others for the organization to function effectively. The seven elements are further categorized into hardware, consisting of strategy, structure and systems, which are the easier to identify and manage; and software, consisting of skills, staff, style and shared values, which are intangible and complex to manage and yet they form the foundation of an organization and are more likely to constitute the basis for the organization’s sustained competitive advantage. There is substantial evidence in the management literature, especially outside health care, that the 7S model continues to be as relevant in explaining organizational effectiveness today as it was when it was developed in the 1980s. 1See the Mckinsey 7S model for organizational design: https://strategicmanagementinsight.com/tools/mckinsey-7S-model-framework/ 6 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Figure 3. The McKinsey 7S model We argue that the hardware and software elements of the model are relevant in understanding the interplay of the key elements needed to shift health system investments towards the attainment of the goals in the triple areas. Thus, the model was used to explore the organizational and management approaches used by health care leaders to improve the functioning of health systems across the 13 health investment elements. Specifically, guided by the 7S model, we identified some key changes that had been implemented across health systems and then we used these as tracer cases in exploring how change was achieved and managed. Managers, particularly at the subnational level, are required to deliver results in the triple areas, which requires modification of management approaches. Therefore, an exploration of the practices across the 7S aspects of health systems will lead to an identification of the practices needed for effective management of health services. Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Methology 8 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 2. Methodology The general approach in analysing the literature on the change management practices required to re-pivot health systems involved a rapid scoping review consisting of a critical analysis of published and grey literature. The methodological approach adopted comprised six steps: a) Defining the scope and the search strategy b) Searching for and identifying evidence c) Appraising and selecting relevant literature d) Abstracting data and organizing evidence e) Synthesizing evidence and drawing conclusions f) Developing a narrative and making recommendations The details on these steps are presented in sections 2.1–2.6. The approach used was considered the most appropriate in explaining how change happens within complex health systems by focusing the analysis on who is involved, how and why and the context within which change processes occur. 2.1 Defining the scope and the search strategy The definition of the scope and search strategy aspects of the data collection process defined the boundaries of the search strategy and the terms to be used to identify the relevant change management practices. Given the objectives of the assignment and the scope of work, the literature search focused on change management that leveraged the 7S model to improve the effectiveness of health services and health systems in general. For comprehensiveness, literature from all the six WHO regions, and in particular Africa, was included. 2.2 Searching for and identifying evidence The first step in the search strategy was identification of grey literature, that is policies, protocols and practice guidelines on the application of the 7S model in implementing change programmes. The next step was a systematic literature search of recognized public health-related databases and renowned journals, that is BMC journals, BMJ Open, SAGE Open Medicine, Elsevier, Oxford, PubMed, African Journals Online, Medline Plus and Global Health Archives, plus Google Scholar. The search terms included [‘7S Mckinsey analysis health system’ AND ‘transition MDGS SDGs’ AND ‘health system reforms’ AND ‘health system governance’ AND ‘change management public health’ AND ‘structure health systems’ AND ‘‘health systems UHC, 7S and health systems change, implementation of 7S in health care, the 7S model and antecedents of change in health services and systems, change in complex health systems, change management in health and social care, Change management in health, 7S in health, Mckinsey 7S framework in health, Change management in leadership, Health Policy Reform, Health Financing Reforms, Health Services delivery Reforms, Human Resources for Health Reforms, Health Information Systems Reforms, Healthcare Leadership and Governance Reforms, Medicines and Health Technology Reforms. Using these search terms, separate searches were conducted for each of the six WHO regions. 2.3 Appraising and selecting relevant literature The relevant literature from the search was assessed before being analysed for the main review to determine if it met the inclusion criteria. This also ensured that the evidence presented was judged along with its contribution to a better understanding and refinement of how change management can be accomplished. Thus, the selection was based primarily on relevance. The inclusion criteria included peer-reviewed and non-peer-reviewed published and unpublished papers in English that were not more than 15 years old. 9Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Figure 4. Process of selection of relevant articles. 2.4 Abstracting data and organizing evidence A data abstraction template was developed in Microsoft Excel and used to collate the relevant content from each paper included in the analysis. The template was then used in organizing the publications’ details such as author, year of publication or authorship, focus, and whether it was on a change programme, plus the WHO region of the programme, if it was implemented nationally or at the sub-national level, its outcome and the 7S’s that explained its outcome. The template was iteratively recalibrated to reorganize the information, first based on whether the programme was successful or not and then based on its WHO region and level of implementation. This made it easy to identify successful or unsuccessful change cases, the level of their implementation within the system and the levers driving successful change. The details of the papers analysed above are shown in tables AP-1 to AP-8 in the appendix. 10 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 2.5 Synthesizing evidence and drawing conclusions All the successful change cases identified in the data abstraction exercise were isolated and examined further to appreciate the context within which the change programmes were implemented and the extent to which key internal elements of the 7S model explained the success of the change programme. This was repeated for a subset of the successful change programmes implemented at the national and subnational levels and the different WHO regions to understand the implications of context at these levels and how that eventually shaped the influence of the 7S’s in delivering change. The process was conducted also for all the unsuccessful cases at the subnational and national levels and different WHO regions to understand the dynamics of how context interacts with the 7S elements to derail or promote the objectives of change programmes. Table 2 contains the thematic areas that emerged from this phase as the drivers of the change following the McKinsey 7S model. Table 2. Emerging thematic areas fostering change along the McKinsey 7S model 11Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 202312 2.6 Developing a narrative and making recommendations We reviewed the findings from the synthesis of the literature described above, looking for patterns and interactions that could provide a plausible explanation for what enabled change and how change happened or failed. From that we developed a summary of the potential change pathways emerging from the interactions of the various elements in each of the 7S areas and used a causal loop diagram (Figure 5) to show how these interactions could lead to successful change. Figure 5 provides a menu of the potential pathways for change that can be validated by policy-makers and other relevant stakeholders working on implementing and managing change within health systems. This stage started early in the evidence synthesis phase as part of the refining of the emerging theory and offering of a potentially helpful way of improving face validity. Practical recommendations that embrace complexity and systems thinking approaches were then made with particular emphasis on the relationships between the interventions and the contexts in which they are used. Figure 5. Elements of the 7S model [137]. 13Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Findingsz 14 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 3. Findings 3.1 Contextual overview of health system reforms and change programmes Improving health care is vital in the 21st century to achieve the triple aims of improving population health, lowering per capita health spending and improving patients’ experience of care [3]. The 2000 WHO report points out that many low- to middle-income countries (LMICs), including China, Colombia, Ghana, India, Kenya, Mexico, Thailand, Vietnam and Zambia, have been reforming their health systems to promote universal access to health care and improve health equity, health service quality and health financing fairness [4]. National governments have priorities determined by their circumstances and needs, but the resulting reforms, often based on the priorities, are largely similar and organized around the six WHO health system building blocks. Our review of the literature on major health systems reforms and changes showed that the reforms most prioritized globally were health financing, health service delivery, HRH, health governance and health information systems (Figure 6). No reforms were found on medical products and technologies that met the inclusion criteria for this study, although this should not be interpreted as an indication of the lack of such reforms, and neither does it dimmish the value of the results and conclusions reported here. Figure 6. Health system reforms and changes prioritized globally. 3.1.1 Health financing reforms Health financing reforms in high income countries, for example in Europe, have included a change from a system financed by general taxation, where budgets were allocated to health care providers, to a mixed system, where financing comes mainly from earmarked payroll taxes, transfers from the state budget and official out-of- pocket payments [5]. Sweden instituted a national choice of care reform that involved health financing by regional taxation with each county council having a unique system [6]. Changes to the payment mechanisms, such as the 15Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 development of diagnosis-related, group-based payment systems and the increased adoption of health technology for patient assessment have been part of the efforts to improve cost containment and achieve greater value for money in the majority of European Union countries [7]. In Latin American countries (LAC), financing reforms have included the introduction of private operators into the three core health financing functions of revenue collection and pooling and service purchasing. Unfortunately, these reforms have yielded results that were opposite of what was anticipated, such as the further fragmentation of insurance funds, increases in health expenditures that have not been not accompanied by improvements in outcomes, and, most importantly, inequity in access to and utilization of health services, as the rich are better covered with private insurance funds. This was the case according to the studies from Argentina, Chile and Colombia [8–10] and the larger LAC region [11]. Health financing reforms in the Central Asian countries have involved pooled budgeting at the national level. The Kyrgyz Republic went further and established a mandatory health insurance fund, a government institution to administer the pooled funds and monitor their use. Other countries have defined their basic benefit packages and comprehensive packages of services for HIV and primary health care based on capitation. Within Asia, countries are implementing various strategies to address out-of-pocket expenditure and protect vulnerable groups like children and pregnant women from catastrophic spending [12–14]. They are also putting up safety nets to ensure financing of emergency care, for example by providing accesses to state sector services, when drugs are not available in public hospitals, patients are told to buy from private providers) [15]. Health financing reforms in the African Region are largely in the form of the introduction, expansion or evaluation of health insurance. Examples are the introduction of community-based health insurance schemes in Burkina Faso and Rwanda to encourage health facility deliveries [16] and the free and subsidized health care provision and reforms for financial protection towards UHC in multiple countries such as Ghana, Rwanda and Senegal [17, 18]. Other health financing reforms focus on performance-based budgeting, for example on the conditions necessary for the success of performance-based financing (PBF) [19] and the political economy of results-based financing (RBF), for example in Zimbabwe [20]. There have been reforms examining the drivers of the policy process and their roles, including the national and external actors and their interests and agendas and the dynamics between them, plus their interaction with the features and context of the health systems, for example in Côte d’Ivoire [22] and Sierra Leone [21]. There are also health financing reforms related to health worker motivation under RBF arrangements in Zimbabwe [23] and to the establishment of sustainable performance-based incentive schemes in Burkina Faso, Ghana and Tanzania [24]. The introduction and implementation of these reforms have been tracked to understand the mechanisms that support or undermine the change they introduce. An example is the tracking of the influence of purchasing reforms on the National Hospital Insurance Fund’s purchasing practices and the implications for strategic purchasing in Kenya [25] and the examination of equity and sustainability in community health insurance schemes in Uganda [26]. There are also reforms in Kenya around exploring community perceptions on health insurance and their preferred design features [27], and on centralizing financial decision-making on the functioning of the South African health system [28]. 3.1.2 Health service delivery reforms The commonly reported health system reforms in health service delivery span the areas of maternal and child health, noncommunicable diseases (NCDs) and mental health, plus the specific focus on the expansion of PHC programmes. Maternal, newborn and child health reforms The reforms covered in the literature on maternal and child health focused on the actors determining the successful implementation of adolescent reproductive health programmes and on the reduction of under-five 16 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 stunting prevalence in Peru. The literature reviewed on maternal, newborn and child health reforms in sub-Saharan African focused on understanding why and in what circumstances the implementation of user fees for hospital-based caesarean section births had succeeded or failed in Benin [29] and on the introduction of Egypt’s facility accreditation programme to determine the effect on a set of family planning, maternal health and child health outcomes of having access to an accredited facility [30]. The maternal, newborn and child health interventions in the literature on Asia included reforms on the introduction of cash incentives, regulation of service provider pricing, quality of care in maternal and newborn health services [31] and promotion of the linkage of education and health programmes, especially in regard to female empowerment as a means to reduce teen pregnancies [15]. NCDs and mental health reforms NCD reforms in Europe placed emphasis on managing chronic health conditions within PHC and provision of better integrated primary health care at the local level [7]. There was also literature on the United Kingdom relating to the integration of care paths across organizations, jurisdictions and geographical boundaries through public and private providers, plus on an agreed, effective, integrated model of care; professional and team development; and integrated governance arrangements [32–34]. Reconfiguration and redesigning of the delivery of services, for example the distribution of medical, surgical, diagnostic and ancillary specialties for stroke, were reported as useful in European countries [35]. Denmark, Germany and the United Kingdom were reported as having recently launched a national strategy on chronic disease management and developed a generic model for management programmes for these diseases, working with their regions and municipalities to strengthen coordination among primary and secondary care levels and the services at other levels for those who were chronically ill [7, 33]. The major changes and reforms on NCDs reported in Africa included (i) assessment of the political priorities and pathways to scale up childhood cancer care in Ghana [36]; (ii) development of an integrated, evidence-based chronic disease management model in South Africa [37], (iii) addressing of the practical challenges of providing long-lasting care for patients with HIV and those with NCDs in Zambia [38] and (iv) translation of the UN Declaration into national policies for diabetes prevention and control in Kenya [39]. Mental health reforms included increasing the budget allocation and implementing radically transformed services such as downsizing mental hospitals and introducing alternatives such as PHC, community mental health teams, day hospitals, acute psychiatric beds in general hospitals, and group homes in Chile [40]. In Africa, there was literature on the deliberate efforts to prioritize mental health management alongside explicit health system reforms to support the change. For example, in South Africa individuals, families and communities were empowered and engaged to promote mental health management [41]; in Kenya mental health care services were integrated at the primary health care level [42] and in Benin, Burkina Faso, Côte d’Ivoire, Niger and Togo assessments of the accessibility of mental health services were undertaken [43]. PHC expansion programmes Driven by the need to rebuild health systems, which was the case for the countries formerly in the Soviet Union, and owing to demographic shifts, Europe and Central Asia came up with 10 evidence-based policy accelerators for strengthening PHC in the WHO European Region. The goal of the PHC reforms in Europe and central Asia was to ensure the provision of people-centred and integrated PHC throughout the life course, as underscored by the Declaration of Astana. Countries such as Bosnia and Herzegovina, Estonia, Greece and Kyrgyzstan have focused on the use of a family-centred PHC model that places emphasis on holistic and user-centric health care [5, 44, 45]. The Government Tajikistan has adopted a business planning tool at the health facility level to strengthen the managerial capacity in PHC, while in 2017 Poland passed a primary health care law to introduce transformative changes in the way primary health care is delivered [46]. India established regulatory processes for checking the quality of health services offered and the safety of the people seeking care and also introduced community health care workers and non-physician cadres at the community level and treatment of chronic diseases such as NCDs at that level, among other reforms [47–49]. 17Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 PHC care reforms in Africa date back to the late 1980s and were guided by the Alma-Ata Declaration. They have gained momentum recently with the countries’ drive towards the attainment of UHC and SDGs. These reforms include national assessments of service availability and service readiness as routine events in countries such as Nigeria [50] and performance management and accountability for PHC, for example in Ethiopia [51]. Others include integration of mental health care services in primary health care in Ethiopia, Nigeria, South Africa and Uganda [52], establishment of a gatekeeper system to strengthen primary health care in Egypt [53] and implementation of community participation and management of CHW programmes at scale in South Africa [54, 55]. There was also literature on the implementation of clinical and administrative standards in primary health care health units in Ethiopia [56] and comprehensive primary health disease prevention and health promotion in Tanzania [57]. 3.1.3 HRH reforms High income countries such as those in Europe and Central Asia are reforming their health workforce, embracing more flexible models such as changing the skill mix or expanding the roles of professionals, especially nurses and doctors [5, 35, 58]. New specialties also are being created, for example family medicine in Albania, Bosnia and Herzegovina and Greece [45, 46]. In the Netherlands, medical specialists are being expected to take on more responsibilities related to organizational tasks and development [59]. European countries have also undertaken reforms in areas such as setting limits on doctors’ working hours and ensuring that reimbursements for health services are in line with the directive on cross-border care, based on regulations from the European Commission [7]. For example, the Netherlands government has set a revenue ceiling for self-employed doctors [59]. There is also performance-based monitoring and rewarding of staff in Germany [33] based on the estimated cost for each patient seen for mental health services [60]. In India, Sri Lanka and Thailand the use of CHWs to scale up health services at the community level and the training of non-health professionals in the regulation and licensing of health care workers in the region has generated good results [61, 62]. In addition, allowing the inflow of skilled health care workers from other countries has been viewed as a key driver of change within the region [63]. In Africa, HRH reforms reported in the literature mostly focused on education reform from fragmented, static curricula to the addressing of complex and adaptive health systems [64]; mentoring when there is shortage of resources [65]; changing of medical and nurse training, for example developing a model for improving the quality of nursing education in Malawi [66]; nursing education reform in South Africa [67]; and education of leaders in hospital management in Ethiopia [68]. There were also multiple examples on the use of incentives in recruiting and retaining health workers. These included the PBF incentives provided in Rwanda to staff, allowing them to retain 40% of the revenues generated from their work; in Eritrea, where individual, community and private health insurance and tax funds have been embedded in the public health care system; and provision of incentives such as allowances for housing, transportation and hardship, and education opportunities [20, 69–71]. Other HRH reforms in the literature included creation of a mid-level cadre and introduction of CHW programmes in various countries [70, 72], creation of the Health Extension Programme in Ethiopia [16], introduction of community health assistants in Zambia [73] and assessment of the effectiveness of the community health strategy on health outcomes in Kenya [74]. There was also focus on exploring the potential of task shifting as an answer to the HRH crisis in Africa [75]; analysis of the changing health worker policies and incentives in the post-war era, for example in Sierra Leone [21] and exploration of how national HRH policy interventions in Zimbabwe impact HRH [69]. 3.1.4 Health governance reforms Health governance reforms were not common among the papers reviewed, and the few papers covering them mainly reported the success in the implementation of innovations, for example how health facilities could use stronger competitive intelligence, strategic leadership, management of technology, and specific characteristics of the facilities’ change processes. The literature particularly related to how conversant the leadership of an 18 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 institution was with the environment within which the institution operated [76]. For example, in a nation in Latin America an alliance of health sector leaders with both technocratic and diplomatic abilities capitalized on the policy window opened up by an electoral victory and within the parameters set by president to universalize health care [77]. In Asia the cases included in the literature focused on the successful implementation of the decentralization of health services, including the provision of autonomy to regional hospitals, strengthening of governance structures at all levels, investment in research and education, proactive disaster response and global health security [63]. For example, in India, the establishment of autonomous organizations to enable accountable and evidence-based good quality health care practices, the production of appropriately trained human resources and the legislation of health as an entitlement for all Indians were outlined as successful [78]. In Africa, the health governance reform most frequently reported on was the decentralization of health systems. Within the decentralized structures, various interventions were reported to have been implemented with the aim of providing better oversight and authority in driving desired change. Examples were on the development of a monitoring and response unit for improving maternal, newborn and child health outcomes in two districts in South Africa; privatization of health service delivery in Sudan [79]; and the impact of management and leadership practices in the performance and implementation of a community health fund in Tanzania [80, 81]. The broader interests captured included tracking of the process of decentralizing power, authority and function across multiple settings. Examples were the investigation of the performance of health workers after decentralization of health services in Uganda [82], exploration of the influence of organizational culture on decentralization reforms in a select LMICs [83] and examination of the intersection between decentralization policies and provision of administrative oversight, stakeholder participation and responsiveness, accountability and regulation [64]. Other health governance topics included collation of perceptions on health systems’ decentralization by policy- makers, health workers and communities, for example in Rwanda and Sudan [79, 84]; monitoring of the effect of decentralization on the health workforce and commodities management in Kenya [85] and determination of the decision space and participation of health care facility managers in South Africa and Uganda in decision-making [86, 87]. 3.1.5 Health information systems The role of digital health, which is reflected in the use of information and communication technology (ICT) in health and related innovations, is taking prominence in the health system reforms and at various levels of the health system with the aim of improving service delivery efficiencies, patient outcomes, quality of care and data systems [88]. Countries are profiting from advancements in digital health and technology and information platforms, which they are using for ensuring the continuity of care through universal population empanelment and national registration systems linking people to particular health facilities [14]. National registration systems have been presented as the hallmark of the civil vital and registration systems for most countries [14]. Digital health was captured as being used as a strategic reform tool in improving service delivery in remote areas, for example in India, which is advancing the use of technology to provide health services to rural and hard to reach areas through telemedicine [88]. Drones were being used to deliver essential drugs and commodities to remote, hard to reach locations and emergency situations in parts of Asia and Africa [14]. The slow embracing of digital health transformation in routine service delivery in the countries despite the generation of huge data in the sector and the low use of data or information (this is termed a data rich and information poor scenario) were highlighted as areas of misalignment in digital transformation in the health sector [89–91]. Also identified in the literature as misalignments were the failure to use health data for health funding models and to prepare the health workforce to utilize and ultimately benefit from digital transformation, despite the fact that health care jobs are relatively and comparatively at a low risk of automation [92]. 19Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 The literature shows that the health sector has capacity challenges such as the relatively low numbers of ICT specialists. There are huge barriers in the implementation of digital transformation that are not related to technology but rather are structural, organizational or institutional, including the lack of policies and strategies in the ministries of health and the failure to transform digital health skills and attitudes across the health sector [92]. The low digital health literacy is a matter of concern for all countries. 3.2 Role and application of the 7S model in implementing health systems change programmes 3.2.1 Strategy A strategy ought to be deployed as a quality tool deliberately aimed at enhancing inclusiveness and engagement of all stakeholders through ensuring the development of shared goals and objectives that are aligned with existing national policies and strategic plans and are adequately financed with the necessary capacity built in for change (see Figure 7). Figure 7. 7S strategy mechanisms that enable successful change management. Organizational and management theorists consider successful organizations to require a set of actions and plans responding to or anticipating changes in their external environment, as change is inevitable [93, 94]. However, to thrive and sustain change, organizations need more than just a set of objectives and action plans. They need a competitive edge. Health system reforms are constant and occur globally. Their planning and designing phase is not well understood. This review used the 7S model to understand the roadmap or the blueprint by which health systems gain a competitive edge or lead in reforming. 20 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Quality of the strategy content Most countries covered in the literature had set up expert strategy structures with clear aims and deliverables. The strategies contained a shared vision for change and a clearly defined and well-articulated problem with a solution. For example, most countries had explicit strategies on introducing and/or expanding their national insurance schemes to improve equity and accessibility to UHC [25, 95, 96]. Other reforms included setting up of groups of experts to create a supportive culture for the change. Examples were the interministerial UHC-specific steering committee in Morocco and the centralization committee specifically set up in South Africa to review expenditure and payment requests for a whole province during the centralization of financial management [28, 97]. The reduction in the prevalence of under-five stunting from 31.3% in 2000 to 13.1% in 2016 in Latin America was partly due to the well thought out strategy with benchmarks and accompanying incentives for all levels of the implementation that achieved their targets, especially the municipal level [98]. In Chile, the progress in mental health outcomes was attributed to the implementation of national plans that had their roots in the United Nations International Covenant on Economic, Social and Cultural Rights [40]. While the proposed changes need to have clear goals and targets [42], there have also been calls for allowing flexibility and creativity so as to accommodate the unique contextual characteristics at implementation sites. A case in point is the initiative to educate African leaders in hospital management [68], which is allowing the opportunities to amend the strategies if situations on the ground are not achieving the desired results [99]. In Costa Rica, good understanding of the environment made it possible for facility managers to engage community members deeply, which created transparency and secured the relevant buy-in from stakeholders [76]. Value of existing policies and guidelines The importance of leveraging existing policies and guidelines to reduce dissatisfaction with and resistance to a reform [59, 100]) and for successful change management was also strongly highlighted. In India, Indonesia and Nepal roles for supporting subnational structures were included when new national health policies and strategies were created [12, 14]. The success in the change to the tuberculosis treatment regimen in Armenia was aligned with the national tuberculosis programme’s strategies and involved all relevant stakeholders, including the patients [46]. In Africa, Zimbabwe’s RBF was presented and perceived as a part of the wider government results-based management programme, which had been launched in 2005 [20]. And in Ghana the scaling up of childhood cancer care leveraged the primary health care strengthening initiatives and extension of health coverage to the broader swaths of the populace, which had an emphasis on the most vulnerable. In Ethiopia, districts and provinces created action plans to guide the implementation processes for clinical and administrative standards for health centres [56]. In some instances, even quarterly business plans for health facilities were developed. Examples were during the PBF implementation in Tanzania [101] and in working to understand how health systems learn from each other in LMICs. Ensuring alignment of operations at national and primary levels was crucial [16]. Other examples of useful strategies for successful change implementation were the use of existing policies and guidelines as a vital mechanism for implementing RBF in Zimbabwe [20], the integration of mental health at the primary health care level in South Africa [52] and the determination of the drivers of health sector performance in Rwanda [84]. Participatory approach and stakeholder mobilization Participatory approaches are essential in the design and implementation of proposed changes and require incorporating shared general principles and wide stakeholder involvement [102]. For example, early ownership of the change by the government was crucial, especially for countries that depend on donors for their health programmes, such as central Asian countries [99]. Furthermore, ensuring that the strategy was consistent, coherent, shared and acceptable to all stakeholders involved was key in ensuring success of the health system reform [64, 81] as were instituting tight controls, policies and regulations around medicines, supplies and governance [52, 103]. Strategies that were locally managed and that allowed for experimentation led to successful change. For example, the Netherlands tried to develop clinical leadership among the medical profession and found that it was beneficial 21Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 to let clinicians develop their own leadership style rather than force top to bottom strategies on them [59]. The development of a communication strategy to accompany the change process also was found to be beneficial, since it resulted in clear articulation of the need for and the process of the change and the expected outcomes [32, 35, 58]. For Africa, the two most valuable strategic approaches to change at the subnational level that were seen across all the literature reviewed were (i) the efforts to ensure local involvement and community participation in the change process through early involvement of local frontline workers and the communities [64] and (ii) the personal initiatives of local leaders and health managers throughout the implementation process, which were harnessed as strategic ways of ensuring success, for example in the performance of the community-based health financing in Tanzania [80] through supportive supervision of district health managers and health facilities. Additional examples emphasize the need to ensure adequate and intensive preparations through communication and obtaining buy-in, as observed in the implementation of PHC reforms in South Africa [54]. Linked to this were efforts aimed at triggering credibility mechanisms such as trust and perceived fairness for positive response to financial incentives. Examples in the literature were the implementation of the user fee exemption policy for caesarean section births in Benin [29] and the involvement and education of relatives of patients with mental illness, which were useful mechanisms in the integration of mental health in primary health care in Kenya [42]. Financing and building capacity for change The literature demonstrated that change strategies have a long-term perspective that goes beyond a single political cycle and should acknowledge that bold reforms in health service financing, organization and provision take time to implement and require political backing system [7, 60]. It is important that for success, the change strategies be adequately financed [104–106]. In addition, and particularly at the lower levels of the health system, assessing and including the capacities needed for the change is crucial. For example, in Canada a community assessment was conducted first in the early planning stages of a change to identify the needs of the community and health care workers [104, 107, 108]. Planning and active monitoring of the annual/multi-annual targets for the provision of health care goods and services were shown to be partly responsible for health systems’ efficiency gains. For example, the relatively high efficiency scores for the provision of general and equitable health service coverage in countries such as Costa Rica were associated with improvements in planning processes, particularly for the benefit package expansions and human resource management [77]. Countries in the South-East Asian Region have developed objective measures to track the attainment of UHC. By using the coverage index and incidence of catastrophic spending (four quadrants), eight countries in that Region identified strategies and interventions that could move them to achieve UHC [109]. In summary, the literature reviewed indicated that the strategy element is applied to support reforms as follows: • A strategy influenced the successful implementation of reform and change programmes if its content was appropriate. This suggests that the content of the strategy matters as much as the presence of one. • A strategy served as a tool to guide the implementation of reform and change programmes by providing the background information for the change and insight on how existing policies have been leveraged to under stand the unique needs of the different stakeholders. • Through espousing a compelling vision for the institution, the strategic plan to mobilizes stakeholders’ commitment to the implementation of the reform or change programme. It is important to emphasize that a clear vision becomes the basis for securing buy-in from all stakeholders and, therefore, their commitment to the implementation of the reform programme. • A strategy serves as a monitoring and evaluation tool through which benchmarks for performance and the accompanying incentives are determined for the implementation of a reform or change programme. In other words, the strategic plan serves as a planning tool to secure accountability in the change management process. 22 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 3.2.2 Structure Structure is important in integrating processes to avoid duplication and fragmentation, in creating new units to support the proposed change, in strengthening existing structures, and in ensuring existence regulatory mechanisms and decentralizing of functions at all levels of the health system (Figure 8). Figure 8. 7S structure mechanisms that enable successful change management. According to the McKinsey 7S model, structure refers to the arrangement of tasks and definition of relationships among the people responsible for performing the tasks. An alignment between structure and other elements of the 7S model is expected to create appropriate linkages for an organization to pursue and achieve its objectives. Although the literature on the nexus between structure and performance in health care is not as expansive as the literature on mainstream management, the results from the review of the existing health care literature suggest that structure, that is organizing structures and coordinating mechanisms, plays an important role in the success of reform or change programmes implemented across Africa, LAC, Europe and Asia at national, subnational and health facility levels. This section discusses the evidence on the different ways in which structure has been deployed in the effective implementation of reforms or change programmes. Process integration The importance of structure for successful reform outcomes was seen as key in process integration, where it was used to reduce fragmentation and consequently the institutional and structural difficulties that often challenge the successful implementation of reforms or change programmes. For example, moving from a fragmented insurance market with multiple drawbacks to efficient pooling of resources was suggested as responsible for the success of health financing reforms in Botswana [103]. There was also evidence from LAC suggesting that the successful use of ICT to address the health needs of an underserved population was related to the ability of those handling the programme to incorporate ICT into existing government structures [110]. The differences in the efficiency, effectiveness and equity between the outcomes of the health systems of Egypt and Cuba could be traced to the 23Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 fragmented nature of health financing and provision systems in Egypt compared with the integrated public system in Cuba, which had better health outcomes [111]. Moreover, Egypt’s health system was not only inefficient but also had perverse incentives, duplication of services, high transaction costs and reduced purchasing power for fund holders [111]. There was evidence to suggest that in India, Indonesia, Nepal, Sri Lanka and Thailand, where reforms in health insurance had been successful and outcomes related to service capacity, equity and access had improved, decentralization was deployed as a tool for integration [14, 31, 62, 112]. This model of integration was based on (i) national level structures that were responsible for policy and guideline development, setting of standards, and monitoring and evaluation [12]; (ii) subnational level structures focusing on supportive supervision, mentorship, monitoring and evaluation (including reviews), and quality assurance [49]; and (iii) the district level handling policy and programme implementation. In situations where reforms failed to achieve the set goals, lack of or inappropriate integration of structures was cited as a major cause. For example, the lack of integration between health financing and service provision was cited as the main challenge responsible for the failure of neoliberal reforms in many parts of LAC in the 1980s and 1990s [9, 113]. Also, attention to coordination improvement among public sector institutions and service providers, and the development of a unified health information management system encouraged the formation of an integrated network of the public health service providers in creating pathways for scaling up childhood cancer care in Ghana [36]. Evidence from the literature review shows that the success of the subnational level PHC programmes in Curitiba was attributed not only to the transformation of vertical-based health practices to a horizontal and integrated model that made for easy interaction among health networks in each district, but also to the integration of urban planning in the implementation of PHC programmes [114]. There is evidence that points to structure being manifested as the rationalization of functions and integration of relationships and procedures at the health facility level. For example, the rationalization of functions, the integration of procedures and the control of people’s functions, as well as professionalism, were key to the implementation of innovations at the health facility level in the United States [76]. Additional evidence on this effect was the use of limited resources in the form of a dispensary staffed by CHWs to provide a wide range of services, from maternal and newborn care to disease prevention and NCD care, even though at the national level programmes were vertical, with some of them, such as those for malaria, HIV, tuberculosis, NCD and maternal and newborn health, were standalone [63]. Evidence also suggests that in multiple countries in Europe implementing PHC reforms, regrouping of units in a bid to promote integration resulted in increased efficiency and reduced waiting time for patients [6, 58]. The literature reviewed also indicates that calibrating structures to ensure regular discussion, networking and sharing of ideas was essential in successfully managing change processes. This was the case Europe and central Asia, where these elements were instrumental in bringing together organizations and services in an integrated health system through contractual relationships or networks [45, 60, 106, 115]. Inclusive governance and accountability Structure has been deployed as a governance tool with the aim of enhancing inclusiveness and engagement of relevant stakeholders and accountability for the successful implementation of change programmes at the national level. There is evidence to the effect that unlike in several other LAC countries, in Costa Rica the bottom-up structure for implementing PHC reforms, based on deep community engagement, strengthened the reforms by c reating transparency and securing buy-in and acceptance of the programme [116]. In Estonia, continual meetings and close collaboration between policy-makers and parliamentarians enabled the development of realistic policies for a move towards family-centred primary medicine [45, 58, 115]. Other evidence indicates that in the implementation of changes at scale, new bodies, units and communities were set up to provide oversight on the change, along with the strengthening of existing local governance structures, provincial and district development 24 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 committees, and district health teams responsible for coordination across sub-sectors within the health system. Examples of this were the implementation of RBF in Zimbabwe and PBF in developing countries [19, 20], and the establishment of a PHC re-engineering task team and deployment of district and subdistrict coordinators as change champions in a province in South Africa [54]. The use of a high level interdepartmental committee chaired by the head of government strengthened the leadership for learning in the pilot of UHC learning systems in six African countries [97]. The vital role of regulatory structures in ensuring the implementation of programmes as planned was emphasized in the literature reviewed. This was reflected in the task shifting reforms in several countries in the African Region [75]. There is also evidence to suggest that governance structures (i) that limit the duplication of action and allow for accountability and ownership of actions, for example in Tanzania [81], (ii) that are guided by policy and frameworks that define the national agenda for health, as was the case of the nursing education reforms in Malawi, [66] and (iii) that are tied to strategic plans guiding the governance of the national health systems [117] are seen as critical factors in the successful implementation of their respective reforms or change programmes. Like at the national level, structure is also used as a tool at the subnational level to create platforms for regular discussion and continuous conversations, networking and sharing of ideas throughout the change process [45, 115]. Decentralization of functions A major structural mechanism for delivering change at the subnational level was the decentralization of functions, with frontline managers being responsible for translating, adapting and embedding programmes within organizational structures and systems [41]. This was key to the success of community health programmes in Belgium, where subnational officials were allowed moderate autonomy in the technical implementation of reforms but were administratively accountable to national officials [46, 106]. It is important to emphasize that the translation, adaption and embedding of programmes within organizational structures and systems at the subnational level means that there is need to create new units to accomplish specific mandates of reforms. For example, Kenya increased the hiring of health workers to implement the county public service boards, but ensure that the appropriate regulations were place to check the process [85]. In Tanzania, the establishment of health facility boards helped to improve communication between communities and health facilities during PBF implementation [101]. In South Africa, a monitoring and response unit was introduced as a decision-making and accountability structure for the purposes of improving maternal, newborn and child health governance at the district level [118]. And also in that country champions from the provincial structures and coordinators appointed at the district and subdistrict levels were critical in the implementation of CHW programmes [54]. The role of structures in ensuring successful implementation of change programmes or reforms at the subnational level is manifested in the establishment of linkages to existing local governance structures in addition to allowing such structures autonomy and decision space, with clear roles and responsibilities and a bottom-up approach to accountability. A typical example is the district autonomy to make informed decisions, set priorities, develop management capacity and control channelling of resources [119]. In Tanzania, for example, regulatory structures, including policies and guidelines to strengthen multisectoral linkages in the planning, implementation and monitoring of services [52], as well as the annual financial audits in PBF implementation [101], were highlighted as responsible for ensuring the implementation of the change programmes as planned. In the United Kingdom, the clarification at the early stages of the intention to integrate cancer services in a region where different stakeholders had different functions made it possible to know which decisions needed to be made and by whom [34] and consequently led to the success of the programme. Evidence from the health facility level suggests that decentralization plays a key role in the implementation of reforms or change programmes. For example, the establishment of health facility boards in Tanzania helped to improve communication between the communities and health facilities in the implementation of PBF training [101]. 25Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Institutional support tool Structure is seen as an institutional support tool to provide the relevant resources for the implementation of change programmes or reforms. For example, institutional support in the form of the necessary resources played an important role in the implementation of the participatory action research interventions in Brazil, Chile, Colombia, Mexico and Uruguay. Structures creating supportive and operational implementation environments were identified as essential in the successful change programmes at the health facility level. The evidence to support this claim includes the emphasis in Nigeria to have functional facilities with essential drugs and equipment as a way to demonstrate the system’s readiness to deliver PHC [50]. Also, in Burkina Faso funding and investment were increased to support the health care cadre operating at the PHC level and in a number of primary health care facilities [120], creating financial incentives and professional systems to simulate the cooperation of health care providers in capacity strengthening programmes [65]. In South Africa, a supportive environment was created by district and provincial offices for health care workers [37]. This was done to create an environment for all employees, to improve their productivity and morale in the integrated management of chronic diseases. There is evidence from Europe and central Asia suggesting that having clear roles for clinical management teams ensures their effective use of health care resources and inspires health care professionals to implement best practices [34, 100, 104, 115]. For example, the restructuring of health care settings and practice environments and of provider roles and scope of practice was important in the adoption of a people-centred model of care with feedback loops on performance, for quality services [60]. Mechanism for regulation At the health facility level, structure was manifested as the regulatory mechanisms that ensured that the implementation of initiatives happened as planned. This was seen in the implementation of policies for strengthening multisectoral linkages in the planning, implementation and monitoring of services for scaling up the integration of mental health in primary health care in six LMICs [52]. There was a similar experience in the implementation of clinical procedures and standards in Zimbabwe to protect health personnel from accidentally contracting diseases [69]. In Europe and central Asia, structural changes were reinforced with legislation to provide a guiding framework for the transformation agenda [58]. In Albania the shift to the use of telemedicine in acute care was made possible by putting in place structures that were backed by policy and procedures to ensure appropriate patient management [7, 107]. 26 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Systems Systems such as financial management systems and robust information systems that are supportive of change help in mobilizing resources and governing of operations. But to succeed they require accountability mechanisms, the use of which should be promoted using bottom-up approaches (see Figure 9). Figure 9. 7S systems mechanisms that enable successful change management. As one of the elements of Mckinsey’s 7S model, systems are concerned with organizational processes and procedures, which suggests that they are at the core of organizations’ activities. Systems determine how business is done and, therefore, are a major focus for organizational leaders, especially in the implementation of change programmes. This section focuses on how leaders implementing reforms or change programmes utilized, changed or created systems to support the success of the reforms or change programmes. Evidence from the literature reviewed suggests that systems in the form of hardware and software played a key role in the successful implementation of change programmes at the national, subnational and health facility levels. Robust financial management and key support systems The existence of financial management systems with the capacity to easily mobilize resources, especially at the local level, was essential in the implementation of change programmes. A case in point was the role played by a good national level financial management system in the successful implementation of RBF in developing countries. The reverse was demonstrated in Sierra Leone, where overdependence on donors and aid undermined the implementation of PBF [21]. Local level autonomy in the allocation of resources and improvements in financing and budgetary allocations at the subnational level were associated with successful change. These played a key role in the implementation of health capacity strengthening programmes in Africa in general and user fee exemption for caesarean section births in Burkina Faso, in particular [29, 65]. 27Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Critical investments in health services, including adequate infrastructure, drugs and supplies, and support for staff in the lower levels of the health system [29, 79, 86], plus schemes that provided funds for procurement of drugs and equipment for health facilities, were essential in sustaining community health insurance schemes in Uganda [26]. In Zimbabwe, a top-up allowance for health personnel and provision of medical supplies and health stands motivated health workers to stay in employment [69], whilst the provision of an enabling practice environment motivated PHC facility managers in the implementation of PHC reforms in South Africa [86]. A user fee exemption policy for caesarean section births in Benin increased health facility use for such cases [29]. At the organizational level, management capacity, access to agile information systems, autonomy in resource allocation [65], support systems for supervisory visits to clinics, provision of medical equipment, training of health care providers [37] and management of supply chain systems [64] were highlighted as key success factors in health systems’ strengthening programmes in the African Region. Robust information systems The existence of robust information systems and data that help to monitor progress in the implementation of change programmes were seen in the literature as crucial to the success of such programmes. Key evidence exists on the importance of information systems and data at the national level. For example, the presence of robust information systems played a crucial role in assessing mental health care in five francophone countries [43] and in pilot testing of health care improvement initiatives and scaling up of health system strengthening interventions in Ghana [121]. Also benefiting from the presence of information systems was the creation of a dialogue platform for broad exchange and sharing of knowledge among actors, ensuring more use of synthesized knowledge in policy-making process [97]. In Tanzania, the use of iCHF digital systems during the implementation of health financing reforms made it possible to monitor daily health facility enrolment without having to travel to the districts [81]. The existence of robust data was essential also in pivoting national and subnational level improvements in health systems in Europe and central Asia [7, 35, 99, 105]. The use of a pool of financial data in five central Asian countries was important in guiding reform processes deemed necessary to drive financial and health systems reform [99]. It is important, though, to emphasize that at the health facility level, the focus was not mainly on the presence of information systems but rather of systems that were integrated and easy to use, since that would determine their acceptability and consequently their use in delivering the changes required in service delivery. Acceptability of such tools depends mostly on their ease of use, perceived benefits to the user and prior training [32, 104, 105, 107, 108], as in the case of Greece, where the relatively easier to use technologies were more widely accepted and adopted than complicated types. Availability of robust information systems such as health management information systems, the District Health Information Software etc. was shown to be key in tracking progress. In addition, adequate skills for collecting, retrieving and using data for decision-making and ensuring that the information remained at the district level for ownership and integration with routine service delivery were emphasized as important factors in the implementation of change programmes [119]. Success was noted in change reforms that prioritized effective communication in both upwards and downwards directions, ensured regular feedback and used channels that were easily accessible to all. This was evident in the implementation of PHC reforms in South Africa [54]. Governance of operating structures and stakeholders Governance of operating structures and stakeholders and regulation of institutions were considered in the literature as important factors for successful implementation of change programmes. For example, the presence of a well-established system for regulation and accreditation of nursing education in Malawi was critical in the success of nursing education reforms [66]. There is evidence suggesting that whilst good regulation of the private sector was responsible for Cuba’s stronger and efficient health financing system with effectiveness and equity factors, compared to that of Egypt [111], in Chile it was a strong and robust system of governance and regulation at the national level, especially for the private sector, that was responsible for relatively better neoliberal reform outcomes than those of the other LAC countries, such as Argentina and Brazil. 28 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Regulation of service providers and accreditation of health facilities were seen as important in the implementation of change programmes for quality of care [122]. Protocols and guidelines standardizing service delivery were considered as key elements of the governance and operating structures needed to aid the implementation of change programmes at both the national and subnational levels. For example, a manual developed by the Ministry of Health in Albania provided instructions for diabetes screening and follow-up care during the introduction of a programme for the expanded screening for the disease [46, 102, 107]. Also in Albania, telemedicine procedures developed at the national level allowed for effective coordination of patient care between health facilities [33, 107]. Systems for promoting accountability Related to the governance of operating structures and stakeholders is the establishment of systems for promoting accountability. At the national level, having non-state actors and independent organizations established to ensure accountability were key in this regard. In India, non-state actors provided checks and balances in health planning, budgeting and implementation of activities at all levels of the health care system [31]. The role of accountability and transparency in change management in health systems was also highlighted in the South-East Asian Region. For example, some countries in the Region had developed health care coverage tracer indicators to monitor progress and accountability at the community level [31]. Successful reforms at the health facility level were seen to have been supported by systems that allowed for community and lower level stakeholders to regularly evaluate higher level health system entities. This is perhaps a reflection of the fact that the current PHC system’s bottom-up accountability approach is inadequate. A peer review system based on a bottom-up approach was used in Ethiopia in cultivating a culture of accountability [51] and in Kenya in assessing the effectiveness of the community health strategy on health outcomes [74]. Mainstreaming of UHC in national development plans Mainstreaming UHC in national development plans was one of the ways in which government systems were used to support reforms. Such systems were essential in assessing national level performance and the indicators relevant for the SDGs [123]. For instance, having national UHC institutional frameworks was shown to work in India and Thailand, where a specific department linked to various government ministries and departments was created to coordinate UHC [31]. In the European Region, the development of monitoring systems that included indicators to measure outcomes at different levels played a key role in health systems improvement at both the national and subnational levels [60, 106]. 3.2.4 Skills Skills development through on-the-job training, mentorship with a focus on leadership and managerial training, alongside technical training, while at the same time ensuring the right skill mix, are useful mechanisms for building capacity to support change and improvements (Figure 9). In the 7S model, skills include factors related to competences, knowledge, capabilities and the skills the employees should possess to perform and fulfil their everyday duties and responsibilities [124]. All organizations need to assess the skills required for effective implementation and reinforcement of new policies, strategies or organizational structure. For effective change in health systems, the literature review indicates that attention to skill development, skill mix and modes of skills transfer is needed at different levels of the health service delivery system. 29Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Figure 10. 7S skills mechanisms that enable successful change management. Skill development Some of the factors identified during the review as required for change at the national level included benchmarking skills and collaborative learning; networks within and outside the organization that can be relied on to rally people for the change; modes of enhancing skills, whether they are on-site or off-site arrangements, mentorship arrangements, and leadership and management skills. The appropriateness of the core competences and the potential skill gaps among the implementing team were key factors in determining the success or failure of an intervention or change reform. In trying to understand why and how LMIC health systems learn from one another from the literature, we found benchmarking and collaborative learning tours to be deemed useful mechanisms for international learning typically early in the policy development process. Capacity building through formal training or on-the-job experience also played a role, with countries mainly training their personnel abroad in the initial stages of the reform programme but gradually developing local capacity and relying on in-country staff with embedded knowledge of the health system, which was the case in Ethiopia and Rwanda [16]. Mentorship and coaching facilitated the successful implementation of the PBF performance-based financing programme in Zimbabwe, where facility managers required innovation skills, power to exercise autonomy and team-based decision-making skills in their dual roles [23]. Inter-professional education was recognized worldwide as a key component in strengthening health care and overcoming the challenges in the practice, as students were taught the necessary skills to become part of the collaborative, practice-ready health workforce [66]. Skill mix The literature reviewed suggests that digital health skills and data use competence among policy-makers at the national level, district managers at the district level and supervisors at the subnational level were key drivers in the successful health system reforms [88]. For example, adequate technology capacity was identified as a key ingredient in deploying e-health to address the health needs of vulnerable and underserved population groups in the Caribbean, Latin America and South-East Asia [88, 110]. 30 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Strong managerial and leadership skills at the national level were singled out as a prerequisite for the successful implementation of reforms in health systems. For instance, the accomplishments in the PHC reforms in Costa Rica that led to dramatic improvements in health outcomes were partly credited to the presence of strong leadership [116]. It is argued that strong leadership made it possible for the reformers to implement their vision, consolidate PHC functions under the single entity of the Costa Rican Social Security Fund (CCSS) and commit human and financial resources to the initiative, including re-allocating staff from their routine work to the technical working groups. Another example is the national expansionary health sector reform in El Salvador, whose success was attributed to the leadership and, more importantly, the technical, diplomatic and networking skills of the Minister of Health and the country head of the Pan-American Health Organization at the time [125]. Modes of skills transfer The literature review highlighted the importance of digital, managerial, mentorship, supervisory and data use and analysis skills, plus collective skill sets. The review indicated that subnational levels were successful in implementing health reforms when they were adequately staffed with a mix of cadres with skills in mentorship, leadership, data analysis and use, collaboration, partnership and supervision [7, 14, 34]. Adequate capacity and capability at the operational levels of the health systems were identified as the core driver of health system changes. Acquisition of the required skills was addressed through ensuring due diligence in the recruitment processes, provision of tools and guides to the implementation personnel, on-the-job experience, supportive supervision and mentoring, promotion of resourcefulness, and efficiency [20]. In designing and conducting capacity building activities, ensuring context-specific training that mirrored the real-life challenges unique to the national health system was vital, for example in the nursing education reforms in Malawi [66]. Furthermore, Malawi’s training institutions collaborated closely with the Ministries of Health to ensure the alignment of the training and the required skills, conducted on-site capacity building to reduce costs and prioritized local actions for the change. Learning was shown to occur successfully outside formal training through peer support, on-the-job training, coaching and mentoring. This was the case in the development of health capacity strengthening programmes in Africa [23, 65] and the implementation of CHW programmes in South Africa [72], where participatory approaches and action-training programmes were used. The innovative training methods shown to influence change incorporated systematic problem-solving tools, coaching sessions, facilitation of experience sharing and learning collaboration as interventions in the improvement off performance of district health systems. The cases in point were the implementation of HRH reforms in peri-urban Zimbabwe [126] and the use in South Africa of clinical decision support tools to support health care providers with clinical expertise and skills in chronic disease management [127]. The need for managerial skills building in addition to clinical and specialist skills, as well as educating health workers on the reforms being implemented to ensure success at the subnational level, received great attention in the literature. Support for post-basic training, including facilitated enrolment in the training, paid study leave and tuition fee waivers, were seen as useful strategies for success, as demonstrated in the implementation of national policy interventions to impact local health care worker’s systems in Zimbabwe [69]. The literature indicated that attending training not only improved knowledge and skills of health workers but also motivated them to work even harder, as the opportunities gave them the chance to step away from the stress and burden of their heavy daily workloads [69]. 3.2.5 Staff Staff capacity increase through innovative practices such as the use of mid-level cadres and task shifting supported by professional cadres, plus seconding of health workers provide the opportunity for filling staffing gaps while ensuring both financial and non-financial incentives are in place to motivate health workers (see Figure 11). Having a robust health workforce information system is useful in staff planning and recruitment processes. 31Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Figure 11. 7S staff mechanisms that enable successful change management. According to the 7S model, the term staff can mean the people, the human resource management interventions or any human resource-related factors and processes used to develop managers, socialization processes and ways of recruiting new workers to any organization [124]. Several factors were identified through the literature review as affecting staff at various levels and requiring change for effective health systems reforms. The key factors driving change at national, subnational and district levels included proper skill mix; adequate staff numbers; distribution of staff for success; recruitment, remuneration and compensation arrangements for staff; performance-based evaluation for staff; involvement of technical staff at bedside and managerial staff at national level; and retention strategies for maintaining staff, including motivational and financial or non-financial incentive options. Staff numbers Having the right number of staff with the right skills to support the different aspects of the change reform was seen as important in ensuring success. African countries faced with high health workforce shortages adopted a number of strategies to address this chronic problem. For example, a number of governments implemented a series of reforms to improve the distribution of health workers in rural and remote areas through the introduction of incentives such as allowances for housing, transportation, hardship and education [1, 2]. Also, policies to use CHWs to improve access to health services in geographically isolated regions were used as was training of non-physician clinicians for emergency services, for example in India, Mozambique and Sri Lanka [63, 75, 78, 103]. Staff performance The performance of health workers was shown to depend mainly on their production, distribution and retention [64]. For instance, the successful implementation of a structural adjustment program in Burkina Faso was attributed mainly to the significant recruitment of health workers in large numbers to support the change [120], while in South Africa, professional nurses were appointed as subdistrict managers specifically responsible for the implementation of a national CHW programme in Gauteng [72]. However, in Ethiopia, high turnover of staff and donors at the Ministry of Health headquarters and the lack of technical skills at the national level resulted in weak ownership of the PBF initiative, while in Sierra Leone such challenges led to the eventual discontinuation of a similar initiative [21]. 32 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 There was evidence in the literature to suggest that personnel remuneration and evaluation systems that generate results are associated with efficiency gains in health systems reform. For example, Chile and Uruguay, the countries with the most efficient health systems in LAC, adopted some degree of pay for performance policies involving reimbursement of some expenses for primary health care personnel in the public sector [77]. Furthermore, policies that allowed the involvement of families in the care of their relatives proved to be effective in addressing mental health outcomes where staff shortages were high. For instance, the Ministry of Health in Chile implemented policies that ensured that people with mental health issues and their families played a key role in preparing mental health plans for the ill family member [40]. In the European Region, the subnational levels were regarded as critical in coordinating successful staff contracts. For example, Bosnia and Herzegovina restructured its PHC system with physicians being assigned to local municipalities and with the change being driven by performance-based contracting. The results were promising, and monitoring and reporting on the performance of the physicians was made easier, as the subnational level was closer to the districts than to the national level [5, 45]. Staff motivation The literature indicated that at the subnational level the retention strategies for staff included motivation and financial and non-financial incentive options. A number of governments implemented a series of reforms to improve the distribution of health workers in rural and remote areas, for example the introduction of incentives such as allowances for housing, transportation, hardship and education [64]. In addition, ensuring proper skills mix and distribution of staff for success were key change factors. Health sector reforms and health systems strengthening required adequate and skilled health workers from different skill backgrounds to support monitoring, evaluation and staff supervision and mentorship in district level interventions [14, 69, 75, 127, 128]. The initiatives included involvement of support cadres in human resources, finance and information to support the operational and administrative functions necessary for change, development of new processes such as the integration of the outreach team’s monitoring and evaluation system into the routine information system. As drivers of the achievement UHC, staff motivation and engagement require variation. This can involve activities such as team building and financial incentives, as these have been shown to translate into attraction of professional values. For example, in several European countries, the shift towards PHC required task shifting and employee incentives, such as holding summer activities [6, 59]. There was evidence in the literature review to support the use of interdisciplinary teams to enhance team building exercises. Wedel in Canada found that visioning exercises helped to build trust among teams [5, 7, 46, 104]. Having contracts directly with subnational levels, meaning shifting from salaried employment, was reported to have been successful in some regions. In Bosnia Herzegovina, during the restructuring of the system for PHC physicians were given performance-based contracts from the local municipalities, and the results were promising [5, 45]. Human resource management’s information system An information management system for health human resources, consisting of a computerized database and an observatory with up-to-date information on the numbers, skills, calibre and cadres of all health care workers at each health facility in each district and province to guide the HRH planning process [128] was regarded as an effective change tool in health systems reform. Staff recruitment and deployment A number of governments have implemented reforms with incentives such as allowances for housing, transportation, hardship and education [64] to improve the distribution of health workers in rural and remote areas but with their coordination at the subnational levels. Some reforms even have included fresh recruitment of health workers within the project period, for instance in South Africa during the implementation of PHC services towards UHC realization [129]. The success of the recruitment and deployment processes was linked to the complementary efforts among the health ministry, the local board and donor partners [69]. Other cases are from 33Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 NGOs and faith-based organizations [119]. Where new recruitment was not possible, wide use of task shifting to address health worker shortages, particularly the use of CHWs for remote and inaccessible areas, was useful [57, 126], as was short-term contracting as an immediate strategy for addressing shortages [71] and the seconding of health care workers to rural areas. High calibre professionals needed an experienced management team to provide the opportunity for success in the transformation. Staff development The review exposed the importance of ensuring adequate capacity at the operational level, for example through refresher training, and of digital, managerial, professional/clinical, and data use and analysis skills. It indicate that capacity strengthening at the lower levels of the health systems was carried out mainly through training on clinical skills. For example, a service availability and readiness survey in Nigeria found out that two thirds of the PHC centres had staff who had received pre-service or recent (within the previous two years) in-service training in at least one of the areas of immunization, HIV, family planning and malaria services [50]. Furthermore, training institutions were shown to support the successful implementation of health system reforms. For instance, in scaling up nursing education in Malawi, the health workers involved highlighted the fact that improving educational capacity through enrolment in the nursing faculty was one of several strategies used to address a complex human resource problem and it contributed to the introduction of deliberate continuous professional development programmes for nurse educators [66]. In Tanzania, although most of the training at the level of professional health workers focused on clinical and technical skill building, training in management skills and approach to customer care changed the way health workers perceived their work during the PBF training [101]. Furthermore, the literature review showed that managers at the district level had limited skills in financial management, planning and leadership that are more prominent at the national level [12]. With decentralized health systems, these skills are very critical at the district level. There are calls to balance education in applied technical skills with development of more abstract modes of thought in management and problem solving [68]. Innovations to address staff shortages The literature reviewed supports the need for telemedicine skills at the district level to scale up services to the primary health care level, geographically challenging locations and rural areas. For example, the states in India had advanced technology to support lower level health facilities with specialized services [88]. However, when introducing digital innovations in hospitals, the intended users need to be fully engaged as they are a part of the system and also need to understand how to solve basic challenges with the technology [34, 60, 102, 108]. At the district level, factors such as engagement of non-health professionals to work as CHWs, task shifting for staff as a mechanism for plugging HRH limitations, regulation of practice and staff motivation and engagement were identified as change drivers for health system reform. While successful reforms call for a skilled, diverse and adequate workforce, evidence from national and subnational levels highlights the increase in the recruitment, task shifting and skill mixes of health workers. But evidence from the lower levels of the health system did not reveal these changes, other than the recruitment of CHWs and engagement of non-health professionals to work under the supervision of professional health care workers and the increase in the density of nurses/midwives in urban PHC centres, as was the case in Estonia, India, Nigeria, Sri Lanka and Thailand [5, 48, 50]. With regard to task shifting and engagement of non-health professional workers, evidence suggests the need for countries to strengthen regulatory processes relating to the scope of practice to ensure health care quality and safety of patients [48]. 3.2.6 Style Style in the form bottom-up, facilitative, transformational, collaborative, multifaceted and context-specific leadership to promote positive change was considered essential for reform success. But the review highlighted the urgent need for leadership training across all levels of the health system and for coordination of partnerships and collaborations (Figure 12). 34 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Style is considered a core element in facilitating change and achieving results through leadership that ensures the efficient mobilization and utilization of the health workforce and other resources. Leadership has increasingly been recognized as a critical lever for health system development. Leadership in health, as in any complex system, is necessary not only to guide and enable the different parts of the system to work towards common goals but also to enable the emergence of a learning, creative and adaptive workforce. Figure 12. 7S style mechanisms that enable successful change management. The enablers of the effective application of style in change management identified in the review included political goodwill and politics of decentralization, leadership capacity and supportive supervision [130, 131], financial and administrative autonomy [80, 132], clear delineation of leadership and managerial roles [131, 132] and stability of leadership [132]. Leadership style Recognizing which type of organizational changes are necessary for each situation can help in successfully applying the appropriate leadership style. Leadership types are categorized based on hierarchy of power and the style a leader adopts. Hierarchy of power • The bottom-up approach was shown to be the most successful and essential when the situation required the mobilization of grassroot effort and support. The literature review showed that this approach builds trust, interest and a shared sense of responsibility in a team. It is, therefore, paramount that organizations move from command-and-control leadership, which is dominant within the frontline service provision sphere, to an approach that is based on networking, cooperation and reciprocity [58, 86, 119, 125]. Participatory leadership was also shown to have an overall effect of spreading motivation and positive staff attitude by allowing collective tackling of problems [130]. Clarity in the roles of employees and the lack of conflicts in the units were considered important for retention of nursing staff [133]. Added to these was the presence of an 35Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 environment with effective upward and downward communication, assurance of regular feedback and use of channels easily accessible to all. This was manifested in the implementation of PHC reforms in South Africa [54]. • The top-down approach is not favoured, as it results in a lack of ownership of a change and resistance to it. This approach may be necessary in certain situations where the decisions to be made have diverse interests from stakeholders and reducing time spent on trying to reach a consensus is essential. A recent study in the United Kingdom demonstrated the necessity of the top-down approach in deciding on which of the hospitals were to be used in reconfiguring stroke services [35]. In Albania, the approach was employed by the Ministry of Health to strengthen preventive services for chronic diseases [60]. A mixed approach depending on the type of decision that needs to be made can be adopted. Leadership styles When used effectively, different leadership styles were found to have a positive association with high levels of patient satisfaction and reduction in adverse effects [133]. The literature review found that effective leadership had an indirect impact on reducing mortality rates by inspiring, retaining and supporting experienced staff in hospitals [133]. • Transformational leadership is also referred to as shared, distributed, participative, facilitative or democratic leadership. It focuses on empowering staff members to be in the forefront of the change process, particularly in the initiation of change. Transformational leaders seek ways to share the leadership process with employees from across all positions, and they typically have the ability to inspire confidence and staff respect. They communicate loyalty through a shared vision that transforms a health care organization for better outcomes. This style was considered to be associated with positive outcomes [1, 7, 29, 32, 34, 43, 58, 80, 106, 130, 132-134]. In Gambia, democratic style of leadership was hailed by subnational leaders as beneficial in understanding what was happening on the ground and in tapping into new ideas [132]. Distributed forms of leadership were displayed during the implementation of the user fee exemption policy for caesarean section births in Benin, where district health committees, including community representatives, played a leadership role in the management of the hospital, which was considered by the local communities as their hospital [29]. The literature review showed that employing a transformational leadership style encourages employees to feel appreciated and motivated [132, 133]. This was noted in Gambia, where health managers and leaders contributed to the working and living conditions of health care workers, which in-turn had an impact on reducing staff attrition [132]. In particular, transformational leadership was shown to result in better patient outcomes, for example for 30-day mortality, safety injuries and pain management. This leadership style influenced these through promotion of skills, increased staff stability and reduced turnout [133]. • In transactional leadership the leader acts as the manager of change and has exchanges with employees that lead to an improvement in the production process. This style views the relationship between health care managers and their staff as transactional and considers that by accepting their positions, employees implicitly agree to obey the leadership and they are paid for doing the work they were hired for. Transactional leadership was shown to be beneficial in improving patient satisfaction in acute care and homecare settings in Canada, where nurse managers, employing a transactional leadership style, introduced human resource reforms, including reviewing staff mandates and improving nurses’ working environment [133]. • Autocratic, authoritarian, authoritative or coercive leadership adopts a coercive approach. It is used when defining a vision for an organization and instilling a sense of discipline. An autocratic leadership style is considered ideal in emergency situations, as the leader makes all decisions without taking into account the opinion of the staff [132, 133]. Authoritarian leadership was seen in Burkina Faso during the decentralization of health services, where district health officers were not given the leeway to respond to local 36 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 health authorities and could only refer them to the national level. This led to the lowering of responsiveness, efficiency and transparency in the health services [120]. • In laissez-faire or non-interfering leadership, the leader passes on the responsibility for decision- making to subordinates and assumes a minimum of initiative in administration affairs. The leader gives no direction and allows the group to establish its goals and work out its problems [119, 131,132, 133]. The results seen from this type of leadership are mixed. In Gambia, the chief executive officers in certain hospitals received minimum supervision from the district health managers in expanding the reach of clinical services and establishing bilateral partnerships that increased the working capital of their facilities [132]. In emergency departments in America, this approach led to decreased patient satisfaction [133]. Enhancing of teamwork Effective leadership has the ability to drive persons towards a common goal and ensure equity among diverse groups. The literature review identified incidents in which teamwork was enhanced by the existence of a formal platform in which to meet and take collective action for resource mobilization and joint learning [1, 43, 66, 81, 130–132, 135]. For example, in the implementation of adolescent reproductive health interventions in LAC, establishment of strong bonds between young people and their teachers, health professionals, parents and friends contributed greatly to the effectiveness of the programme [135]. In Tanzania, strengthening collaboration with politicians, religious leaders and NGOs was fundamental in instituting governance reforms [81]. In Nigeria, hospital managers encouraged teamwork and participation of staff in planning for health sector reforms [83]. Building strategic alliances and partnerships The role of leadership at all levels of health care was underscored by the nature of input required of leaders in the creation of partnerships. There needs to be an ecosystem that enables the participation of diverse actors and that nurtures debate. In the literature reviewed, leaders had the responsibility of identifying the partnerships that would be essential in achieving their goals and to define the roles of each partner. Private sector collaborations were required for improved health system performance. For example, in Gambia, Indonesia, Zimbabwe and five francophone countries, private–public partnerships were found to be essential for the success of change programmes [1, 12, 43, 69, 132]. In Gambia, subnational level managers considered building alliances with diverse stakeholders as a necessity in ensuring the mobilization of adequate resources and expansion of health care access and community outreach. Working in partnerships involved having regular planning meetings. The joint use of research findings by stakeholders to implement district-specific solutions was also hailed as a major strength [132]. Transcending cultural practices in health care delivery by use of special skills The integration of innovations into existing health care management practices requires strong leadership, owing to the incorporation of technological advancements in innovations among other elements. The review showed that to be able to navigate the technological advancements, considerable financial and administrative authority would be required [131, 132]. A study in Gambia demonstrated that hospital managers were able to start using information and communication technology for hospital records after they received the necessary guidelines disseminated by the Ministry of Health, but the process of this change was left at the discretion of each hospital manager. In reforming PHC in Sweden, hospital managers had the advantage of possessing entrepreneurial leadership skills that enabled them to be competitive and to show immense engagement in the health improvement work, which yielded success [6]. Champions of change emerged as crucial in rallying support for a change and ensuring its sustainability. In such instances, the decisions regarding the change process were made by those in the official leadership position, and it was important for such people to be charismatic [16, 21, 102]. For example, the Ministry of Finance in Zimbabwe was the key champion in the country’s political economy analysis of RBF [20], while in Sierra Leone the World Bank was the main driver of PBF adoption and implementation [21]. 37Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 In summary: • The leadership styles that were successful had in common the key principles of viewing the role as a collaborative, multifaceted and dynamic process requiring the leader’s engagement with individuals, teams and system level actors. • Leadership was successfully applied in building of teamwork and strategic partnerships, retention of human resources, improvement of the quality of care and patient satisfaction, and identification of champions for change. • Leadership development can be supported by research to demonstrate the interaction with specific political, socioeconomic and cultural contexts to identify opportunities for health systems strengthening by the effective application of style. 3.2.7 Shared values Shared values breathe life into all 7S’s by ensuring that the commitment to the change is shared and the values are espoused through community participation and promotion of equity, social justice and patient-centred approaches, as well cultivating a learning and knowledge sharing culture (Figure 13). Creating conducive cultures and collective corporate values for health system transformation is a key ingredient in the ownership and sustainability of change efforts. Organizations and individuals must understand the core values of their organization, which is important in defining the organization’s long-term goals and objectives. Shared values interlink with the other six change elements and is responsible for their propagation. Some of the drivers in the application of shared values that were identified in the literature included effective leadership [133], lack of individualism [34], ethics and professionalism [6] and supportive supervision [80]. Figure 13. 7S shared values mechanisms that enable successful change management. Ensuring community engagement and participation in decision-making Shared values were manifested in the engagement with the community, which was important for guaranteeing programme implementation success. Community engagement and participation leads to awareness creation, enhancing ownership and accountability of projects. Acknowledging that the voice of the community was important in decision-making on health ensured that services met the needs of users [2, 12, 39, 54, 70, 88, 96, 127, 136]. In Kenya, for instance, the active engagement of patient groups in policy development proved to be an effective tool in implementing new directives and guidance [39]. Other examples included the joint review of health policies by the Ministry of Health and health management teams in Eritrea to ensure community participation for the success of decentralization efforts [70]. 38 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 A culture of accountability ensures that organizations and individuals have adequate procedures and processes by which they justify and take responsibility for their actions. Accountability ensures that there was proper use of resources and that quality is maintained at the same time in the provision of services [12, 28, 51, 85, 88]. In Kenya, during the recruitment of senior public servants for the decentralization process, public participation and accountability assurance through dialogue and consensus building were critical [85]. Relationship accountability was viewed as a key ingredient in reinforcing positive supervisory relationships during institutionalization of financial management reforms in South Africa [28]. Shared understanding and commitment A shared understanding of the required change and what it involves is critical in inclusive problem definition and providing solutions to problems. It ensures that both the implementers and the beneficiaries approach the solutions and implementation with the same perspective and there is better likelihood of success. There was evidence from the literature to suggest that the relatively higher levels of effectiveness, efficiency and equity of the health financing system in Cuba compared to the Egyptian system to some extent was explained by the relatively better shared understanding and the definition of the challenge in Cuba [111]. The shared commitment and motivation in the implementation of the CHW programme in a province in South Africa were evidenced by how the CHWs came together and discussed their role with pride, valuing the opportunity to make a difference in their communities [72]. A culture that continuously strives to improve health care is fundamental in driving employees towards a common goal, and hence better health outcomes [6, 105, 115]. Respondents in Europe valued a long-standing culture of quality improvement and attributed its linkage to change as a contributing factor to the success in health reforms for ensuring integration of health services [105]. Development of collaborative networks and positive relationships with partners Shared values were shown to be critical in developing and maintaining partnerships, which were important for guaranteeing programme implementation success. It is paramount that organizations utilize the power of partnerships to actualize their goals. The literature review showed that collectively identifying, participating in and helping build partnerships at all levels allowed joint problem solving [16, 43, 80, 97, 110, 136]. In Tanzania, success in implementing a community health financing programme was associated with supportive supervision, constant encouragement from health staff and frequent communication between health managers and community members [80]. Organizations that employed multisectoral collaboration as a guiding principle in their work operations were successful in achieving positive health outcomes for example in tackling the social determinants of health. For instance, there was shared understanding in Cuba of the channels to health care improvement, which were considered to be similar to equitable investments in other sectors, in particular in education, housing, water and sanitation and improved traffic regulation. The shared understanding was based on the fact that health care solutions were multisectoral necessitating a paradigm shift. An example was the framing of the stunting problem, which was now seen as not just as a feeding challenge but a problem needing multisectoral preventive action delivered in an integrated manner involving all the stakeholders [98]. For multisectoral collaboration, the roles of each player had to be clearly defined and the individual and organizational benefits of participations elaborated well. Propagation of a learning, knowledge sharing and adaptive culture The use of shared language and information was highlighted as influential in producing significant progress in providing ideas and facilitating the transfer of evidence and leaning for health system change across many countries[5, 6, 16, 34, 97, 115, 116] . A culture that promotes readily sharing of knowledge and demands data in decision-making has been proved to be successful in implementing change. In the Netherlands, all professionals participating in a project implementing outcome-based quality improvement in heart centres committed to share patient information with referring nurse physician teams, and that led to the successful implementation of a pilot project [115]. Demand for data was noted in Sweden during the institution of primary health reforms 39Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 at the local level, where performance measurement data formed a substantive agenda item in the different settings, such as staff meetings, morning gatherings and weekly newsletters [6]. Shared values were also seen in the adaptation of regional and global best practices to the unique nuances of the local sociocultural and political context of stakeholders. In Cost Rica, PHC reforms leveraged the core values of stakeholders and ensured that promising regional and global practices were adapted to the cultural, political and economic contexts of the stakeholders [116]. Subnational health managers in Gambia also noted that global health initiatives and global policy declarations such as the Alma-Ata Declaration on primary health care provided the impetus for the reform of the delivery of community health services [132]. Ensuring equity and social justice for all Employees collectively should live the values of providing quality health care for all. It was demonstrated in the literature review that ensuring equity for all, and especially for the most vulnerable and needy in the society such as orphans, the elderly and people living with disabilities, was important in guaranteeing the successful performance of health systems [6, 26, 64, 82, 117]. Equity also considers ethnicity, religion, physical accessibility, decision-making, gender and autonomy and respect of patients or clients. This involves giving clients the opportunity to express their needs and having their interests in the forefront [82]. An assessment of the performance of health systems in Uganda after decentralization indicated that all the health workers took clients’ needs seriously and tried to incorporate them in the treatment plan, which resulted in the greater patient satisfaction and successful health outcomes. Equity can be applied by ensuring that data are used to drive decisions and that all relevant stakeholders are involved in the decision-making process. In Rwanda, social justice practices allowed poor people and people living in extreme poverty access to primary health care services [117]. In Sweden, it was evident that in the build-up to the integration of health services, members of staff were trained in social justice and had a clear vision of the goal, such as the need for shortening the waiting list. Furthermore, a patient-centred approach ensured that the needs of patients were at the forefront in designing the implementation of policies and reforms, as was seen in Sweden, where managers overruled the financial logic of the reform to safeguard patient needs and reinforced professional values [6]. This entailed putting the patient first [6, 19, 23, 54, 96]. In Ghana, a shared decision-making approach involving patients and physicians led to increased patient satisfaction and in some cases more effective clinical care [96]. In summary: • Successful organizational change in this era of rapidly changing technology, globalization, economic uncertainty, demographic transition and pandemics begins with, and depends on, changing the individual consciousness of employees in health care. • Shared values were applied in fostering community and multisectoral engagements, enhancing quality, ensuring adaptation of best practices and fostering movement towards patient centredness. • More research is needed to clearly demonstrate the role of values in change management, especially at the national and subnational levels. 40 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Conclusion and Implications 41Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 4. Conclusion and implications 4.1 Conclusion This literature review focused on the attempts to provide plausible change management strategies that could help countries move their health systems to change and improvement, which would contribute to the attainment of UHC, health security and coverage of health determinants. The review shows that investing in all the building blocks of health system development is crucial in achieving these triple aims. The building blocks in question are (i) the delivery of effective, safe and quality personal and non-personal health services with appropriate medical products, vaccines and other technologies, (ii) adequate and fair health financing, (iii) a well-performing and motivated health workforce, (iv) health information systems, (v) leadership, and (vi) governance. The lessons from this literature review will contribute some key lessons to the efforts for the achievement of UHC in the African Region. The majority of the health service delivery reforms reported in this review focus on strengthening and improving PHC through multiple approaches, including disease prevention and health promotion. Linked to this is investment in the health workforce, largely involving the use of CHWs to reach rural and remote areas, alongside programmes aimed at linking communities to primary health facilities. There was literature on the need to address inequities within communities in the provision of care, being mindful of the vulnerable populations, plus calls for a stronger role for the state in the stewardship of the health system, which were rooted in the broader political struggles for social, economic and health justice. While there is a massive push for the attainment of UHC, there isn’t much focus on the how the social determinants of health and community participation influence that journey. Addressing the determinants of health calls for engaging beneficiaries as active participants in the dynamic co-production of health. This review captures the lessons on the value of co-producing health and having shared goals among all the actors across the system, including the local communities. This can be fostered by, for example, inviting experts in the development and design of the change strategy, applying evidence-based standards and policies in change strategies and involving individuals and their families when designing change programmes. Health determinants influence access to and effectiveness of health care coverage, and so other sectors should be involved in health, working in close collaboration with, and under the stewardship of, a mix of public and non-public providers. However, multisectoral collaboration is rarely adopted in change and reform initiatives, with the very few efforts only recently seen with the COVID pandemic. While this literature review calls for better integration of the structures and systems for the management of change and reforms, the suggestions on how to achieve health security include stronger partnerships between macro and micro facilities whilst at the same time building a system for ongoing learning and improvement. Health preparedness for acute shocks requires having the right information via health information systems and strengthening the capacity of the health workforce for data collection, analysis and use. Health systems also require the strengthening of the public health infrastructure, building up of the health care workforce capacity and, most importantly, recruiting, educating and retaining more workers. These should be routine investments made in the system to better prepare for shocks and disruptions. This review has raised the issue of the invaluable role of human-centric strategies that put people first by ensuring shared commitment to change and having mechanisms in place that address transparency and accountability. The need for strong and facilitative leadership, collaborative decision-making and information sharing among stakeholders has been highlighted by this review as critical to successful change management. All these considerations can support the adaptability and flexibility underpinning health security for resilient health systems. 42 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 4.2 Policy implications We see various implications from the literature review on the use the McKinsey 7S model to understand and guide health programme change design, implementation and sustainability. As these implications are drawn from both successful and unsuccessful health system reforms and from countries with differing contextual settings, caution ought to be exercised in determining what might be applicable in a particular health system. Nonetheless, there are cross-cutting lessons and guidance for instituting change and reforms that emerged, including those discussed below. 4.2.1 Strategy The evidence gathered from the literature review shows strategy in the context of the McKinsey 7S model as applied in critically thinking about the quality of the strategy content and strategy leveraging, along with the policies in existence related to the planned change. It is also used as a tool for ensuring stakeholder mobilization and engagement early in the design and implementation phases of the reform and as a basis for defining the financing and capacity needed to drive the change. To successfully design and implement a strategy for change and reforms, policy-makers within African countries could consider the following thoughts. • Developing a coherent strategy to guide the change process is critical and requires the early involvement of subject matter and government experts and clear goals and targets, but also allowing for flexibility to match emerging contextual changes. • A strategic plan espousing a compelling vision is an important tool for securing buy-in from all stakeholders and commitment to the implementation of the reform through having a clear communication strategy and accommodating personal initiatives at all levels, from the government to the local level. • An important successful strategic approach involves embedding change in national policies and strategies, annual work plans and action plans, as this addresses the unique needs of the different stakeholders, promoting the reform and minimizing resistance to it. • A successful strategy can be used as a planning, monitoring and evaluation tool through which benchmarks for performance and accompanying incentives are determined to secure accountability in the implementation of a reform or change programme. 4.2.2 Structure The literature reviewed suggests that the structure element of the 7S model was manifested in the implementation of change programmes through process integration, accountability through inclusiveness and transparency, decentralization of functions, regulation of programmes and stakeholders, and garnering of institutional support. In line with this, policy-makers may focus on deploying any or a combination of the options below, aligning them with the other 7S elements: • Integrating functions such as human resources, health financing and service delivery etc. so that they are embedded in any change programme. This can happen at the national, subnational or health facility level and could also include cross-sectoral integration, where outcomes are derived from the work of different sectors. This can be the case especially at the subnational level, where outcomes are more likely to reflect the inputs from different sectors that operate under the same governance structure at that level. At the subnational level, the transformation of vertical practices and procedures into an integrated organization can support better interaction across functions, levels and sectors for better outcomes for the change programme. • Embedding change programmes into existing structures reduces duplication and transaction costs. Alongside this is role definition for the various levels of the health system involved in the change programme and the setting up of a robust coordination mechanism to ensure synchronization and avoid duplication and redundancy. • Establishing structures at all levels that will ensure that the implementation of the change happens as expected and allows for deep community and stakeholder engagement using a bottom-up approach to ensure accountability. This is important for transparency and accountability and obtaining buy-in from relevant stakeholders. 43Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 • Prioritizing decentralization of functions by equipping frontline managers with translating and adapting capacity. Embed the change programmes within organizational structures and systems and establish regulatory bodies that carry national level authority but are present at either the subnational or health facility level to oversee the implementation of change programmes. • Interest policy-makers in creating supportive and operational environments that are conducive to and will support the implementation of the change programmes. 4.2.3 System The literature reviewed suggests that the role of systems in the implementation of successful change programmes or reforms is seen in the form robust financial management and key support systems, robust information systems, governance of operating structures and stakeholders, systems for promoting accountability, and the mainstreaming of UHC in national development plans. Policy-makers can implement a combination of the following prescriptions in a manner that is appropriate for their context: • Develop robust financial management and key support systems related to the capacity of the system to mobilize local resources and efficiently allocate, track and account for the resources in the implementation of the change programme. • Build robust information systems for the surveillance and monitoring of the reform inputs, processes and outcomes. It is important to emphasize that the focus is not merely on the presence of information systems but of systems that are integrated, easy to use and have in-built sustainability mechanisms to ensure that their use will be continuous, especially at the lower levels, where data are generated. Countries must prioritize their digital health strategy, governance, and institutional and operational capacity development, with priority being given to country ownership, sustainability and domestic financing. • Develop systems to regulate the operating structures and stakeholders in the reform programme in the form of well-established accreditation systems for the regulation of health staff and health service providers, especially the private health sector, as well as protocols and guidelines to standardize service delivery, particularly at the subnational and health facility levels. • Build systems that will promote accountability. This can be achieved through establishing operating structures and systems that allow non-state actors and independent organizations operating in the health sector to hold custodianship of the health system at all levels and have oversight of the use of resources. In addition, provide a peer review system based on a bottom-up approach to accountability. This will make it possible for the community and lower level stakeholders to regularly evaluate the higher level entities. 4.2.4 Staff • Consider innovation in human resources by, among other methods, approaches introducing a new cadre of non-physician health workers as a mid-level health provider supported by one or two multipurpose workers or CHWs. • Consider the use of digital health technologies and ICT platforms to ensure continuity of care through universal population empanelment, as well as civil and vital registration systems with linkages to health facilities. 4.2.5 Skills • Skills learning should go beyond formal training and include peer support, on-the-job training, coaching and mentorship, and countries should consider on-site skills transfer rather than out-of-facility training. • Prioritize health workforce’s acquisition of skills in leadership, management, financial management, digital health, data use, critical thinking and team building to enhance efficiency and productivity in the health workforce. 4.2.6 Style • Institute leadership training as part of the organization’s culture, targeting all cadres and levels of staff. • Employ a bottom-up approach in setting priorities. This is achieved by engaging the lowest level of employees in the change process from the onset. 44 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Confer substantial financial and administrative authority to subnational and health facility levels to ensure their autonomy. This can be achieved by allowing the two levels to be in charge of their budgets and staff deployment. • When bringing together diverse groups of people, use participative leadership, as it is the most ideal in driving the group towards a common goal. This will ensure equity among all parties and foster taking of collective responsibility for actions. • Before instituting a change, select champions of change to enable greater buy-in. To ensure success, select individuals who are charismatic and possess entrepreneurial skills. • Support leadership development through research to demonstrate the interaction of the programme with specific political, socioeconomic and cultural context. This can be carried out using qualitative research to identify opportunities for health systems strengthening through effective application of style. 4.2.7 Shared values • Create a platform for knowledge sharing. This could be a simple mechanism such as a shared social media platform or more complex mechanisms such as continuous medical education and conference attendance. • Clearly define the expectations for individuals and the organization to strengthen accountability. This is achieved by annual work plan development and reviews, service charters and employee appraisals. • Ensure community representation in all the activities. All activities regardless of how technical they are should include the participation of community members to ensure the interests of the users are taken into consideration in reforms. • Entrench quality improvement indicators in the overall monitoring and evaluation mechanisms of the organization. • Create a body of experts responsible for adapting best practices. This can be an ad hoc group that is called upon to provide advice on the best ways of adapting global or regional best practices. • Adapt a non-discrimination policy. This is achieved by spelling out the code of conduct for employees that endorses zero tolerance to discrimination and includes a statement on the repercussions. • Conduct research to determine the values held by staff that may be detrimental to the overall performance of the organization. The literature review indicated that interactions among the various elements of the 7S model often strengthen the mechanisms and drivers of a change. For instance, in order to achieve shared commitment to a change, the strategy development process will require stakeholder engagement early in the process; a transformative leadership style; advocacy for collective action, as well as shared values that incorporate multisectoral collaboration; engaging of community voice and values; and smart coordination of partnerships. However, that shared commitment to change can only work in the presence of supporting structures such as financial and information systems to finance the change and monitor its progress, governance, and the requirements set by the regulatory systems to ensure accountability and oversight over the stakeholders tasked with the change process. Change actors will be successful if they are available in adequate numbers, spread across all the levels of the health system based on their skills, and are of the right skill mix, which requires context-specific training using problem solving approaches and non-traditional, inexpensive methodologies such as on-job training, mentoring and coaching. Our interpretation of how various elements of the 7S model interact as leverage points for consideration by policy-makers and other system actors who are involved in health system change and reform across the world is shown in Figure 5. The emphasis in the description of the interactions among the elements of 7S model is not just on the relationships between the hardware and software elements of the model but across all the 7S elements. Most organizations often have in place the three hardware elements of strategy, structure and system, as these are perhaps much easier to identify, but the software elements of skills, staff, style and shared values are often forgotten. The software elements represent the organizational culture and values, which are more embedded in processes and are not easily identifiable. 45Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 From the literature review, the majority of the changes and reforms instituted by countries had guiding policies and strategies in place to leverage in the process of their implementation, as well as infrastructural and resource investments, and in some instances governance and operating systems. However, where change implementation was successful the hardware investments by themselves had not been enough and software elements also had been considered. This involved co-designing and co-creation interactions of various actors across the system, bottom-up leadership and investment in local champions to nature others, and capacity building not for just technical skills but also for leadership and management. Countries need to understand that even with brilliant strategies and great structures and systems, without recognizing the human element in health systems, including having adequately skilled and motivated staff who possess the necessary cultural competence to serve their communities, change is likely to fail. 46 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Recommendations for re-pivoting African health systems 47Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 5. Recommendations for re-pivoting African health systems The findings emanating from the literature review provide the basis for guiding policy-makers who are about to implement a new health care reform programme or those who are looking for ways to improve the outcomes of existing national, subnational or health facility reform programmes. We propose a systematic approach for adoption by policy-makers to ensure a good level of alignment among the 7S’s to support the implementation of reform programmes. To take concrete steps to rectify the shortcomings that may be identified during an assessment of a health care programme, policy-makers should consider the following menu of options based on the 7S model and supported by existing literature. For those starting a new reform programme, the following steps could be followed: 1. The situational analysis that precedes the formulation and implementation of the reform programme should aim to understand the role of the 7S elements in the success of the reform to be implemented. 2. The situational analysis should also seek to identify and determine the levels of the 7S elements that are considered important in the successful implementation of the reform. 3. The 7S’s seen as important in the success of the reform programme should be considered in determining its vision and objectives, given that they provide an idea of what is realistically plausible. 4. With the understanding of the 7S model and of which of its elements can influence the reform programme, policy-makers should come up with the vision and objectives of the reform and the necessary changes to be made across the different 7S elements of the health system, especially those elements that are relevant for the reform to be implemented. 5. Policy-makers can then proceed to implement the reform, including the relevant changes, to ensure alignment among the 7S’s and of the core strategies to be implemented in the reform programme. 6. The implementation of the reform programme should be monitored and evaluated to ensure that any shift among the 7S elements is noticed and the required change made so that that element can support the implementation of the objectives of the programme. To improve the outcomes of existing reform programmes, the following steps can be considered: 1. A status assessment to be undertaken of the relevance of the 7S approach to the successful implementation of the reform programme; 2. The determination of the current status of the 7S elements considered essential for the successful implementation of the reform programme; 3. A recalibration of the vision and objectives of the reform programme so that they are realistic and feasible in the context of the statuses of the 7S elements and the existing constraints; 4. Implementation of the relevant changes that will lead to improvements in the statuses of the 7S elements and the core strategies underlying the reform programme; 5. Monitoring and evaluation of the implementation process to ensure that any shift among the 7S elements is noticed and the required changes are made to ensure that the 7S elements can support the implementation of the objectives of the reform programme. 48 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Limitations 49Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 6. Limitations Most of the studies included in the literature review were case examples of change initiatives with a limited sample breadth and a lack of details on the research methods. The quality of the studies, therefore, was challenging to appraise, as reported information was inadequate. Generalizing the findings from such studies was difficult also when case examples were utilized. However, the studies included, which were of a wide range, demonstrated consistent commonalities across change principles and applications of change management models across multiple settings and change projects in health. Retrieving qualitative studies from biomedical databases was a challenge, since such studies are not widely published in the health area. A wide combination of search terms was used to optimize the search, plus grey literature and online resources were included to maximize the reach of the search and improve the results’ validity. Only English language literature was reviewed, and potentially relevant titles and articles published in other languages might have been missed. Where reforms were reported, mostly they had not been evaluated, hence it was difficult to judge the value added among their 7S’s. Nevertheless, the wide variety of studies covered on a reform can be associated with its success. The ultimate aim of every health system is to ensure healthy lives and well-being for all people at all ages. The WHO UHC framework for action identifies the areas for which countries need to prioritize actions in the impact, outcome, output, process and input domains. These provide the logical approach for planning and monitoring actions, allowing the countries to predict and attribute trends and achievements in health care. This review has been particularly instrumental in providing a menu of possible actions that countries can employ when deciding on and prioritizing the relevant actions for investing in both health care’s hardware and software processes and inputs. For example, we have demonstrated that to ensure the rational and effective delivery of essential health services, countries need to leverage existing policies, standardized guidelines and the processes for integration of disease programmes for wider health sector outcomes. In addition, to have motivated, productive and fit-for-purpose health workers requires training that goes beyond the technical clinical skills to include leadership and managerial capacity building, provision of financial and non-financial incentives, and use of digital health technology and ICT to support health workers for continuity of care. The range of actions needed to establish facilitative governance requires bottom-up, collaborative and inclusive leadership employing transformational and distributed leadership styles and creating a learning culture characterized by shared values among all the actors across the system. This review provides a menu of recommendations for countries to consider in managing large health system changes and reforms following the McKinsey 7S model to improve the outputs and outcomes of their health systems. However, the extent to which and how this can be achieved is subject to countries’ prioritization of these options taking into account their need, feasibility, cost-effectiveness, equity implications and perceived sustainability. Countries will also need to consider their enabling factors such as the global and regional commitments, intersectoral collaboration, partner coordination and accountability mechanisms. Whichever menu of recommendations for managing change the countries choose, it must be linked to the wider health system outputs and outcomes such as access to quality health services, availability and coverage of essential services, financial risk protection and resilience in service provision. 50 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 References 1. Witter, S., H. Wurie and M.P. Bertone. The free health care initiative: how has it affected health workers in Sierra Leone? Health Policy and Planning, 2016. 31(1):1–9. 2. Kidia, K.K. The future of health in Zimbabwe. Global Health Action, 2018. 11(1):1496888. 3. McCarthy, D. and S. Klein. The triple aim journey: improving population health and patients’ experience of care, while reducing costs. 2010. 4. World Health Organization. The world health report 2000 – health systems: improving performance. 2000. World Health Organization. 5. Atun, R.A. et al. Introducing a complex health innovation – primary health care reforms in Estonia (multi methods evaluation). Health Policy, 2006. 79(1):79–91. 6. Avby, G., S. Kjellström and M.A. Bäck. Tending to innovate in Swedish primary health care: a qualitative study. BMC Health Services Research, 2019. 19(1):1–10. 7. Hernández-Quevedo, C. et al. 20 years of health system reforms in Europe: what’s new? Eurohealth, 2018. 24(2):23–28. 8. Cavagnero, E. Health sector reforms in Argentina and the performance of the health financing system. Health Policy, 2008. 88(1):88–99. 9. Barrientos, A. Comparing pension schemes in Chile, Singapore, Brazil and South Africa. 2002. 10. Ewig, C. and A.H. Bello. Gender equity and health sector reform in Colombia: mixed state-market model yields mixed results. Social Science & Medicine, 2009. 68(6):1145–1152. 11. Homedes, N. and A. Ugalde. Multisource drug policies in Latin America: survey of 10 countries. Bulletin of the World Health Organization, 2005. 83:64–70. 12. Mahendradhata, Y. et al. The Republic of Indonesia health system review. 2017. 13. Behera, D.K. and U. Dash. Healthcare financing in South-East Asia: Does fiscal capacity matter? International Journal of Healthcare Management, 2020. 13(sup1):375–384. 14. Ved, R.R., G. Gupta and S. Singh. India’s health and wellness centres: realizing universal health coverage through comprehensive primary health care. WHO South-East Asia Journal of Public Health, 2019. 8(1):18. 15. De Silva, A., T. Ranasinghe and P. Abeykoon. Universal health coverage and the health Sustainable Development Goal: achievements and challenges for Sri Lanka. WHO South-East Asia Journal of Public Health, 2016. 5(2):82. 16. Witter, S. et al. What, why and how do health systems learn from one another? Insights from eight low-and middle-income country case studies. Health Research Policy and Systems, 2019. 17(1):1–13. 17. Yaogo, M. Free versus subsidised healthcare: options for fee exemptions, access to care for vulnerable groups and effects on the health system in Burkina Faso. Health Research Policy and Systems, 2017. 15(1):21–39. 18. Daff, B.M. et al. Reforms for financial protection schemes towards universal health coverage, Senegal. Bulletin of the World Health Organization, 2020. 98(2):100. 19. Ireland, M., E. Paul and B. Dujardin. Can performance-based financing be used to reform health systems in developing countries? Bulletin of the World Health Organization, 2011. 89:695–698. 20. Witter, S. et al. The political economy of results-based financing: the experience of the health system in Zimbabwe. Global Health Research and Policy, 2019. 4(1):1–17. 21. Bertone, M.P. et al. The bumpy trajectory of performance-based financing for healthcare in Sierra Leone: agency, structure and frames shaping the policy process. Globalization and Health, 2018. 14(1):1–15. 22. Duran, D. et al. The role of health system context in the design and implementation of performance-based financing: evidence from Côte d’Ivoire. BMJ Global Health, 2020. 5(9): e002934. 23. Kane, S. et al. Coming full circle: how health worker motivation and performance in results-based financing arrangements hinges on strong and adaptive health systems. International Journal of Health Policy and Management, 2019. 8(2):101. 24. Ye, M. et al. Establishing sustainable performance-based incentive schemes: views of rural health workers from qualitative research in three sub-Saharan African countries. 2014. 51Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 25. Mbau, R. et al. Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya. International Journal for Equity in Health, 2020. 19(1):1–18. 26. Kyomugisha, E. et al. Strategies for sustainability and equity of prepayment health schemes in Uganda. African Health Sciences, 2009. 9(2). 27. Mulupi, S., D. Kirigia and J. Chuma. Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya. BMC Health Services Research, 2013. 13(1):1–12. 28. Wishnia, J. and J. Goudge. Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa. BMJ Global Health, 2020. 5(10):e003524. 29. Dossou, J.-P. et al. Opening the ‘implementation black-box’ of the user fee exemption policy for caesarean section in Benin: a realist evaluation. Health Policy and Planning, 2020. 35(2):153–166. 30. El-Shal, A., P. Cubi-Molla and M. Jofre-Bonet. Accreditation as a quality-improving policy tool: family planning, maternal health, and child health in Egypt. The European Journal of Health Economics, 2021. 22(1):115139. 31. Mahipala, P. Reorienting the focus towards the Sustainable Development Goals: challenges and opportunities for Sri Lanka. WHO South-East Asia Journal of Public Health, 2016. 5(2):77. 32. Jackson, C.L. et al. Seriously working together: integrated governance models to achieve sustainable partnerships between health care organisations. Medical Journal of Australia, 2008. 188:S57–S60. 33. Ham, C. and J. Smith. Removing the policy barriers to integrated care in England. 2010: Citeseer. 34. Smyth, L. Making integration work requires more than goodwill. Healthcare Quarterly (Toronto, Ont.), 2009. 13:43–48. 35. Fraser, A., J.I. Baeza and A. Boaz. ‘Holding the line’: a qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London. Health Research Policy and Systems, 2017. 15(1):1–9. 36. Denburg, A.E. et al. Political priority and pathways to scale-up of childhood cancer care in five nations. PloS One, 2019. 14(8):e0221292. 37. Maimela, E. et al. Interventions for improving management of chronic non-communicable diseases in Dikgale, a rural area in Limpopo Province, South Africa. BMC Health Services Research, 2018. 18(1):1–9. 38. Aantjes, C.J., T.K. Quinlan and J.F. Bunders. Practicalities and challenges in re-orienting the health system in Zambia for treating chronic conditions. BMC Health Services Research, 2014. 14(1):1–14. 39. Shiroya, V. et al. Challenges in policy reforms for non-communicable diseases: the case of diabetes in Kenya. Global Health Action, 2019. 12(1):1611243. 40. Minoletti, A. Mental health in Chile: guest editor’s introduction. International Journal of Mental Health, 2012. 41(1):3–6. 41. Babatunde, G.B., A. Bhana and I. Petersen. Planning for child and adolescent mental health interventions in a rural district of South Africa: a situational analysis. Journal of Child & Adolescent Mental Health, 2020. 32(1):45–65. 42. Jenkins, R. et al. Health system challenges to integration of mental health delivery in primary care in Kenya – perspectives of primary care health workers. BMC Health Services Research, 2013. 13(1):1–8. 43. Maiga, D.D. and J. Eaton. A survey of the mental healthcare systems in five Francophone countries in West Africa: Bénin, Burkina Faso, Côte d’Ivoire, Niger and Togo. International Psychiatry, 2014. 11(3):69–72. 44. Dimitri, P. Child health technology: shaping the future of paediatrics and child health and improving NHS productivity. Archives of Disease in Childhood, 2019. 104(2):184–188. 45. Atun, R.A. et al. Diffusion of complex health innovations – implementation of primary health care reforms in Bosnia and Herzegovina. Health Policy and Planning, 2007. 22(1):28–39. 46. WHO, R.o.f.E. Catalogue of resources to support health services delivery transformations. 2016. 47. Kastor, A. and S.K. Mohanty. Disease-specific out-of-pocket and catastrophic health expenditure on hospitalization in India: do Indian households face distress health financing? PloS One, 2018. 13(5):e0196106. 48. Taneja, D. National rural health mission – a critical review. Indian J Public Health, 2005. 49(3):152–155. 49. WHO, R., Research for universal health coverage. 2013. 52 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 50. Ekenna, A. et al. How ready is the system to deliver primary healthcare? Results of a primary health facility assessment in Enugu State, Nigeria. Health Policy and Planning, 2020. 35(Supplement_1):i97–i106. 51. Fetene, M.T. et al. Magnitude and associated factors of substance use among pregnant women attending antenatal care in public hospitals of eastern Ethiopia. BMC Psychiatry, 2021. 21(1):1–12. 52. Petersen, I. et al. Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform. BJPsych Open, 2019. 5(5). 53. Ward, T. Implementing a gatekeeper system to strengthen primary care in Egypt: pilot study. EMHJ - Eastern Mediterranean Health Journal, 16 (6):684–689, 2010. 54. Schneider, H. et al. Whole-system change: case study of factors facilitating early implementation of a primary health care reform in a South African province. BMC Health Services Research, 2014. 14(1):1–11. 55. Schneider, H. et al. The challenges of reshaping disease specific and care oriented community based services towards comprehensive goals: a situation appraisal in the Western Cape Province, South Africa. BMC Health Services Research, 2015. 15(1):1–11. 56. Argaw, M.D. et al. Improved performance of district health systems through implementing health center clinical and administrative standards in the Amhara region of Ethiopia. BMC Health Services Research, 2019. 19(1):1–13. 57. Nyamhanga, T. et al. ‘We do not do any activity until there is an outbreak’: barriers to disease prevention and health promotion at the community level in Kongwa District, Tanzania. Global Health Action, 2014. 7(1):23878. 58. WHO, Regional Office for Europe. Strengthening people-centred health systems in the WHO European Region: framework for action on integrated health systems delivery. 2016. 59. Denis, J.-L. and N. Van Gestel. Medical doctors in healthcare leadership: theoretical and practical challenges. BMC Health Services Research, 2016. 16(2):45–56. 60. WHO, Regional Office for Europe. Lessons from transforming health services delivery: compendium of initiatives in the WHO European Region. 2016. 61. Bezbaruah, S. et al. Roles of community health workers in advancing health security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region. WHO South-East Asia Journal of Public Health, 2021. 10(3):41. 62. WHO. Report of the High-Level Preparatory (HLP) Meeting for the Sixty-eighth Session of the WHO Regional Committee for South-East Asia. 2015. WHO Regional Office for South-East Asia. 63. Koh, J.J.K. et al. Singapore’s role and contribution in health globally: a qualitative study exploring perspectives of global health actors in Southeast Asia. Asian Journal of Public Affairs, 2017:17–18. 64. Senkubuge, F., M. Modisenyane and T. Bishaw. Strengthening health systems by health sector reforms. Global Health Action, 2014. 7(1):23568. 65. Lapão, L.V. Seriously implementing health capacity strengthening programs in Africa: comment on ““Implementation of a health management mentoring program: Year-1 evaluation of its impact on health system strengthening in Zambezia Province, Mozambique”. International Journal of Health Policy and Management, 2015. 4(10):691. 66. Bvumbwe, T. and N. Mtshali. Nursing education challenges and solutions in sub-Saharan Africa: an integrative review. BMC Nursing, 2018. 17(1):1–11. 67. Blaauw, D., P. Ditlopo and L.C. Rispel. Nursing education reform in South Africa – lessons from a policy analysis study. Global Health Action, 2014. 7(1):26401. 68. Kebede, S. et al. Educating leaders in hospital management: a pre-post study in Ethiopian hospitals. Global Public Health, 2012. 7(2):164–174. 69. Taderera, B.H., S. Hendricks and Y. Pillay. Health personnel retention strategies in a peri-urban community: an exploratory study on Epworth, Zimbabwe. Human Resources for Health, 2016. 14(1):1–14. 70. Chol, C. et al. Stakeholders’ perspectives on facilitators of and barriers to the utilisation of and access to maternal health services in Eritrea: a qualitative study. BMC Pregnancy and Childbirth, 2018. 18(1):1–12. 71. Shemdoe, A. et al. Explaining retention of healthcare workers in Tanzania: moving on, coming to ‘look, see and go’, or stay? Human Resources for Health, 2016. 14(1):1–13. 72. Munshi, S., N.J. Christofides and J. Eyles. Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa. BMJ Global Health, 2019. 4(Suppl 10):e001564. 53Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 73. Zulu, J.M. et al. Innovation in health service delivery: integrating community health assistants into the health system at district level in Zambia. BMC Health Services Research, 2015. 15(1):1–12. 74. Olayo, R. et al. A quasi-experimental assessment of the effectiveness of the community health strategy on health outcomes in Kenya. BMC Health Services Research, 2014. 14(1):1–13. 75. Lehmann, U. et al. Task shifting: the answer to the human resources crisis in Africa? Human Resources for Health, 2009. 7(1):1–4. 76. do Carmo Caccia-Bava, M., V.C. Guimaraes and T. Guimaraes. Testing some major determinants for hospital innovation success. International Journal of Health Care Quality Assurance, 2009. 77. Moreno-Serra, R., M. Anaya-Montes and P.C. Smith. Potential determinants of health system efficiency: evidence from Latin America and the Caribbean. PLoS One, 2019. 14(5):e0216620. 78. Reddy, K.S. et al. Towards achievement of universal health care in India by 2020: a call to action. The Lancet, 2011. 377(9767):760–768. 79. Noory, B. et al. Exploring the consequences of decentralization: has privatization of health services been the perceived effect of decentralization in Khartoum locality, Sudan? BMC Health Services Research, 2020. 20(1):1–10. 80. Joseph, C. and S.O. Maluka. Do management and leadership practices in the context of decentralisation influence performance of community health fund? Evidence from Iramba and Iringa districts in Tanzania. International Journal of Health Policy and Management, 2017. 6(5):257. 81. Afriyie, D.O. et al. Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders’ perspectives. BMJ Global Health, 2021. 6(8):e005964. 82. Lutwama, G.W., J.H. Roos and B.L. Dolamo. A descriptive study on health workforce performance after decentralisation of health services in Uganda. Human Resources for Health, 2012. 10(1):1–10. 83. Mbau, R. and L. Gilson. Influence of organisational culture on the implementation of health sector reforms in low- and middle-income countries: a qualitative interpretive review. Global Health Action. 2018. 11(1):1462579–1462579. 84. Sayinzoga, F. and L. Bijlmakers. Drivers of improved health sector performance in Rwanda: a qualitative view from within. BMC Health Services Research, 2016. 16(1):1–10. 85. Tsofa, B. et al. How does decentralisation affect health sector planning and financial management? a case study of early effects of devolution in Kilifi County, Kenya. International Journal for Equity in Health, 2017. 16(1):1–12. 86. Muthathi, I.S., J. Levin and L.C. Rispel. Decision space and participation of primary healthcare facility managers in the Ideal Clinic Realisation and Maintenance programme in two South African provinces. Health Policy and Planning, 2020. 35(3):302–312. 87. Chen, J. et al. Does decentralization of health systems translate into decentralization of authority? A decision space analysis of Ugandan healthcare facilities. Health Policy and Planning, 2021. 36(9):1408–1417. 88. Agarwal, D. et al. Bringing health care closer to people – A review of various telemedicine models under the national health mission in India. Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine, 2020. 45(3):274. 89. Bates, D.W. and A. Bitton. The future of health information technology in the patient-centered medical home. Health Affairs, 2010. 29(4):614–621. 90. Kraus, S. et al. Digital transformation in healthcare: analyzing the current state-of-research. Journal of Business Research, 2021. 123:557–567. 91. Slawomirski, L. Bringing health into the 21st century. In: OECD. Health in the 21st Century: putting data to work for stronger health systems. 2019. OECD Publishing, Paris. 92. WHO, OECD and IBRD. Delivering quality health services: a global imperative. 2018. WHO. 93. Salimian, H. et al. Alignment in the organizations strategy window (concentration on business strategy and operations strategy). African Journal of Business Management, 2012. 6(51):12016–12022. 94. Mintzberg, H. The strategy concept II: another look at why organizations need strategies. California Management Review, 1987. 30(1):25–32. 54 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 95. Rao, K.D. et al. Progress towards universal health coverage in BRICS: translating economic growth into better health. Bulletin of the World Health Organization, 2014. 92:429–435. 96. Braithwaite, J. et al. How to do better health reform: a snapshot of change and improvement initiatives in the health systems of 30 countries. International Journal for Quality in Health Care, 2016. 28(6):843–846. 97. Akhnif, E. et al. Are our ‘UHC systems’ learning systems? Piloting an assessment tool and process in six African countries. Health Research Policy and Systems, 2018. 16(1):1–14. 98. Huicho, L. et al. Drivers of stunting reduction in Peru: a country case study. The American Journal of Clinical Nutrition, 2020. 112(Supplement_2):816S–829S. 99. Dominis, S., A.S. Yazbeck and L.A. Hartel. Keys to health system strengthening success: lessons from 25 years of health system reforms and external technical support in Central Asia. Health Systems & Reform, 2018. 4(2):160–169. 100. Belias, D. et al. Change management – obstacles and perspectives for the integration of changes in Greek public hospitals. Advances in Management and Applied Economics, 2019. 9(2):37–50. 101. Manongi, R. et al. Does training on performance based financing make a difference in performance and quality of health care delivery? Health care provider’s perspective in Rungwe Tanzania. BMC Health Services Research, 2014. 14(1):1–9. 102. Sokol, R. et al. A change management case study for safe opioid prescribing and opioid use disorder treatment. The Journal of the American Board of Family Medicine, 2020. 33(1):129–137. 103. Achoki, T. and A. Lesego. Implementing health financing reforms in Africa: perspectives of health system stewards. Annals of Global Health, 2016. 82(5):903–911. 104. Wedel, R. et al. Turning vision into reality: successful integration of primary healthcare in Taber, Canada. Healthcare Policy, 2007. 3(1):80. 105. Nicholson, C., C. Jackson and J. Marley. A governance model for integrated primary/secondary care for the health-reforming first world – results of a systematic review. BMC Health Services Research, 2013. 13(1):1–12. 106. Suter, E. et al. Ten key principles for successful health systems integration. Healthcare Quarterly (Toronto, Ont.), 2009. 13(Spec No):16. 107. Latifi, R. et al. Access to specialized care through telemedicine in limited-resource country: initial 1,065 teleconsultations in Albania. Telemedicine and e-Health, 2016. 22(12):1024–1031. 108. Hospodková, P. et al. Change management and digital innovations in hospitals of five European countries. In Healthcare. 2021. Multidisciplinary Digital Publishing Institute. 109. Tangcharoensathien, V. et al. Defining the benefit package of Thailand universal coverage scheme: from pragmatism to sophistication. International Journal of Health Policy and Management, 2020. 9(4):133. 110. Farach, N. et al. Stories from the field: the use of information and communication technologies to address the health needs of underserved populations in Latin America and the Caribbean. JMIR Public Health and Surveillance, 2015. 1(1):e4108. 111. Gericke, C. Comparison of health care financing in Egypt and Cuba: lessons for health reform in Egypt. EMHJ-Eastern Mediterranean Health Journal, 2005. 11(5–6):1073–1086. 112. Healy, J.M. et al. A framework for comparative analysis of health systems: experiences from the Asia Pacific Observatory on Health Systems and Policies. WHO South-East Asia Journal of Public Health, 2018. 7(1):5–12. 113. Almeida, P. The sequencing of success: organizing templates and neoliberal policy outcomes. Mobilization: an International Quarterly, 2008. 13(2):165–187. 114. Massuda, A., C. Titton and P. Poli Neto. Remembering Alma-Ata: challenges and innovations in primary health care in a middle-income city in Latin America. Revista Panamericana de Salud Pública, 2018. 42:e157. 115. Van Veghel, D. et al. Organization of outcome-based quality improvement in Dutch heart centres. European Heart Journal-Quality of Care and Clinical Outcomes, 2020. 6(1):49–54. 116. Spigel, L. et al. Implementing sustainable primary healthcare reforms: strategies from Costa Rica. BMJ Global Health, 2020. 5(8):e002674. 55Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 117. Sanogo, N., A. Fantaye and S. Yaya. Universal health coverage and facilitation of equitable access to care in Africa. Front Public Health, 2019. 7:102. 2019, PubMed. 118. Schneider, H. et al. District governance and improved maternal, neonatal and child health in South Africa: pathways of change. Health Systems & Reform, 2020. 6(1):e1669943. 119. Tumusiime, P. et al. Towards universal health coverage: reforming the neglected district health system in Africa. BMJ Global Health, 2019. 4(Suppl 9):e001498. 120. Haddad, S., A. Nougtara and P. Fournier. Learning from health system reforms: lessons from Burkina Faso. Tropical Medicine & International Health, 2006. 11(12):1889–1897. 121. Phillips, J.F. et al. What do you do with success? The science of scaling up a health systems strengthening intervention in Ghana. BMC Health Services Research, 2018. 18(1):1–10. 122. Mohanty, S.K. and A. Kastor. Out-of-pocket expenditure and catastrophic health spending on maternal care in public and private health centres in India: a comparative study of pre and post national health mission period. Health Economics Review, 2017. 7(1):1–15. 123. Kumar, P. et al. Aligning developmental programs to implement SDGs in India: challenges and the way forward. Journal of Contemporary Issues in Business & Government, 2021. 27(6). 124. Alshaher, A.A.-F. The McKinsey 7S model framework for e-learning system readiness assessment. International Journal of Advances in Engineering & Technology, 2013. 6(5):1948. 125. Clark, M.A.. The new left and health care reform in El Salvador. Latin American Politics and Society, 2015. 57(4):97–118. 126. Taderera, B.H., S.J.H. Hendricks and Y. Pillay. Human resource for health reform in peri-urban areas: a cross-sectional study of the impact of policy interventions on healthcare workers in Epworth, Zimbabwe. Human Resources for Health, 2017. 15(1):1–13. 127. Petersen, I. et al. Health systems strengthening to optimise scale-up in global mental health in low- and middle-income countries: lessons from the frontlines. A re-appraisal. Epidemiology and Psychiatric Sciences, 2020. 29. 128. Lehmann, U., N.A. Twum-Danso and J. Nyoni. Towards universal health coverage: what are the system requirements for effective large-scale community health worker programmes? BMJ Global Health, 2019. 4(Suppl 9):e001046. 129. Fusheini, A. and J. Eyles. Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of health care provision. BMC Health Services Research, 2016. 16(1):1–11. 130. Gilson, L. and I.A. Agyepong. Strengthening health system leadership for better governance: what does it take? 2018, Oxford University Press. ii1–ii4. 131. Figueroa, C.A. et al. Priorities and challenges for health leadership and workforce management globally: a rapid review. BMC Health Services Research, 2019. 19(1):1 11. 132. Chigudu, S. et al. The role of leadership in people-centred health systems: a sub-national study in the Gambia. Health Policy and Planning, 2018. 33(1):e14–e25. 133. Sfantou, D.F. et al. Importance of leadership style towards quality of care measures in healthcare settings: a systematic review. In Healthcare. 2017. Multidisciplinary Digital Publishing Institute. 134. Almajali, D.A. and A. Tarhini. Antecedents of ERP systems implementation success: a study on Jordanian healthcare sector. Journal of Enterprise Information Management, 2016. 135. Pozo, K.C. et al. Improving adolescent sexual and reproductive health in Latin America: reflections from an International Congress. Reproductive Health, 2015. 12(1):1–7. 136. Meier, B.M., C. Pardue and L. London. Implementing community participation through legislative reform: a study of the policy framework for community participation in the Western Cape province of South Africa. BMC International Health and Human Rights, 2012. 12(1):1–14. 137. Chmielewska, M., Stokwiszewski, J., Markowska, J. et al. Evaluating Organizational Performance of Public Hospitals using the McKinsey 7-S Framework. BMC Health Serv Res 22, 7 (2022). 56 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Appendices Abstraction of Data on Hardware and Software (McKinsey 7S). Table AP-1: Abstraction of Data on Hardware for AFRO Table AP-2: Abstraction of Data on Hardware for Asia Table AP-3: Abstraction of Data on Hardware for Europe Table AP-4: Abstraction of Data on Hardware for LAC Table AP-5: Abstraction of data for Software: AFRO Table AP-6: Abstraction of data for Software: Asia Table AP-7: Abstraction of data for Software: Europe Table AP-8: Abstraction of data on software for LAC Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 57 Table AP-1: Abstraction of data on hardware for the WHO Regional Office for Africa Schneider District Health Innovations in governance Formation of non-hierarchical A monitoring and response unit was PHC and hospital services et al., 2020 governance and governance could add significant value collaborative networks, improved introduced as a decision-making and improved reforms to strengthening of district coordination between community accountability structure. maternal, health systems for neonatal and improved MNCH. child health in South Africa: pathways of change Achokiand Implementing Health financing Thesuccessofanyhealth Unless there are tight controls, Expansion of health insurance If an appropriate regulatory Lesego, health financing reforms financing reform is demand for medicines and other coverage would attract more private framework is not in place, 2016 reforms in Africa: dependent on sound health technologies is likely to sector participation in the medicine competition between the public perspectives of policies, regulations and increase as health insurance access value chain with the goal of and private sectors might be health system accountability measures. coverage expands. Adaptive making a profit. This presents counterproductive, leading to stewards reimbursement measures such as opportunities for both increased spurious acts such as pilferage or capitation at the PHC level or some collaboration and a level of leakage of health products, as well form of case-based payment system competition across the sectors, as as introduction of substandard would reduce the incentive for well as challenges and risks that have health products. Well-designed overservicing in many settings. to be anticipated and managed. partnerships would also present Legislation, market dynamics or a Therefore, if proper regulations are in an opportunity to improve combination of both toward place, the proposed measure to procurement and logistics consolidation in the health insurance expand health insurance coverage in management systems, which is a market could enhance the Botswana would translate into lower perennial challenge in many public effectiveness and efficiency of health administrative costs, better health systems. Appropriate service delivery. bargaining and purchasing options incentives and accountabilities for users, and effective risk sharing, encouraging health system all factors that enhance efficiencies decision-makers at all levels to in health service delivery. In addition, reduce wastage and ensure quality the proposed reform would provide and value for money would be the health system with a more essential to sustain the progress in efficient option of pooling resources the efforts to improve access to compared with the prevailing medicines. fragmented insurance market, which has multiple drawbacks. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202358 Chol et al., Health system Health Restoring health systems In Rwanda, through performance- Decentralization through presidential Angola introduced fiscal 2018 reforms in five financing, HRH after disasters in countries based financing (PBF) staff received decree decentralization across sub-Saharan and health that have experienced incentives allowing them to retain municipalities, while in African countries governance wars 40% of the revenues they generated. Mozambique a MoH-donor reforms Eritrea introduced community and agreement led to a decrease in private health insurance and tax vertical financing from 82% in funds for health, plus individual 2001 to 50% in 2007. health insurance embedded within the public health system. In 2006 Ethiopia initiated a district-based system financed by the government and development partners, a fees retention policy to provide revenues for local health facilities and a community-based health insurance scheme. In Rwanda, the community- based health insurance contributed to increases in facility-based deliveries. Mbau and Influence of Health Understanding of culture Gilson, 2018 organizational governance can facilitate the culture on the reforms development and implementation negotiation of mutually of health sector agreeable approaches to reforms in low- conflict resolution, solving and middle- of problems, decision- income countries: making, and management, a qualitative all of which characterized interpretive the implementation of the review reforms across the different settings in the reviewed literature. Petersen et Re-appraisal of NCO, mental Health care provision At the policy and population levels, Governance remains important, with Integrated clinical information al.,2020 health system health reforms needs to be responsive to policies and regulations that are front-line managers being systems are central to capture strengthening to people's needs and health promoting, for example responsible for translating and information on multiple optimize mental expectations, placing at its regulations relating to alcohol adapting programmes within conditions, so as to optimize health epicentre the consumption, and that may need to organizational and systems multimorbidity care and facilitate empowerment and be implemented by other sectors are governance architecture to continuity of care necessary for engagement of individuals, important, as are governance issues, customize and embed them within long-term conditions. Systems for families and communities the system (Scott et al., 2014). dispensing chronic disease Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 59 to promote and protect their health. particularly of an intersectoral nature. medication and information systems for tracing patients lost to care to reduce non-adherence require a robust community sub- system that includes CHWs who interface with the formal health system, households, community structures such as FBOs, civic groups and local political structures, plus other sectors providing services at the community level. Senkubuge et al., 2014 Strengthening health systems by health sector reforms Health financing, HRH, health governance, health information reforms There is growing recognition that the global healthagendaneedsto shift from an emphasis on disease-specific approaches to strengthening of health systems, including dealing with social, environmental and economic determinants through multisectoral responses. Data show an overall trend of improvement of equity in access and outcomes due to many health sector reforms and health systems interventions. These include ensuring that services are free at the point of delivery, engaging communities and CSOs in the planning and delivery of health services and introducing a decentralization agenda in the delivery of services. The focus is on the interaction between health sector reforms and two key factors in the management of supply chain, namely, procurement and distribution, and quality. A number of procurement and distribution reforms in many countries have resulted in a reduction in the price of some drugs, particularly those for the treatment of HIV/AIDS and tuberculosis, due to the establishment of drug facilities and mechanisms such as the WHO/UN prequalification programme. Wishnia and Goudge, 2020 Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa Health financing Finance and clinical managers often do not have a shared vision of the goal of the health system, and this drives tension and impacts negatively on relationships. This leads to an organizational culture that is competitive and dismissive of the needs of the collective, which To improve financial audit outcomes, the provincial department of health instituted a radical public financial management centralization reform. A centralization committee was established composed of financial, clinical and support service managers who met once a week to review expenditure and payment requests for the whole province. The committee was chaired by the chief financial officer. Its establishment Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202360 weakens the health system. annulled all delegations from the districts and facilities. Members of the committee are senior managers within the head office, with none coming from the district health offices or hospitals. Braithwaite et al., 2016 How to do better health reform: a snapshot of change and improvement initiatives in the health systems of 30 countries For countries with high GDP per capita, the focus is on new IT systems or trialling innovative funding models. Wealthy or less wealthy countries are embracing ways to enhance the quality of care and keep patients safe via mechanisms such as accreditation, clinical guidelines and hand hygiene campaigns. Until recently, patients' out-of- pocket payments constituted nearly half of Indonesia's health funding. The middle-income country is now introducing a national social insurance scheme that will improve health care equity and accessibility and make Indonesia the largest nation with UHC. Most studies suggest that reforms- including the largest structure in the history\of the NHS, new hospital star ratings and networks of "collaboratives" have helped improve productivity, quality and safety, with fewer deaths from cancer and cardiovascular disease now recorded. In South Africa, delayed availability of antiretroviral drugs has transformed the prospects of HIV/AIDS patients. In that country's Free State Province, a decline in maternal mortality is attributed to a new adverse incident monitoring system. Norway launched a three-year patient safety campaign, adopting a non-punitive approach to the reporting of adverse events. In 2012 events contributing to a death or requiring intervention or a long hospital stay fell to 13.9% from 16.1% in 2011. Ekenna et al.,2020 How ready is the system to deliver primary healthcare? Results of a primary health facility assessment in Enugu State, Nigeria Continuing medical education, funding and security were identified by health workers as key enablers of service delivery. On the day of the assessment rural PHC centres had more functionality than did their urban counterparts in safe water supply (21 [46.7%] versus 13 [28.9%]) and access to flushable toilets (9[60.0%] versus 8 [53.3%]). More urban PHC centres (10; 66.6%} had at least 50 basic equipment available than rural PHC centres (15; 33.3%}. The National Primary Health Care Development Agency provided solar-powered refrigerators to PHC centres to improve vaccination supply. Fetene et al.,2021 Experiences of managerial accountability in Ethiopia's primary Cultivating a culture of accountability in health care systems for improving the quality of health care Systems that allow the community and lower level stakeholders to regularly evaluate higher level health system entities indicated Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 61 healthcare system: a qualitative study that the PHC system's bottom-up accountability process is inadequate. Participants called for the decentralization of evaluation, making it a feature of every level within the health system. Accountability needs to be consolidated into a shared performance measurement and improvement system. Stakeholders to improve their activities and how they improve their activities and how they engage in health care practice. Legal empowerment of patients and managers would help to hold poor providers accountable and protect good providers. Haddad et al.,2006 Learning from health system reforms: lessons from Burkina Faso Health financing Through the reforms, the health sector benefited from a significant flow of resources. There were significant increases in public expenditures, health care staff, primary care facilities and availability of generic drugs. Integrating health development policies with strategic plans for poverty reduction can provide new opportunities for African countries to redesign their health systems. Investment has been focused on increasing the number of primary care facilities, resulting in significantly increased coverage such that 80% of the population now lives within 5 km of a public primary care facility. One of the most striking aspects of the reform was that the structural adjustment programme, with the commitments of external partners, greatly benefited capital investments. These represented, on average, 31% of public spending on health between 1990 and 1994 and 49.5% between 1996 and 2000. Witter et al., 2019 What, why and how do health systems learn from one another? Insights from eight low-and middle-income country case studies Health financing, HRH reforms, health governance, MNCH reforms The findings emphasize the agency of local actors and the importance of developing national and subnational institutions for gathering, filtering and sharing evidence. Growing government financing, confidence and leadership in setting parameters within which evidence is used were highlighted in Cambodia. The content of the reforms also matters. If reforms are technical and do not imply large structural changes, they will be easier to adopt, for example in Nepal. Evidence is considered by decision-makers if it is politically relevant, accessible and In Bangladesh, Burkina Faso, Cambodia, Georgia, Rwanda and Solomon Islands technical assistance programmes were perceived to be of importance if they provided learning about reforms in other countries and in supporting reform implementation. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202362 locally applicable. This was seen in Georgia, for example. Noory et al., 2020 Exploring the consequences of decentralization: has privatization of health services been the perceived effect of decentralization in Khartoum locality, Sudan? Health governance reforms The study highlighted the strong effects of health care budget cuts and privatization of drug supply systems after the implementation of decentralization. These led to the focusing on profit- making by internal hospital pharmacies and removal of free treatment schemes for vulnerable populations. The budget cuts and deficits resulted in deterioration of quality and capacity of decentralized hospitals, thereby facilitating privatization. All radical reforms and their related profit-making schemes force the implementation of decentralization to weaken the public sector, facilitate the private sector and commodify health. Revenue generation might be associated with decentralization and its transfer of power and authority to local levels. Study participants mentioned many forms of privatization and profit-making schemes being imposed in routine functionalities of some laboratory services, such as those related to cost recovery, public-private partnerships and transformation of public hospital pharmacies into retail pharmacies. The lack of sufficient investment in public health services could lead to inadequacies in capacities and infrastructure, unavailability of drugs and delayed treatment. This directly and indirectly enabled the private sector to flourish. El-Shal et al.,2021 Accreditation as a quality-improving policy tool: family planning, maternal health, and child health in Egypt MNCH reforms The results emphasize that a high, continued level of commitment, which is a reflection of strong political will, is indispensable in the success of quality improvement interventions in LMICs in the long run. A significant proportion of MNCH costs was financed through donor funding, constraining the ability of the health sector reform programme to generate revenues from different sources and making it financially unsustainable in the long run. Fusheini and Eyles, 2016 Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of UHC reforms Local involvement is seen as central in UHC reforms, and thus the district health system is a key component of UHC reform efforts. The district health approach encompasses a set of elements such as community involvement, integrated and holistic health care delivery, intersectoral collaboration and a strong bottom-up approach to planning, policy development and management. The national health Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 63 health care provision insurance conditional grant funds were disbursed by the districts in the last quarter of the year. These were primarily spent on procuring equipment and refurbishing health facilities. The introduction of CHWs, improvements in monitoring the health of children and decongesting clinics through the new modes of chronic illness medication distribution are significant positives. Githendu et al., 2020 Transformation of the Tanzania medical stores department through global fund support: an impact assessment study Availability of essential medicines and other health commodities increased, indicating improved capacity to meet demands emanating from the health facilities. This could be attributed to several factors related to the Global Fund support, notably the better quantification and forecasting of capabilities owing to availability of data through EPICOR, training of staff, and improved warehousing capacity to hold a wide portfolio of products and direct their delivery to facilities through a modern fleet. Steady efforts were made for a comprehensive logistic system redesign aimed at enhancing efficiencies in the procurement and distribution of medicines and health commodities in the country. This required a strong financial position to negotiate preferential procurement terms directly with wholesalers or manufacturers. The apparent strengthening of the medical stores department's financial position, as shown by sales increases, could have played a role in this. Modern warehousing facilities at both the central and zonal levels were good investments that enabled the medical stores department to attain better visibility and storage of medicines and other health supplies, creating optimal conditions and, thus, enhancing performance. This has been attained by ramping up the efficiency and reliability of its operations. In addition, the respondents in the leadership of medical stores department revealed that the support had benefited the overall financial position of the organization. The delivery times were reported to have become significantly shorter and health facilities managers were confident to receive their orders on time, reducing the need for overstocking and the resultant expiries. Through better collection and use of high quality data, decision-makers at various levels were empowered to effectively quantify and forecast needs and have better visibility of the distribution systems. Kidia, 2018 The future of health in Zimbabwe Galvanizing local and global health communities to take action during these times has the potential to reprioritize health and In 2012, official development aid accounted for 60% of Zimbabwe's health financing. Without this assistance, even basic health resources would have been limited. More problematic than aid itself are Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202364 even pivotal health care reform. the overly vertical programmes that do not go beyond specific, disease- focused interventions. Mbau et al., 2020 Examining purchasing reforms towards purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya Health financing Kenya has prioritized the attainment of UHC through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, NHIF introduced reforms in premium contribution rates, benefit packages and provider payment methods. NHIF officials and media reports indicated that NHIF was implementing various strategies to curb fraudulent activities. The strategies included online notifications for inpatient admissions, centralized authorization (letters of undertaking) for surgical procedures and specialized imaging studies, and use of biometrics for identification of beneficiaries. Gaps in the service delivery infrastructure for the new benefit packages in public health care facilities limited the availability of essential medicines, laboratory supplies and specialized services such as dialysis, chemotherapy, radiotherapy and organ transplant. The unaffordability of the increased premium rates limited access of certain citizen groups to the entitlements. Provider payments were delayed, which was attributed to the inefficiencies in the demanding manual claim process, the limited number of NHIF claims and benefits staff and the limited financial resources within NHIF. Mulupi et al., 2013 Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya UHC reforms As Kenya continues to prepare for UHC, it is important that communities be educated and engaged to ensure that the national health insurance scheme (NHIS) is acceptable to the population it serves. Dropout rates were mainly attributed to the lack of funds to renew annual membership (45.5%), loss of employment or retirement, in cases where membership was linked to employment (36.4%) and inadequacy of the benefits package (11.4%). Factors that made it easy for people to belong to health insurance schemes were affordable contribution rates and favourable contribution mechanisms, for example where members were allowed to make their contributions in instalments or had them deducted directly from their earnings from agricultural produce like tea and coffee. Close to half of the household survey respondents (46.5%) favoured a progressive contribution structure, where the richest contributed a larger share of their income towards an NHIS. Despite the negative perceptions of the quality of care in the public health system and the belief that private facilities offered better services, when it came to collecting revenue for a NHIS, the community clearly favoured a system where the government collected the revenue and purchased services on behalf of the population. Tsofa et al., 2017 Devolution and its effects on health workforce and commodities management- early implementation Health governance reforms HRH and essential medicines and medical supplies (EMMS) management functions were rapidly transferred to counties before appropriate county-level Under the devolved government system, the Public Services Commission is mandated to provide employment for national government employees, and oversight of the entire public service at both the national and county There was lack of clarity over which structures and institutions at national and county levels would be responsible for specific welfare aspects of health workers. An agreement was reached that specified that for an interim period of six months the national MoH would continue processing and paying salaries for all health workers on behalf of the counties, then invoice the county Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 65 experiences in Kilifi County, Kenya structures and adequate capacity to undertake these functions were in place. Harnessing the full potential benefits of this increased autonomy requires targeted interventions to clarify the roles and responsibilities of different actors at all levels of the new system and to build the capacity of the counties to undertake certain specific HRH and EMMS management tasks. levels. At the county level, the constitution provides for the establishment of county public service boards to serve as the overall employer of all public servants in that county. This led to several positive effects. The county gained the ability to determine the actual number of HRH staff to have based on its budget and to decide where to deploy them. For EMMS, decentralized procurement improved the fill rate in health facilities, and the county was able to ensure that all facilities were supplied with EMMS irrespective of their registration status. This allowed previously non- functioning facilities to operate and, thus, previously underserved areas to have access to a facility. It is, therefore, likely that widened decision space at the county level enhanced local level equity in the allocation of health resources and health service provision at the county level and ensured services reached previously underserved populations. governments for reimbursement. The national MoH employed a pull system for EMMS management and supplies for public health facilities, where MoH would allocate a quota of its annual budget for EMMS to the Kenya Medical Supplies Agency. Jenkins et al., 2013 Health system challenges to integration of mental health delivery in primary care in Kenya - perspectives of primary care health workers MNCH reforms Improvement of medicine supplies and information systems, explicit inclusion of mental health in district level targets, and management and supervision to primary care are likely to greatly improve primary care health worker effectiveness and enable training programmes to be followed by better use in The health workers in the focus groups indicated that clear targets for mental health need to be established and monitored from the national level to the community level. There is need to use protocols for managing common psychiatric disorders. Ongoing support, supervision and training on mental health are crucial. Patient summary sheets and the drug ordering system need to be revised to facilitate drug supply to the community. Physical investigations were difficult to carry out owing to the lack of resources in the clinics, poverty of the clients and long distances to suitably equipped facilities. A common challenge for both groups was the lack of appropriate medications in the health facilities. The drug supply was poor due to difficulties in using the pull system that required health workers to order drugs for the clinics depending on clients' needs and clinic workload. It was impossible to use data from the tally sheet to order specific medicines in adequate quantities. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202366 the field of newly acquired skills. Lehmann et al.,2009 Task shifting: the answer to the human resources crisis in Africa? HRH reforms While task shifting holds great promise, its long- term success hinges on political and financial commitments. It requires a comprehensive and integrated reconfiguration of health teams, changed scopes of practice and regulatory frameworks, and enhanced training infrastructure, as well as availability of reliable medium- to long-term funding. Delegation of tasks from one cadre to another, previously often called substitution, is not a new concept. It has been used in many countries and for many decades, either as a response to emergency needs or as a method to provide adequate care at primary and secondary levels, especially in understaffed rural facilities, to enhance quality and reduce costs. Task shifting requires careful attention to the organization, structure and resourcing of health services. As Samb et al. 2007 argued, in the context of HIV/ AIDS services, task shifting "must be aligned with the broader strengthening of the health system if it is to prove sustainable." Joseph and Maluka, 2017 Do management and leadership practices in the context of decentralisation influence performance of community health fund? Evidence from lramba and lringa districts in Tanzania Health governance reforms The study indicates that the performance of community-based health financing largely depends on the personal initiatives of the top district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team and the Ministry of Health and Social Welfare should strengthen the supportive supervision mechanisms for district health managers and health facilities. The community health fund (CHF) was the main source of the finances used to pay for the incentives to health providers, district health managers and health committees. lramba district's attempt to introduce a portable CHF and a referral system were commended by respondents as an initiative that motivated members to join CHF. lramba district increased the increased the rate of user fee payments in order to encourage households to enrol with CHF. Ireland et al., 2011 Can performance- based financing be used to reform health systems in Health financing The success or failure of PBF as a comprehensive social intervention is entirely dependent on the In most cases, there is a need for new institutions or structures, ranging from independent purchasing bodies to CSOs charged with community There is need for a flexible public finance management system that has the capacity to easily mobilize resources to the local level. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 67 developing countries? context. The conditions necessary for the success of PBF include strong leadership and management support, accurate information and reporting systems, increased funding and training. oversight, plus strengthening of existing structures, especially health information systems. Witter et al., 2019 The political economy of resuIts-based financing: the experience of the health system in Zimbabwe Health financing Adoption of results-based financing (RBF) was aided by its ideological retrofitting into an earlier government performance management policy. The main beneficiaries of RBF were front-line providers, who gained small but critical resources, but these were subject to high degrees of control and sanctions. RBF was later presented and perceived as an enactment of the wider government results-based management (RBM) programme, which had been launched in 2005. It provided an ideological justification for RBM, what one key informant called ideological retro-fitting. RBF is now seen as testing of the RBM approach, which is also of interest to other sectors. A key driver from the facility side was enthusiasm with the increase in funds that RBF facilities were earning compared to districts, which were still receiving fixed-rate inputs, that is before 2014. The governance of the RBF programme was linked to existing local governance structures, such as provincial and district development committees, and the district health team, which coordinated activities across the subsectors within health. From the patients' perspective, RBF contributed to greater drug and staff availability and infrastructure improvements, such as the mothers' waiting homes that many facilities built using RBF funds and with wide community support. The resources that RBF brought to the under-financed health system in Zimbabwe represented a small but significant increment in public resources for health of around 3% of the estimated per capita need for an essential health care package, or 5% of the available funding. Munshi et al.,2019 Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa Health human resources This paper explores ward- based PHC outreach teams and managers' perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of implementation. The unintended consequences of the inadequate preparation for the new policy at the local level included resistance of CHWs by facility-based staff. As a result, ward-based PHC outreach teams did not feel integrated into the community health system. CHWs complained that they did not have basic supplies such adult nappies, linen savers and gloves. CHWs felt their productivity was hampered because they did not have stationery, identifiable uniforms or cell phones to contact team leaders. Transport emerged as a significant implementation barrier in areas where CHWs had to cover large distances on foot to reach households in the catchment area. Maiga and Eaton, 2014 A survey of the mental healthcare systems in five MNCH reforms Assessment of aspects of mental health care in five francophone countries and The five countries currently have pilot projects informed by the WHO Mental Health Gap Action There is a lack of mental health policies in these countries. Benin developed, validated and adopted a None of the five countries possesses detailed information about mental, neurological or Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202368 Francophone countries in West Africa: Benin, Burkina Faso, Cote d'Ivoire, Niger and Togo how they are reforming services to make them more accessible Programme, which are complete (Benin), in progress (Niger) or due to commence (Burkina Faso, Cote d'Ivoire and Togo). Generally, these involve taking a systems approach to coordination and integration of mental health into routine health services. mental health policy in 2009, but it is not well endorsed. In the other four countries, the annual health strategic plan routinely has a mental health component but this is rarely implemented. Services are unevenly distributed geographically, with their great majority based in the capital cities. substance use disorders in its decentralized services. There are few primary level or community mental health services. Health information systems at the primary level do not distinguish mental, neurological or substance use disorders as distinct categories. The provision of psychotropic drugs in these five countries is characterized by unreliability of supply and poor drug quality at both the primary and secondary levels of the health pyramid. Lapao,2015 Seriously implementing health capacity strengthening programs in Africa Health human resources Deeper involvement of health authorities and more rigorous approaches are seriously desirable for the proper development of health capacity strengthening programmes in Africa. Ideally, integration between hospitals and PHC creates value that requires at least four conditions: alignment of primary and secondary care activities, existence of an information system that enables the sharing of medical records to support the decision-making, coordination of care, and clinical governance. Legislation may be required to define the responsibilities and procedures of decision-making among the different levels of governance, to review the legal definitions of tasks that can be performed by the various groups and to create financial incentives and professional systems to stimulate the cooperation of providers. To be effective when adopting mentoring strategies, one needs to properly integrate mentoring within the organization's governance. At the organizational level, one needs to ensure there are management capacities, access to agile information systems and autonomy in the allocation of resources. Institutional and organizational mechanisms are essential determinants of the success of health reform. There is need to consider the typical service organization. African hospitals and health centres usually provide a set of essential services, that is obstetrics and gynaecology, emergency and general surgery, internal medicine, basic diagnostics and supply of medicines and vaccines, which suffers from frequent stocks disruptions. Technology and the Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 69 Internet are fundamental support for communication. Petersen et al.,2019 Scaling up integrated primary mental health in six low- and middle- income countries: obstacles, synergies and implications for systems reform PHC strengthening and expansion Guidelines were regarded as beneficial, and their alignment with those existing and training processes helped improve the quality of the fit of the innovation. Integration packages to provide human rights- based mental health care were viewed as beneficial in Ethiopia, and the integrated guidelines were highlighted as simplifying comprehensive care, making patient flow more efficient and strengthening referral pathways. A good degree of compatibility between intervention characteristics and existing policies and guidelines is vital in health systems' implementation processes. In relation to governance, the need for policies to strengthen multisectoral linkages in the planning, implementation and monitoring of services was emphasized. The need to improve financing of integrated mental health care emerged as a crucial issue, with the need for a dedicated mental health budget at the PHC level identified as an unresolved policy issue across all the countries. Leveraging existing health system features and processes promoted greater synergy with the prevailing health system. A need identified was to include some essential mental health indicators in the national health information system that can assist in monitoring care quality. Improved health information systems can assist promotion of the uptake and embedding of a new intervention through supporting change management by creating the will to identify and find solutions to bottlenecks that emerge during service delivery, which is to be expected during introduction of systems innovations. Ward, 2010 Implementing a gatekeeper system to strengthen primary care in Egypt: pilot study PHC strengthening and expansion Patients insured with the national health insurance organization were exempt from paying referral fees, as the organization was responsible for these Up to 60% of Egypt's population is reported to use private clinics, suggesting that overuse was even greater within the subset of the population using public hospitals. The pilot system in Menouf was successful in directing patients away from hospitals towards primary care facilities. Muthathi et al.,2020 Decision space and participation of primary Health governance reforms The study found that PHC facility managers reported the lack of involvement in Most participants were of the opinion that they were not equipped with the necessary Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202370 healthcare facility managers in the ideal clinic realisation and maintenance programme in two South African provinces the conceptualization of the Ideal Clinic Realisation and Maintenance programme and high levels of participation in its implementation, while participants reported narrow decision space on the critical areas of the availability of essential medicines and on basic resuscitation equipment. resources by the national or relevant provincial department of health. The PHC facility managers voiced their frustrations over the lack of control over the budget and supply chain management, which constrained their ability to ensure the availability of medicines and basic resuscitation equipment in these facilities. The absence of essential medicines and medical equipment leads to distrust of the health care system by the public and decreases their utilization of a health care facility. There is need to ensure the presence of adequate resources, an enabling practice environment and support to PHC facility managers within a context of prioritizing the PHC approach. Shiroya et al.,2019 Challenges in policy reforms for non- communicable diseases: the case of diabetes in Kenya NCDs, mental health reforms The implementation process was largely health- sector driven. The non- health sector remained largely uninvolved, contrary to global recommendations. This, in addition to the fragmented health governance and weak monitoring systems, continues to undermine existing gains and efforts to fight diabetes and NCDs on a wider scale. The emphasis is on primary care level prevention of diabetes with interventions targeting obesity, physical inactivity and unhealthy diet; resource mobilization; capacity building; partnership and coordination; diabetes policies, legislation and regulations; research; and monitoring and evaluation. The step from the Kenya National Diabetes Strategy KNDS 2010-2015 to the Kenya National Strategy for Prevention and Control of NCDs 2015-2020 illustrates a move away from a disease-specific focus to a broader approach. The strategy was supported by accompanying guidelines for treatment and capacity building and aimed to align with existing health programmes. There was a lack of a monitoring framework to evaluate the implementation progress and of concrete baseline data. Policy implementation was described as piecemeal and with predominantly weak monitoring and evaluation systems. The country relies on donor-led or international research to develop policies, which often do not mirror local problems. NHIF, a government body mandated to facilitate Kenya's UHC agenda, includes diabetes care in its medical cover package. Investment in implementation research to generate relevant local data and improve progress monitoring is warranted for Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 71 evidence-informed decision- making. Dossou et al.,2020 Opening the 'implementation black-box' of the user fee exemption policy for caesarean section in Benin: a realist evaluation MNCH reforms Trust, perceived coercion, adherence to policy goals and perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes In the faith-based hospital, the perceived financial opportunities made managers adopt the policy once they saw that the reimbursements were effective and timely. To be adopted and micro- implemented properly, the policy will have to trigger mechanisms such as trust, perceived pressure, positive response to financial incentives, perceived fairness in the resource allocation and an intrinsic adherence to the policy goals and values. In addition to the reimbursements, MoH provided free kits of drugs and consumables during the first year of the policy. Managers, providers, users and community representatives reported that there were no formal channels such as complaints procedures for patients to engage with the management team. In the interviews, providers declared that the hospital management team effectively supported them in the implementation of the policy, for instance with regular supply of the maternity unit with caesarean section kits. For effective implementation, the required resources are needed, including drugs, supplies and information, to be available in a timely manner at the point of service delivery, and a general conducive work setting. Rao et al., 2014 Progress towards universal health coverage in BRICS: translating economic growth into better health UHC reforms Although national governments have played a prominent role in the reforms, private financing constitutes a major share of health spending in BRICS. South Africa's NHIF will be funded from taxes and through active purchasing. Where the private sector health care delivery is large, UHC will depend critically on the extent to which the resources within the sector are harnessed. In this situation, such coverage is most likely to be achieved through the strategic purchasing of services from both public and private providers of health care. This should ensure that health services of good quality are available to all citizens. NHIF's purchasing should enable the government to Government-sponsored insurance schemes remain focused entirely on hospital care. Despite new investments in public primary care, many outpatients have been kept away from the public sector - and its promise of low cost health care - by inadequate coverage and a common belief that the private sector offers better quality. There was UHC in the Soviet health system with all citizens entitled to health services and complete financial risk protection, but this collapsed with the breakup of the Soviet Union. Although they In India the public sector system, which had been expected to be a vehicle for delivering low cost health care to all Indians, failed to deliver on its promise because it was underfunded, undersupplied and understaffed. Not surprisingly, out-of-pocket payments to private providers and rising medical costs placed a large burden on poor households and became an important cause of impoverishment. In addition, the fall of the incumbent government in the 2004 election signalled to Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202372 draw on human resources from both the public and private health sectors. The pooling of health funds between the federal and territorial governments is fragmented. This makes it difficult to implement any countrywide reforms, leading to geographical variations, inefficiencies and inequity. are made at the central level, national policies often have to be implemented by subnational entities that are largely autonomous. This often leads to multiple sources of fragmentation and high potential for duplication of effort and consequent inefficiencies. the new government the importance of fundamental issues such as health. Out-of-pocket payments for health care remain very high and very common in several BRICS countries. In India's case, payments for outpatient care have been inadequately addressed by health reforms. Taderera et al., 2016 Health personnel retention strategies in a peri-urban community: an exploratory study on Epworth, Zimbabwe HRH reforms The review of salaries, engagement of international strategic partners, payment of top- up allowances, support towards post-basic training and development, mobilization of more health personnel, non- monetary incentives and health care worker protection were critical towards the retention of health personnel in the Epworth peri-urban community between 2009 and 2014. Community health volunteers were recruited, trained and deployed to provide assistance to medical and non-medical staff at the two municipal clinics and one mission clinic. To start with, remuneration packages were reviewed in 2009 to denominate them in United States dollars because the local currency had lost its value owing to high inflation. This also followed the introduction of the multicurrency regime that legalized the use of foreign currency denominations in Zimbabwe. There were clinical procedures and standards to protect health personnel from accidentally contracting diseases. Amongst these were prophylaxis guidelines and a protocol outlining procedures for handling HIV/AIDS patients for accidental exposure. The local board intervened through a top-up allowance for health personnel at the two municipal clinics, while the mission did the same for some of its workers. The amount paid was about a quarter of the monthly salaries, it was paid mid-month and it was separated from monthly salaries. The local board provided free residential stands to health personnel as a form of long-service benefit. Workers who had been at the two municipal clinics for at least five years received this benefit. Health personnel also expressed appreciation for the support they received from the board related to the provision of medical supplies and sundries. Witter et al., 2016 The free health care initiative: how has it affected health workers in Sierra Leone? HRH reforms Fast-tracking of recruitment and deployment to fill gaps in staffing were undertaken, plus payroll cleaning to eliminate ghost workers. Salary improvements were introduced to ensure that health workers were adequately paid and motivated to handle the increased workload. A combination of political momentum, donor buy-in and deployment of rapid technical A system of monitoring staff absences was introduced, linked to a new staff sanction framework. There were challenges as well, some of which predated the free health care initiative and still remain to be addressed, such as the lack of certain cadres, the unequal distribution of staff across the districts, and the need for a revised training policy and for a Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 73 assistance worked to bring in a series of major changes for health staff. These were continued over 2010- 2012. more systematic package of financial and non-financial incentives, especially for those working in rural areas. Zulu et al., 2013 Developing the national community health assistant strategy in Zambia: a policy analysis HRH Reforms There is need to recognize that actors' power or position in the political hierarchy- more than their knowledge and understanding of the issue - may play a disproportionate role in shaping the process as well as content of health policy reform. The members of the strategic team complained that there were no regular updates on what was being done, by whom and at what time. The poor communication systems within the strategic team were noticed also with regard to the accessibility to the strategy and the awareness of its contents. Afriyie et al., 2021 Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders' perspectives Health governance reforms Governance factors that emerged from participants as facilitators of reforms included a shared strategic vision for a single mandatory health insurance, community engagement and collaboration with diverse stakeholders in the implementation of health financing policies and enhanced monitoring of the improved community health fund (iCHF) enrolment owing to the digitization of the registration process. Governance factors that emerged as barriers to the implementation were a lack of transparency, limited involvement of the private sector in service delivery, weak Having clearly defined policy guidance is an important element of good governance. Stakeholders' responses about the current health financing strategies and arrangements were consistent and coherent. Most stakeholders reported sharing the strategic vision with the aim to implement a mandatory and single national health insurance. Governance factors that were cited to contribute to inadequacy of resources included system design, poor regulation and incentives, weak accountability of revenues and limited intelligence or information. Community level stakeholders mentioned ensuring accountability in the submission of the premiums collected by enrolment officers as an issue. Participants explained that one of the challenges affecting implementation of iCHF was that its design did not account for financial resources to support districts' community education and awareness activities. Regional level participants mentioned that the iCHF digital system enabled them to monitor daily enrolment without having to travel to the district levels. The availability of medicines in public health facilities was often limited, therefore, even iCHF members may have had to pay out of pocket for medicines at pharmacy outlets. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202374 Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 75 assessment of the effectiveness of the community health strategy on health outcomes in Kenya functional, and this could be easily identified from the chalkboards that were updated on a monthly basis and topics for dialogue drawn from the chalkboards. Dialogue was the major component of the community health strategy, based on evidence from the community dialogue days, which had attracted more participants than the community action days. Consistent with the aims of the community health strategy, the model emphasized collection of relevant data for evidence-based planning and provided a forum for exchange of information between the providers and clients. Maimela et al.,2018 Interventions for improving management of chronic non- communicable diseases in Dikgale, a rural area in Limpopo Province, South Africa Integration of health services The focus is on the development of a model that focuses on integrating nursing services providers, CHWs and traditional health practitioners, including a well- established clinical information system for health care providers. A novel aspect of the model is the inclusion of community ambassadors who are on treatment for NCDs and are, thus, repositories of knowledge, whocanserveasabridge between health care workers and community members. The creation of a supportive environment by the district and provincial offices for the health care workers was identified as a need in enhancing the environment for all employees to improve their productivity and morale. Support systems in the form of supervisory visits to clinics, provision of medical equipment and training of health care providers should be provided. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202376 I Bvumbwe and Mtshali, 2018 A middle-range model for improving quality of nursing education in Malawi HRH Transforming and scaling up of nursing education emerged as the main concept of the model, and the main strategies in the model included curriculum reforms, regulation, transformative learning, provision of infrastructure and resources, and capacity building. There is need to have curricula that respond to the health care users. The findings show that there is a mismatch between the type of nurses and the expectations of the service users. Several factors have been associated with this situation including inadequate financing of the health systems, high illiteracy level and lack of competent health service providers. There is a disjoint between competence needs and the population's health needs. The need for more space, infrastructure and resources cannot be ignored owing to the increasing number of students. Infrastructure and resources to support transformative methods are needed at both educational and practice institutions. Transformation needs to take place at national, institutional and programme levels, guided by policy and frameworks that define the national agenda for health. A well-established system of regulation and accreditation of nursing education in Malawi, the Nurses and Midwives' Council, ensures that all nursing programmes being offered in the country are approved and accredited. Maningi et al.,2014 Does training on performance- based financing make a difference in performance and quality of health care delivery? Health care provider's perspective in Rungwe Tanzania HRH Most of the health facilities were able to implement some of the PBF concepts in their workplaces after the training, such as developing job descriptions for their staff, creating quarterly business plans for their facilities, costing their services, entering service agreements with the government, improving record keeping and customer care, and involving the community as partners in running their facilities. The training aimed to improve general knowledge and skills on how to implement the PBF intervention. The participants included different cadres of staff working in FBOs and government health care facilities in Rungwe district. The establishment of facility boards has helped to improve communication between communities and health facilities. The lack of job descriptions was cited as key issue. However, hospital administrators were able to design job descriptions for all cadres after attending the PBF training. It is well documented that workers who are aware of their roles and responsibilities are more likely to perform their duties better and hence improve the overall quality of care. Prior to PBF training in Rungwe, none of the health facilities had business plans, but they used annual plans derived from five- year strategic plans. After the PBF training, most health facilities developed their quarterly business plans in a participatory manner. There was lack of financial transparency and accountability prior to the PBF training. The PBF approach addressed these concerns through fostering implementation of well- established financial systems, including annual financial auditing. Chen et al., 2021 Does decentralization of health systems translate into decentralization of authority Health governance reforms Managerial functions that require less financial or logistical investment, that is discipline, may be more susceptible to differences in de jure and de facto decision space than those that necessitate greater investment in those areas The findings elaborate upon previous research establishing synergistic relationships between de facto decision space for district level administrators and institutional capacity in Pakistan. A similar relationship was seen in Uganda between de facto decision space for lower level facility managers and the Public hospitals and level IV health centres can independently requisition drugs from the National Medical Stores - Uganda government's central medical supplies distributor. This is because they are assumed to be large enough to have the human resources and technical capacity Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 77 (i.e., recruitment and promotion). Decision space was significantly positively associated with some managerial performance indicators, such as essential drug availability, but not others, such as performance management and quality improvement measures. median essential drug availability, which can be interpreted as a possible outcome of improved capacity. to manage their own supply chains. Scheneider et al., 2014 Whole-system change:case study of factors facilitating early implementation of a primary health care reform in a South African province PHC strengthening and expansion The factors that helped change to happen in the pilot sites of the Northwest Province were (1) alignment of the scopes of work, training and M&E systems with, for example, the structured processes of household screening, such that teams were able to begin their work with a sense of self-efficacy, (2) community dialogues that facilitated entry in communities, (3) the support and mediating roles of the team leader and (4) support and oversight from the subdistrict or district management and the Health Systems Trust. A donor-funded partnership with a national NGO, Health Systems Trust, secured not only technical support for planning but also skilled facilitators able to work with a range of internal and external actors. Implementation involved a sequence of steps starting with formal planning at the provincial level. This was followed by a fairly intensive subdistrict process facilitated by Health Systems Trust, consisting of community dialogues, participatory planning, nomination of CHWs and team leaders for training by district and subdistrict players, the establishment of PHC outreach pilot teams in each subdistrict, and the mapping of households in the pilot areas. The implementation process paid attention to system inputs, that is planning, information, and workforce management and training and their alignment, plus the selection of pilots and a deliberate focus on communication and engagement with communities and local managers. These structures included the PHC Re-engineering Task Team, or the Task Team, a full-time coordinator or champion seconded from the provincial structures, and coordinators appointed for the district and subdistrict levels. These coordinators served as liaison between local area managers, team leaders and management in the district offices and the province. The establishment of special implementation structures, that is the Task Team and coordinators at various levels, and the partnership with the NGO were key mechanisms for bringing together line and support managers for up and down communication and problem solving, and for holding the players accountable. Community dialogues served as mechanisms for information dissemination and mobilization of support for household profiling and registration, as well as explaining the new roles of CHWs. The Health Systems Trust played an important role in generating evidence for planning and implementation. It conducted a baseline audit of the numbers of CHWs in the province employed through nongovernmental intermediaries and undertook geo- mapping of households in pilot wards to plan the household registration process. The absence of dedicated financial resources from national or provincial government was the most significant threat to sustained implementation at scale. Funding was particularly required for the large numbers of additional nurses required as team leaders and to ensure a fairer remuneration dispensation for CHWs, who were expected to work full time. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202378 Shemdoe et al., 2016 Explaining retention of healthcare workers in Tanzania: moving on, coming to 'look, see and go', or stay? HRH Perceptions of personal safety and feeling that patient outcomes were compromised by poor care or as a result of perceived failed promises were cited as the reasons for wanting to leave. Staying and coping with unsatisfactory conditions was often about being settled into a community rather than into the post. Health workers who were previously urban dwellers were particularly unsettled, confronted with poor mobile communication and transport, lack of safe water and electricity, and fear and superstition from resident locals. The lack of equipment was perceived as critical, principally when this meant workers would be unable to protect their personal safety. Transport issues, leaving workers exposed to night time dangers, were particularly pertinent to female workers. Schneider et al., 2015 The challenges of reshaping disease specific and care oriented community based services towards comprehensive goals: a situation appraisal in the Western Cape Province, South Africa NCDs, mental health conditions Reorienting community- based services that have origins in care responses to HIV/AIDS and tuberculosis presents an interrelated set of resource mobilization, system design and governance challenges. These include not only formalizing community-based teams themselves, but also defining new roles and forging new relationships and mind-sets within the PHC system, and creating greater capacity for contracting and engaging a plural set of actors, that is the government, NGOs and the community at the district and subdistrict levels. Measures are required to ensure greater retention and stability of the existing core cadres while expanding their numbers, redefining and extending their roles and investing in their training; designing new, aligned, and integrated management systems; reshaping relationships in the PHC system among CHWs, NGOs, communities and other sectors; and creating the capacity for governance of community-based services at local levels. There is a question as to which, between integration into the public sector workforce and remaining within the NGO sector is the most appropriate organization location for community-based services and CHWs. At the time of the appraisal, NGOs were in reality returning routine monthly activity reports through an elaborate community-based services information system that involved 46 data elements and extensive form filling. This system produced information that was regarded as of poor quality and which no one trusted. There were effective systems of financial management, but the day-to-day performance of CHWs and NGOs was seen as difficult to manage and control. NGOs had their own and diverse imperatives and did not necessarily share the vision of the health department. The system was unstable with poor retention and high turnover of CHWs owing to low stipend payments. There was little direct supervision of CHWs by NGO nurse coordinators, and the referral systems feeding the platform were complex. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 79 Phillips et al.,2018 What do you do with success? The science of scaling up a health systems strengthening intervention in Ghana The common factors linked to success of health systems strengthening included the application of the principles of 'acorn-to- oak tree' principle (a small- scale initiative can lead to system-wide reforms); the 'data-to-information-to- intelligence' principle (the role of IT and data are becoming more critical for delivering efficient and appropriate care, but must be converted into useful intelligence); and the 'many-hands' principle (con" In the United States of America, success was found through improvements of safety systems in surgical care. In Jordan, enhanced accreditation and regulatory standards were identified as success factors. In Namibia, a country with a multitude of complex challenges, success was nurtured through the implementation of quality management systems. An environment where the appropriate stakeholders are engaged and are communicating effectively and collaborating, and where governance, leadership and accountability are assigned in the right places This systemwide initiative aimed to optimize responses to patient emergencies with the most appropriate medical resources. The programme implemented colour-coded, standardized observational charts with clinician prompts for escalation if a patient deteriorated. By funding projects that are initially modest in scale and piloting or testing the improvement initiatives, reformers can help shape the environment, preparing the ground for later implementation of measures that can lead to systemwide enhancements. Akhnif et al., 2018 Are our 'UHC systems' learning systems? Piloting an assessment tool and process in six African countries UHC reforms Assessing the extent to which UHC systems and processes at the country level operate as learning systems The possible actions identified for strengthening the learning capacity of the UHC system included creation of a national community of practice platform to share knowledge, some training on leadership for leaders of UHC organizations, creation of a group of experts to promote the learning systems' culture, and auditing of the existing strategies to identify bottlenecks and suggest corrective actions. In Morocco, the creation of an inter-ministerial steering committee for UHC allowed a strategic positioning of the UHC agenda at the level of the government, with a clear benefit in reducing the gap between knowledge and strategic decision- making. The creation of a high interdepartmental committee chaired by the head of the government has strengthened learning by the leadership for because of the generated need to prepare for the meetings of this committee. The creation of a sectoral framework for dialogue on health and nutrition under the leadership of MoH offers a platform for broad exchanges between actors on major issues of the health sector. This is a platform for sharing knowledge by using the latest technology, broadening the occasions and spaces for meetings to share knowledge among actors, and better positioning research to ensure more use of the synthesized knowledge in the policy-making process. Aninanya et al.,2014 Establishing sustainable performance- HRH reforms The study showed that health workers have considerable interest in In Tanzania policy-level respondents broadly favoured financial incentives in the form of either a further salary Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202380 based incentive schemes: views of rural health workers from qualitative research in three sub-Saharan African countries performance-based incentive schemes and are concerned about their sustainability. There is a need to further explore the use of non-financial incentives in such schemes, as such incentives were considered to stand a greater chance of being integrated into local budgets. Ensuring participation of health care providers in the design of such schemes is likely to achieve buy-in and endorsement from the health workers involved. increase for all workers or payment of extra duty, housing and transport allowances. Taderera et al.,2017 Human resource for health reform in peri-urban areas: a cross- sectional study of the impact of policy interventions on healthcare workers in Epworth, Zimbabwe HRH reforms The impact of post-2008 HRH reform policy interventions on health care workers in Epworth, a peri-urban community in Harare, Zimbabwe, and the implications towards health sector reform policy in peri-urban areas The enquiry revealed policy result areas that included financial and non-financial incentives, support for basic and post-basic training, health and safety welfare, deployment of adequate staff, and workload levels, deployment of community health volunteers, provision of equipment and tools of trade, and salaries. The payment of salary top-up allowances is the main financial incentive often used in health care worker reform interventions. In Malawi, these allowances facilitated the implementation of the six-year Emergency Human Resources Programme. The HRH reform interventions in peri-urban communities must include the provision of a free or specially subsidized medical aid scheme for health care workers, particularly The exodus of community volunteers was compounded by the lack of equipment and uniforms and unfulfilled promises that included non-payment of an allowance, which also undermined motivation. Also compounding the issue were low salaries. Despite the denomination of salaries in US dollars and elimination of delays in their payment, health care workers found them inadequate to meet all their basic expenses, amongst which were transport, food, rental expenses, clothing and school fees. Information and knowledge about safety protocols must be disseminated through training to all health care workers so as to ensure their safety. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 81 those who work in high risk areas of health care delivery. Kebede et al., 2010 Educating leaders in hospital management: a new model in sub- Saharan Africa HRH reforms The lessons learned include the need to: (1) balance education in applied technical skills with more abstract thinking and problem solving, (2) recognize the interplay between management education and policy reform, (3) remain flexible, as policy changes have direct impact on the project, (4) be realistic about resource constraints in low-income settings, particularly information technology limitations, and (5) manage the transfer of knowledge for longer term sustainability. Flexibility and creativity played a crucial role in effective programme design, as policy changes that affected the trainees were frequent and dynamic. For the North, the process of transferring responsibility for an institution in the South without abandoning the institution remains a strategic challenge. Inadequate infrastructure, particularly in information technology, substantially limits productivity in education. Limited and slow Internet connections can be limiting in executive education with chief executive officers working in various settings across the country. Be realistic about the resource constraints in low-income settings, particularly information technology limitations. Bertone et al.,2018 The bumpy trajectory of performance- based financing for healthcare in Sierra Leone: agency, structure and frames shaping the policy process Health financing Adopting shared frames to ensure a common and inclusive understanding of technical concepts such as PBF may be useful to ensure the political sustainability of reforms. Also, the actual frames that define negotiation and implementation should remain flexible, allowing for disrupting events (e.g., the Ebola epidemic in Sierra Leone) and for time to develop national capacity and ownership in order to Very few or no links were made to some aspects of PBF such as increasing autonomy and accountability as an integral element of the wider health financing architecture. So the new discourse was grounded in old narratives narrowly related to increased income for staff and facilities. Historical and structural legacies shape the context of policy-making on health financing in Sierra Leone (including and beyond PBF) in a way that is mostly defined by the lack of domestic funding and aid dependency. An important feature is the financial dependency of Sierra Leone on aid funding. The national health accounts for 2013 revealed that 24.4) of the total health expenditure of US$ 95 per capita is contributed by development partners, with an additional 7.2% by NGOs. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202382 ensure longer term political support and better health system integration. Sayinzoga and Bijlmakers, 2016 Drivers of improved health sector performance in Rwanda: a qualitative view from within Health governance reforms There is need for policy- makers and scholars to acknowledge the complexity of health systems and the fact that they are dynamic and influenced by society's fabric, including the overaII culture of performance management in the public sector. Community health activities came out as having contributed most to better health sector performance, followed by improvements in HRH. Expansion of physical health infrastructure scored the lowest. PBF should therefore not be simply seen as a financing mechanism or an initiative that enhances staff motivation and/or community involvement, but also as an instrument that nurtures a climate of continuous performance appraisal and problem solving. Improved water supply and sanitation are considered important determinants of health sector performance, as are clear organizational or institutional frameworks and their coordination, strategic or target-based planning, accountability, teamwork and stakeholder engagement. The elements cited as improvements in the health system included the close monitoring at all levels of trends in key indicators and the corrective measures that were being taken; the community health information system and rapid SMS alert, and the standardized community health information system introduced by MoH that makes data collected by CHWs available at the subnational and national levels and that complements the health facility-based data in the national health information system. Meier et al., 2012 Implementing community participation through legislative reform: a study of the policy framework for community participation in the Western Cape province of South Africa PHC strengthening and expansion Supporting community health committees through a participatory policy would require investment in how to mobilize communities to select representatives, how to ensure that the committees meet regularly, how to engage health services management, and how to coordinate communities with management at the local clinic level. The government lacks a clear vision on how the district health system can institutionally support community engagement to promote meaningful participation of the community in the health system. Western Cape has begun to put in place formal institutions for district health system oversight. But the Cape Metro Health Forum executive has not been able to collaborate adequately in a process in which it has no legislative standing or defined mandate within the district health system. Given these institutional limitations to community participation under informal arrangements, the Cape Metro Health Forum representatives expressed significant alienation from the health system, highlighting how a lack of defined authority has left the forum without any formalized basis to engage with the district health system. Several stakeholders noted There remains ambiguity over how the department might communicate effectively with its constituents, give voice to community representatives and relate institutionally to community participation structures. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 83 that the lack of clearly defined processes for representation creates an environment in which community representatives do not have a clear relationship with the communities for whom they claim to speak. Argaw et al., 2019 Improved performance of district health systems through implementing health center clinical and administrative standards in the Amhara Region of Ethiopia PHC strengthening and expansion The majority of the district health system performance management scores were significantly improved in four areas, that is leadership and governance, health centre-health post linkage, clean and safe health facility, and quality improvement and health information systems. This result could be due to the technical and financial support provided to successfully implement change packages. Through the involvement of stakeholders, the project enhanced the capacity in the use of systematic problem-solving tools, developing agreed action plans and ensuring appropriate measures and actions were taken. During the intervention period, improvements occurred in the average scores of the standards met such as in leadership and governance (from 73% to 77%), health centre- health post linkage (from 73% to 77%), clean and safe health facility (from 69% to 75%) and quality improvement and health information systems (from 68% to 75%). The project strived to institutionalize social accountability and implemented health system strengthening initiatives so that the community would receive safe and quality health services at the PHC level. The tailored technical, financial and other resource support enabled the district health system managers to create a conducive work environment for the health workforce. The participants included managers who were directors of the health centre, board chair and health centre- health post linkage focal person who was responsible for assessing, focusing, planning, organizing, aligning, implementing, monitoring and evaluating the health system strengthening activities. Kyomugisha et al., 2009 Strategies for sustainability and equity of prepayment health schemes in Uganda Health financing Fairness was seen through the very low fees required for the services received, with members paying less than non-members but both groups getting the same treatment and with no patient being discriminated against based on gender, age or social status. The insurance schemes were not sustainable because they operated on small budgets, had low enrolment and lacked government support. The Unfairness was depicted in the way non-members of scheme were often given better treatment than members in community health insurance health facilities. Non- members paid cash and usually paid more than members, so health workers felt they needed to be given first priority in treatment. Premiums levied as a flat sum pose a disadvantage to the poorest and are, therefore, regressive in that they do not favour low income earners and those with diseases that are expensive to treat. The lack of a legal framework and policy to govern community health insurance schemes could create their distrust among people. The schemes provided some funds for the procurement of drugs and payment of equipment for the health facilities to which they were attached. The removal of user fees from public sector facilities did not necessarily improve access. There are still problems such as unofficial fees, drug stock-outs and overworked staff, who are usually too tired to provide quality service. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202384 effect of the abolition of user fees on the scheme's enrolment was minimal. Aantjes et al.,2014 Practicalities and challenges in re- orienting the health system in Zambia for treating chronic conditions NCDs, mental health reform Challenges exist in the form of the lack of proper NCO prevalence data for planning, a concentration of technology and skills to detect and treat NCDs at secondary and tertiary levels in the health system and limited interest by donor agencies to support the transition. The national health policy, for example, is aligned with national community and economic development policies and seeks to provide all Zambians with quality health care as close to the family as possible. This implies a commitment to provide integrated disease treatment and management at the level of PHC. Primary health facilities such as health posts were established, as well as mechanisms to engage communities. These included neighbourhood health committees and elaboration of home-based care into community home-based care as the antiretroviral therapy programme expanded and as NGO and FBO care organizations diversified their services. The coordination of activities was extensive and involved overseeing staff at the PHC health facilities, community agents such as neighbourhood health committees and community volunteer caregivers, and the managers and supervisors of NGO and FBO community health and social welfare programmes. HIV services, including provision of antiretrovirals and management of opportunistic infections, have been decentralized to the PHC level, thereby showing the ability of the system to deliver quality health care as close to the family as possible. Zambia has been a recipient of large amounts of dedicated funding for health system strengthening and HIV interventions since the mid-2000s. Data on HIV/AIDS are consistently collected through the country's health management information system, which is supported by data retrieved from a countrywide electronic system tracking patients who test positive for HIV or are enrolled in treatment services. This system, called Smart Care, captures and stores individual patient information on a chip card that is provided to the patients. Nyamhanga et al., 2014 'We do not do any activity until there is an outbreak': barriers to disease prevention and health promotion at the community level in Kongwa District, Tanzania PHC strengthening and expansion Decision-makers at national and district levels lack the necessary political will to prioritize disease prevention and health promotion. The importance of disease prevention and health promotion stated in the national health policy is Disease prevention and health promotion activities are not adequately articulated in the comprehensive district health plan. The respondents revealed that governance structures for disease prevention and health promotion at the village level are weak. The present structures are the village health committee, dispensary governing committee, and ward development committee. The lack of transparency in the way the Disease prevention and health promotion activities are grossly underfunded. From the resource allocation point of view, such activities are marginalized, as only 25% of the district health funds are allocated to them. Platforms for tapping people's felt health needs and for organizing community- based initiatives are virtually non- Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 85 not reflected in district health plans. There is gross underfunding of community-level disease prevention and health promotion activities and limited community participation. committees are constituted results in their incompetency. existent. That is, the system of involving communities through committees does not provide enough room to reflect the communities felt health needs in the council's comprehensive health plan. Sanogo et al.,2019 Universal health coverage and facilitation of equitable access to care in Africa UHC reforms Although UHC seems to increase the use of health services, shortages of human resources and medical supplies, sociocultural barriers, physical inaccessibility of health services and lack of education and information, decision- making power and gender- based autonomy, along with previous experiences for example during prenatal visits and fear of caesarean delivery were still found to deter access to and use of health services. In Madagascar, exemption from payment for health care in rural areas has led to an increase in the use of health services. In Ghana, the introduction of the government health insurance scheme saw an increase in the proportion of pregnancies with at least four antenatal visits. In Malawi, the shortage of health care providers and materials, combined with various factors such as late bill payments and lack of transparency, has greatly affected the health system's performance. Ghana has witnessed a rapid increase in its supply of professional health workers. In Rwanda, social justice initiatives allow people living in poverty and the more advantaged social classes as defined by WHO standards to have access to primary health services. A study shows that in Ghana a key area of misalignment between the operations of the national health insurance and PHC was the delays in reimbursements of claims for services provided by health care providers, which served as a source of demotivation for service providers. Ghana and Rwanda are success stories in this area, as they have strategic plans for the governance of their health systems according to WHO standards. Lutwama et al., 2012 A descriptive study on health workforce performance after decentralisation of health services in Uganda Health governance While the study shows that health workers are productive, 50.4% of them reported that their organizations did not have indicators to measure their individual performance. The findings indicate that the health workers were skilled and competent to All health workers indicated that that they had initiated better ways of performing their core tasks. A large proportion of health workers (90.2%) agreed that they had developed new and improved methods to help their work units or teams perform better. Of the health workers, 80.1% agreed that their skills were suited for the type of work they did. The majority of health workers {79.7%) indicated that availability of drugs and equipment improved their productivity. Most health workers (70.3%) indicated that their health facility management encourages them to perform well. 86 Managing change towards universal health coverage: service provision in Africa | Technical Brief | November 2023 Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 87 Table AP-2: Abstraction of data on hardware for Asia Mahipala, 2016 Reorienting the focus towards the Sustainable Development Goals: challenges and opportunities for Sri Lanka Health system reform Development of measurement approaches for UHC using coverage index and incidence of catastrophic spending (four quadrants) Service capacity and access achieved with a free medical health care facility established within 4.8 km of every household, and a health care facility can be found, on average, not further than 1.4 km from any home Coverage index tracer indicators developed for accountability, and availability of 100 essential medicines at the community level Tangcharoensathien et al., 2020 Framework for managing the COVID- 19 infodemic: methods and results of an online, crowdsourced WHO technical consultation Access to quality care, financial reforms, PHC strengthening Development of measurements for UHC using coverage index and incidence of catastrophic spending (four quadrants) and identification of strategies for eight countries Development of objective measures for UHC Behera and Dash, 2020 Is health expenditure effective for achieving healthcare goals? Empirical evidence from South-East Asia Region Health financing reforms Increasing expenditure on health Policy in place, strategy in place Ved et al., 2019 India's health and wellness centres: realizing universal health coverage through comprehensive primary health care Health system, HRH, financing and pharmaceutical reforms, digital technology and ICT Reforming comprehensive primary health care through reforms in HRH and financing, providing free dispensing of medicines at the community level and using digital technology and information management systems Use of digital technology and information systems Mohanty and Kastor, 2017 Out-of-pocket expenditure and catastrophic health PHC reforms Establishment of the National Health Mission, introduction of cash incentives and regulation of service Regulation of service providers, accreditation of Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202388 spending on maternal care in public and private health centres in India: a comparative study of pre and post national health mission period providers on pricing and quality of care health facilities for quality Taneja, 2005 National rural health mission - a critical review PHC reforms Decentralizing village and district level health planning and management, introducing a non- health professional cadre at the community level Decentralization of health services Reddy et al., 2011 Towards achievement of universal health care in India by 2020: a call to action Health system reform Creation of the Integrated National Health System in India through provision of universal health insurance; establishment of autonomous organizations to enable accountable, evidence-based, good quality health care practices; development of appropriately trained human resources; restructuring of health governance to make it coordinated and decentralized; and introducing legislation of health entitlement for all Indian people Integrated health service delivery Establishment of independent organizations to ensure accountability Bezbaruah et al., 2021 Roles of community health workers in advancing health security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region Human resources reform Use of CHWs to respond to an emerging health security issue The priority staff are the staff providing direct care Managerial staff at national or district level Healy et al., 2018 A framework for comparative analysis of health systems: Health system, decentralization and reform, health Decentralizing health policies in Indonesia; introducing a mandatory new health insurance scheme for decentralization Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 89 experiences from the Asia Pacific Observatory on Health Systems and Policies financing, human resources entire rural communities in China; introducing a single-pool mandatory health insurance scheme for low- income groups, government and company employees in Indonesia; introduction of a single-pool mandatory national health insurance scheme in Philippines; strengthening PHC to respond to the needs of aging populations and NCDs in Thailand; promoting autonomy in the management of finances and services in the Philippines and Thailand; introducing clinical governance of hospitals with clinicians dominating as hospital leaders in India and Thailand; establishing health technology assessments in Thailand, Vietnam and India; regulating dual practice in Indonesia and Thailand; introducing civil and vital registration systems; and reducing out-of-pocket payments for health services. Mahendradhata et al., 2017 The Republic of Indonesia health system review Decentralization and health financing Decentralization of health financing, introduction of greater autonomy in health financing, improving quality of medical education, introducing a national health insurance Decentralization Ofrin et al., 2020 Strengthening risk communication systems for public health emergencies in the WHO South-East Asia Region Policy reforms Community engagement and risk communication Community engagement and participation Holzhacker and Agussalim, 2019 Sustainable development goals in Southeast Asia and ASEAN:nationaland regional approaches Health financing, health service integration Integration of service delivery Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202390 Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 91 Table AP-3: Abstraction of data on hardware for Europe Dominis et al.,2018 Keys to health system strengthening success: lessons from 25 years of health system reforms and external technical support in Central Asia General health system strengthening Change around three control knobs - financing (pooled budgeting) regulatory systems and organizational processes, (health information systems and improved human resources) Policy choices made early listed were regarded as key determinants of success Institutional changes to align with the insurance scheme would take some time Application of a pool of financial data to guide processes Latifi et al., 2016 Access to specialized care through telemedicine in limited-resource country: initial 1,065 teleconsultations in Albania Service delivery and health information systems Development of policies and procedures, building of network systems and infrastructure, and training will be carried out in phases Policies developed at the national level with help from international partners and disseminated to lower levels Structures defining how patients will be referred from one level to another and how different levels of will hospitals interact Integrated telemedicine and e-health programme, electronic virtual library, virtual education programme, telemedicine to be part of the MoH budget, and development at the national level of standard operating procedures and their dissemination Nicholson et al., 2013 A governance model for integrated primary/secondary care for the heaIth- reforming first world - results of a systematic review Health system delivery, care integration Policies and restructuring Strategies that support sustainability of health reform implementation should be adequately financed Integrated ICT, committed resources Avby et al., 2019 Tending to innovate in Swedish primary heaIth care: a qualitative study PHC Introduction of policies and financial reforms Policies were put in place to guide the change. Most importantly, the policies were required to be of professional relevance. Creation of centres for integrating health and well- being, regrouping the units created to reduce waiting time for patients, ordering group activities. Visible and understandable performance measurements, e-health services and accessible feedback tools were developed and also applied. Denis and van Gestel, 2016 Medical doctors in healthcare leadership: Mixed financial service delivery Introduction of legislation, financial reforms, market- based reforms Joint and collaborative policy initiatives that pay serious attention to Collaborative work between medical doctors and the state is still an emerging phenomenon. The use of financial incentives to let the executive board and the medical doctors in Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202392 theoretical and practical challenges and organization capacity development and policy coherence can be a promising avenue. A compensation policy is needed for doctors who take up additional roles. Organizational policies with overly focused top-down performance indicators and competition seem to turn out to be counterproductive. hospitals agree on common goals has been predominant. Fraser et al., 2017 'Holding the line': a qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London Systemwide health service reconfiguration Implementation of policy change, power mobilized by senior managers in order to maintain the status quo Report on the current state of stroke services created a blueprint for change with a useful degree of 'strategic ambiguity. A communication strategy was created. A hub and spoke model was chosen. The hierarchical power of a Strategic Health Authority executive over key managerial and professional actors highlights how senior managers could hold the line throughout key national health service organizations. Evidence-based literature was developed to form the basis for challenging the current systems and proving why change had to take place. Wedel et al., 2007 Turning vision into reality: successful integration of primary healthcare in Taber, Canada Health care service delivery Policy and reconfiguring of service delivery, including utilizing population health research, integrating health care service delivery, creating sustainable collaborative partnerships and practices, improving cost- efficiency within the health care system and developing and implementing social and health care policy Organizational change strategies were used to address resistance at the system and personal levels, as well as to remove barriers at the infrastructure level. Co-location led to a significant improvement in communication among health care providers. Clear roles for each clinical management team were defined that ensured effective use of health care system resources and supported health care professionals in implementing best practices. An integrated electronic information system used programme budget marginal analysis to redefine priorities and develop success indicators. Services for NCDS were integrated. Smyth, 2009 Making integration work requires more than goodwill Health service delivery integration and governance Organization and clinical setup changes The governance strategy has influenced public accountability Early in the integrated planning and implementation process, clarity was required on the types of decisions to be made, by whom and within what parameters. With multiple partners with unique boundaries with organization structure was it was challenging making a decision as organization felt the need to protect their tuff. The multiple care pathways and the need for their integration have increased the need for collaborative relationships. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 93 Suter et al., 2009 Ten key principles for successful health systems integration Health service delivery Bringing together organizations and services into an integrated health system through contractual relationships or networks typically requires development of governance structures that promote coordination. The success of integrated health systems depends on well-developed performance monitoring systems that include indicators to measure outcomes at different levels. There are protocols and procedures that reflect the importance of measuring care processes and outcomes, and of using the information for service improvement. Systemwide computerized information systems that allow data management and effective tracking of utilization and outcomes also are available. Almajali et al.,2016 Antecedents of ERP systems implementation success: a study on Jordanian healthcare sector Health service management and governance Training, supportive leadership, ease of use, user satisfaction and enterprise resource planning (ERP) implementation success ERP Van Veghel et al.,2020 Organization of outcome-based quality improvement in Dutch heart centres Service delivery Quality is often part of the key elements in a strategy. Often, quality is not well defined, and in strategies, it is usually limited to high level definitions. The heart centres have a multidisciplinary organizational structure and have meetings to discuss outcomes. Challenges in data infrastructure, data management and acquisition of high-quality data are seen as some of the important barriers to realizing outcome-based improvements. Atun et al., 2007 Diffusion of complex health innovations - implementation of primary health care reforms in Bosnia and Herzegovina Service delivery Organizational (decentralization), financial (budget funding), clinical (creation of family medicine teams, establishment of specialist training and management programmes) and relational changes Policies or innovations are not simply disseminated but rather are assimilated into the health system Misunderstanding or lack of understanding of the scope, objectives and values of the family medicine reforms and changing organizational routines led to a division of cultures. The new family medicine model that placed emphasis on holistic and user-centric health care Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202394 Atun et al., 2006 Introducing a complex health innovation - primary health care reforms in Estonia (multi-method evaluation) Health financing, service delivery, governance Changes in organization, regulation, financing, resource allocation, provider payment systems and service provision The strategic planning responsibility was retained by the national team, and some planning responsibilities were decentralized to the county level. Close collaboration between the two enabled the development of realistic policies. A consolidated tripartite polyclinic structure was introduced, where hitherto services had been separate for women, children and adults. Organizationally, the hospital sector has been rationalized and novel organizational structures such as independent practitioners and partnerships have been established in PHC. There is increased effectiveness of PHC with enhanced continuity and comprehensiveness of services, reduced hospital referrals from family physicians for chronic conditions and improved management of chronic illness in the PHC setting, evidenced by the changing prescribing patterns. These point to the increased uptake of best practices and improved user satisfaction. Hernandez- Quevedo et al.,2018 20 years of health system reforms in Europe: what's new? Heath financing, device delivery, HR Enacting various laws and policies, changing payment systems, introducing quality of care committees A roadmap with cross-party support and buy-in from a wide range of stakeholders including health workers can be a powerful tool. Changes in the models of care involving networks and integrated pathways. The successful introduction of active purchasing mechanisms, for example, also relies on good data, so it is necessary to strengthen IT capacity in parallel. Ham, 2010 Working together for health: achievements and challenges in the Kaiser NHS beacon sites programme Service delivery Service delivery innovations, telephone- based service that provides proactive care to patients with long-term conditions in Birmingham, closer integration of health and social care via Care Trusts in Solihull and Torbay, and a focus on long-term conditions and leadership development The programme is embedded in a comprehensive organizational development plan, a competency framework designed for consultants, the redesign of acute care, and two key financial strategies in the Integrated Care Pilot to take into account the interests of the acute care and primary care providers' services such as building new emergency centres. An organizational merger in 2006 inevitably consumed the time and energies that might otherwise have been directed at other issues. Measuring the system performance in terms of quality, timeliness and cost over time is proving an effective way of getting clinicians and managers to see issues from the patient rather than the organizational perspective. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 95 Harris, 2012 The North West London Integrated Care Pilot: innovative strategies to improve care coordination for older adults and people with diabetes Service delivery and HR coordination Implementation of the Integrated Care Pilot programme that developed and established financial and governance arrangements The Integrated Care Pilot programme partners' group is chaired by an independent chairperson and bound by the requirements and stipulations of a legally binding establishment agreement. The presence of a board, operation teams and subcommittees with defined mandates An IT tool to extract and use data from general practices, acute care trusts, community services, social care and mental health care services Jackson et al.,2000 The primary care amplification model: taking the best of primary care forward Health service delivery The development of a formal partnership between the University of Queensland and Queensland Health enabled the development and piloting of the primary care amplification model at Inala Primary Care. The practice's strategic plan requires it to support local services in areas of important population need, identify key service gaps for the local community and promote useful local education and research activities involving local practices. All patients are referred by local general practitioners (GPs) and return to the care of their GP following stabilization of acute complications. Effective two way communication with these GPs is a priority. Inala Primary Care uses a multi-site information management and technology platform for all clinical and practice management functions. Jackson and Nicholson, 2008 Making integrated healthcare delivery happen - a framework for success Health service delivery Introducing a service integration framework, change management and clinical practice, training and professional development, ICT and appropriate clinical and organizational governance Effective communication strategies, assisted with building alliances and teamwork, result in greater feelings of equity, trust, respect and goodwill between organizations and individuals. Establishing improved communication between providers with the use of ICT has been a key focus. A pilot e- referral and e-booking system was established between local GPs and hospital outpatient departments. Suter et al., 2009 Ten key principles for successful health systems integration Service delivery integration Multiple aspects highlight 10 essential areas to change in the health system. Resources have been committed to the development of processes and strategies that support implementation of guiding principles for integration. A flatter, more responsive organizational structure that fully uses the skills and talents of employees and is independent of, but accountable to, the government and the health organization's rostered members and providers facilitates integration. Other factors are an organic structure with diverse communication channels that efficiently transfer information Shared protocols, well- developed performance monitoring systems that include indicators to measure outcomes at different levels are essential for health systems integration. Based on evidence, such as best practice guidelines, clinical care pathways and decision- making tools are essential for the functioning of interprofessional teams and Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202396 across organizational boundaries, and roles and responsibilities of all team members being clearly identified to ensure smooth transition of patients from one type of care to another. help to standardize care across services and sites, thus enhancing service quality. This means that the system takes responsibility for an identified population in a geographic area, with clients having the right to exit if they wish to seek services from other providers. Sokol et al., 2020 A change management case study for safe opioid prescribing and opioid use disorder treatment Health system delivery, health products and technology Routine monitoring of patients, such as checking urine toxicology, setting up controlled substance agreements and using the state's prescription drug monitoring programme Our strategy began with developing shared general principles for safe opioid prescribing and then supporting patients through education and health informatics systems. The institution-wide chronic pain working group develops quality improvement metrics around safe prescribing behaviours. The medical director provides oversight of clinicians managing patients receiving chronic opioids, which was part of a larger, institution- wide project. Guidelines were developed for prescribing opioids, based on institution-level approaches and policies around safe opioid prescribing. Processes were instituted that created a safe and welcoming environment that destigmatized opioid use and greatly expanded use of medications for opioid use disorder primarily through shared medical appointments. Hospodkova et al., 2021 Change management and digital innovations in hospitals of five European countries Digital health Setting national laws to enforce mandatory use of an IT system Use of IT to change patient flow and for telemedicine, patient treatment, M-health and artificial intelligence Nilsen et al., 2020 Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses General health system strengthening Change in general According to the health care professionals, organizational changes that were clearly communicated to allow for preparation increased the chances for their success. Belias et al., 2019 Change management- obstacles and perspectives for the General health system strengthening Change in general There must be strategies, such as training programmes, to fully inform all participants of Clear supportive structures with rules and policies Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 97 integration of changes in Greek public hospitals forthcoming changes, otherwise there will be dissatisfaction and refusal to adopt the changes. Book Saltman et al., 2011 Governing public hospitals: reform strategies and the movement towards institutional autonomy Several qualitative case studies Transferring some decision- making control to provider organizations, autonomy and corporatization Report WHO Euro, 2016 Catalogue of resources to support health services delivery transformations: working document Health service delivery Create a strategic plan, develop a communication strategy Activate platforms for regular discussion, promote community coalitions Set targets and measures for monitoring WHO Euro, 2016 Strengthening people-centred health systems in the WHO European Region: framework for action on integrated health systems delivery Health systems delivery Multiple Shared vision for strategizing change, coupling a clearly defined and well-articulated problem with a solution Facilitating communication and open dialogue through regular discussions and platforms to allow for continuous conversations, networking, sharing ideas and providing support throughout the process WHO, 2015 WHO global strategy on integrated people- centred health services 2016-2026 Integrated, people-centred service delivery Multiple A strong policy framework and a compelling narrative for reform is needed Dedicating resources for reform, systems research and knowledge sharing WHO, 2019 Primary health care organization, performance and quality in North Macedonia Health service delivery Aligning organizational structures Using clinical guidelines and protocols, granting access to health data in a secure and safe way, measuring performance and the quality of care Country document Ministry of Health, Netherlands Outcome based healthcare 2018- 2022 Outcome-based health care Financial and content- level agreements with various stakeholders Addressing organizational bottlenecks in local initiatives, making structural solutions available Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 202398 Table AP-4: Abstraction of data on hardware for Latin American and the Caribbean Vargas et Understanding the Health services, clinical Healthcare coordination is considered The paper suggests that the The paper also The paper al.,2020 factors influencing coordination key in improving care quality. Although content of the interventions, suggests that the indicates that the participatory action research (PAR) has which in this case is likely to institutional support different implementation of been used effectively to bridge the gap be the strategy, was key to responsible for characteristics of participatory between evidence and practice in other the success of implementing providing the the PAR process interventions to areas, little is known about the key the PAR interventions. This necessary resources have a bearing improve care success factors of its use in health care suggests that the quality of was important for the on institutional coordination. An organizations. This article analyses the the strategies deployed is an implementation of support and analytical factors influencing the implementation important success factor in the PAR interventions professionals' framework based of PAR interventions to improve clinical the implementation of PAR motivation. on an evaluation in coordination from the perspective of interventions. These are Latin America the actors in public health care participation, networks of Brazil, Chile, Colombia, flexibility, Mexico and Uruguay. Interventions consensual were implemented to improve decision-making, communication and clinical agreement the local steering between primary and secondary care. committee's Results reveal that contextual factors, leadership and the PAR process and the intervention's the facilitating content influenced their role of implementation, interacting across researchers. This time. First, institutional support, refers to the set providing necessary resources, and of systems that professionals' and managers' were put in place willingness to participate emerged as to ensure that contextual pivotal factors, influenced the process by other factors related to the system worked out (alignment with policy and political seamlessly. cycle), networks (lack of time due to Evidence is work overload and inadequate working provided that conditions) and individuals (not implementation knowing each other and mutual through an mistrust). adequate PAR process can become a factor for motivation and cohesion Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 99 that is crucial to the adoption of care coordination interventions, leading to better results when certain contextual factors converge. Cash- Gibson et al.,2015 SDH-NET: a South- North-South collaboration to build sustainable research capacities on social determinants of health in low-and middle-income countries Health services, research capacity building on social determinants of health This article describes how a collaborative project (SDH-Net), funded by the European Commission, has successfully designed a study protocol and a S-N-S collaborative network to effectively support research capacity building in LMICs, specifically in the area of social determinants of health (SDH). This project seeks to elaborate on the vital role of global collaborative networks in strengthening this practice. There was a national mapping exercise to assess the needs of the related research systems through the analysis of their characteristics, stakeholders, institutions and ongoing SDH activities. Further, current local SDH research capacities were identified within the LMICs involved in the project. The examination of the national mapping reports led to the development of a strategic plan to guide the SDH research capacity building approach. The paper suggests that appropriate systems were put in place to implement the programme for the SDH research capacity agenda. Farach et al.,2015 Stories from the field: the use of information and communication technologies to address the health needs of underserved populations in Latin America and the Caribbean Health information systems As ICT availability grew exponentially in the last 20 years, their use in health has been widely espoused, with many emphasizing their potential to decrease health inequities. Nonetheless, there is scarce availability of information regarding ICTs as tools to further equity in health, specifically in Latin American and Caribbean settings. The aim was to identify initiatives that used ICT to address the health needs of underserved populations in LAC, and among these projects explore the rationale behind There will always be a strategy to handle ICT, even though the paper does not mention this as a key factor in ensuring the successful use of e-health in responding to the health needs of vulnerable populations. The success of such programmes depends on the ability of those handling the programme to incorporate ICTs in existing government structures. Emphasis was laid on the need for systems for standardization of processes. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023100 the selection of ICT as a key component, probe perceptions regarding their contributions to health equity and describe the challenges faced during implementation. do Carmo Caccia- Bava et al., 2009 Testing some major determinants for hospital innovation success Hospital level Hospitals have adopted new policies, methods and technologies to change their processes, improve services and support other organizational changes necessary for better performance. The literature regarding the four major areas of strategic leadership, competitive intelligence, management of technology, and specific characteristics of the organization's change process propose their importance in successfully implementing organization innovation. While these factors may indeed be important to enhance hospital performance, the existing literature contains limited empirical evidence supporting their relationship to successfully implement innovations in hospitals. This study aims to empirically test these relationships proposed in the literature by researchers in separate knowledge areas. The results provide clear evidence regarding the importance of competitive intelligence, strategic leadership, management of technology, and specific characteristics of the hospital's change process to the success of business innovation regarding products, business processes, organizational structure and organizational culture. Given the importance of effectively implementing business innovation in these days of hyper competitiveness, it behoves top The study shows that competitive intelligence, which is about how managers keep in touch with the happenings in their markets, is important for successfully implementing innovations. This in some form is related to intelligence strategy and is also concerned with the way the organization learns about its environment and therefore decides its direction. While other Latin American countries implemented health reforms solely in a top- down direction, Costa Rica's strategy of deep community engagement strengthened its reform by creating transparency and building buy-in. This suggests the adoption by Costa Rica of an appropriate structure for delivering the reform. The study suggests that the characteristics of the change processes are also important drivers of successfu1 innovation implementation at the hospital level. The emphasis in this sense is on rationalization and integration of relationships and procedures, coordination, integration and control of functions, and people's professionalism in relation to service supply and management quality. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 101 Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023102 effectiveness, efficiency and equity, with the objective of identifying the determinants of success in the Cuban health system, from which valuable lessons for current health reforms in Egypt may be derived. Parallel subsystems are clearly micro- inefficient, as they create perverse incentives, duplication of services and higher administration costs, as well as lower the purchasing power of fund holders. This suggests that appropriate structures are important for delivering success in a reform programme. extreme of successfully banning private medical practice. The political feasibility of such an extreme measure in Egypt is probably low. However, much stronger regulation of the private sector is urgently needed. This suggests that a much stronger system for regulation, especially of the private sector, is important for the success of reforms. Massuda et al.,2018 Remembering Alma-Ata: challenges and innovations in primary health care in a middle- income city in Latin America Health services delivery, PHC This report identifies the challenges andinnovationsofPHC implementation in Curitiba, beginning with a brief history of the city's health system development. The city was a pioneer in linking urban planning with health system design, improving access to health care and obtaining good health outcomes over the past 30 years. This report covers those years, as well as the challenges and strategies implemented during the most recent political cycle (2013-2016). There are substantial lessons that can be garnered from the experience of this middle-income city in Latin America, lessons that may be useful as the Region moves toward the Sustainable Historical analysis highlights the key role of urban planning in the implementation of PHC in Curitiba, influenced by the Alma-Ata recommendations before there were any national policies for the area. The prioritization of PHC in the health system, together with the introduction of the innovative practices described in this report, produced increased access, improved performance and coordination of care by PHC teams. A normative framework for the role of PHC in the health system was To develop more accessible, comprehensive and efficient PHC, the central idea was to induce the transformation of vertical-based health practices to a horizontal and integrated model of organization based on interaction among health networks in each health district. The theoretical and methodological concepts used as Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 103 Development Goal of Universal Health Coverage by 2030. established by a municipal decree in 2013. It redefined guidelines and set common goals for all PHC services in Curitiba. This suggests that planning was key to achieving the success recorded in Curitiba in the context of this case. references were Starfield's systematization of PHC, Campos' amplified clinic and participative management, and the guidelines of the National Basic Care Policy. This suggests the tinkering of the existing structure for the purposes of delivering the objectives of the reform. Barrientos, 2002 Health policy in Chile: the return of the public sector? Health financing, health services delivery The paper looked at health reforms in Chile in the context of what happened in other Latin American countries. The reforms pushed for private sector involvement in health, which happened mostly through private insurance and private provision of health services. Though the reforms resulted in larger fragmentation of insurance funds with the better off, healthier and richer moving to private funds, attempts were made to cover those with insurance in a public system with a further reconstruction of the public system to make it more responsive. There was in place a focused strategy that was implemented in what seemed to be a systematic fashion. There were in place appropriate structures for resource allocation to fit the strategy that was being implemented. The reform had a much stronger and robust system of governance and regulation, especially of the private sector compared to what Argentina and Brazil had, where the reforms failed because private operators undermined them. Clark, 2015 The new left and health care reform in El Salvador Health financing and health services delivery El Salvador is the only Latin American country in which a new left administration has designed, initiated and made substantial headway on a national, expansionary health reform. The paper addresses the question in the area of public health care. An alliance of health sector leaders with The leftist party after coming into power had the benefit of awareness on what the neoliberal policies of the previous government had been and how people had responded to them via the mass social movements, and The reform was implemented using the right structures, as the party itself believed in institutions. Although the decision by the minister to integrate This seems to have been a well thought out reform with all the systems put in place by technocrats were led by the Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023104 both technocratic and diplomatic abilities capitalized on the policy window opened by the Farabundo Marti National Liberation Front's (FMLN) electoral victory and worked within the parameters set by President Mauricio Funes, the FMLN, and civil society to universalize health care. The new minister of health, a professional highly esteemed inside and outside the country, was able to engage both a large social movement protesting neoliberal policy and an energetic health diplomat sent by the Pan- American Health Organization. In designing its reform, this alliance benefited from international as well as bottom-up policy diffusion. so it had a clear strategy in terms of what to do. This seemed to be a bottom-up approach. all service provision institutions was seen as not politically viable, suitable consideration was given to the appropriate institutions for implementing the reform. experiences of the diplomat health minister, together with the Pan-American Health Organization's country director. Huicho et al.,2020 Drivers of stunting reduction in Peru: a country case study Health services, maternal and child health Peru reduced its under-five child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016. The study aimed to understand the driver of success in the implementation of interventions that led to the dramatic progress. The results suggest that the drivers of change included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. The key enablers included the economic growth and the consolidation of democracy in the country since the early 2000s and the acknowledgement that stunting reduction needed much more than food supplementation. The results were achieved through efforts using a multisectoral approach, strong civil society advocacy, and keen political leadership. Peru's experience offers useful lessons on how to tackle the The narrative from the paper suggests that there was a well thought out strategy that had been agreed among the actors (civil society, the Ministry of Economy, the president etc.) with the benchmarks to be achieved and accompanying incentives for all levels of implementation that achieved their targets, especially at the municipal level. There is emphasis in the paper showing that the success of the intervention in Peru was to some extent due to the ability of the implementers to mobilize and coordinate different sectors and work with them to deliver the intervention. This was in sync with the conceptualization of the problem from the initial stages as a multisector problem. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 105 problem of stunting under differing scenarios, with the participation of multiple sectors. Moreno- Serra et al., 2019 Potential determinants of health system efficiency: evidence from Latin America and the Caribbean Health system governance and efficiency This paper examines the levels of health system efficiency and their possible determinants across LAC countries using national-level data for those countries, as well as for other emerging and developed countries. The study found that efforts to increase health system efficiency could be focused on a few key policy areas associated with the broader access to health services and better outcomes. These areas included general governance aspects, in addition to improvements in specific dimensions of the quality of health system institutions, notably stronger reliance on results-based management in the production of health care goods and services. According to the paper, planning, along with active monitoring of annual or multi-annual targets for the provision of health care goods and services (which seems to highlight the potential benefits of initiatives to incorporate a medium-term perspective in the general budgets and health budgets) is seen to influence health systems efficiency. The paper explains that the relatively higher efficiency scores for the provision of general and equitable health service coverage in countries such as Costa Rica is due to improvements in planning processes, particularly around benefit package expansions and human resource management. The paper suggests that several LAC countries that have made relevant progress in efficiency gains have also made progress in improving public sector regulation, transparency and accountability to citizens, for instance by embarking on sensible open government reforms - and these may make policy-making and public spending processes more efficient. In Costa Rica, the implementation of a General Comptroller's Office web-based tool allowing citizens to monitor public spending is believed to have favoured better public spending targeting Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023106 through fostering citizens' engagement and social control of government expenditures. Similar initiatives have been adopted in Chile and Uruguay, and may be behind these countries' relatively high public sector efficiency performance - and health sector efficiency - within the region. Minoletti et al.,2012 Twenty years of mental health policies in Chile: lessons and challenges Health system, mental health Over the last 20 years, Chile has increased the mental health's share of its public health budget and implemented policies that have radically transformed psychiatric services in the country. Both national and international factors have contributed to this process. The implementation of two national mental health plans has led to downsizing of mental hospitals and developing of community alternatives such as PHC, community mental health teams, day hospitals, acute psychiatric beds in general hospitals and group homes. The annual number of new persons starting treatment for mental disorders in the public sector increased by 343% between 2004 and 2007, with depression being the condition responsible for most visits. The Chilean The paper attributes the progress made in mental health outcomes in Chile to some extent to the implementation of national plans that take have their roots in the United Nations International Covenant on Economic, Social, and Cultural Rights, which provides the most comprehensive article on the right to health in the international human rights law, which Chile has ratified. The paper suggests that Chile addressed the issue of mental health through two strategies: investment of small yet gradually increasing proportions of the national The paper suggests that Chile changed the structure of delivering mental health and that to a large extent promoted availability of and accessibility to mental health care. For example, Chilean policies have stressed the relevance of primary care for the treatment of common mental disorders, that is depression and anxiety; specialized outpatient centres to support primary care teams and to treat people with severe The paper suggest that the Chilean authorities saw the integration of mental health service into the traditional health system. Although this was difficult Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 107 experience has been successful in terms of increasing availability and accessibility of services and demonstrating that with a modicum of political support, it is possible to implement an effective and efficient community-based network of primary and secondary care facilities. health budget on mental health services and allocation of new funds to develop geographically accessible decentralized services that meet people's diverse needs. mental disorders; day hospitals and psychiatric beds in general hospitals to manage acutely ill persons and severe crises; and group homes to address the need for social support for persons with severe mental disability, enabling them to exert their right to live in the community. This is a transformation of the structure of inpatient care, where the main aims are a reduction of long-stay beds and an increase in the number of beds in acute general hospitals and group homes. Cavagnero, 2008 Health sector reforms in Argentina and the performance of the health financing system Health financing The study examined the health reforms in Argentina and their impact on the three interrelated health financing functions (revenue generation, pooling and purchasing). For funding, the reforms aimed at introducing reimbursement mechanisms for services offered to the insured population in self-managed hospitals. This notwithstanding, the hospital budget increased only marginally owing to complexities in administration procedures for claiming payments and the lack of regulation and enforcement by MoH. Catastrophic health expenditure reduced, but it There was no clear or comprehensive strategy on the reform to be undertaken. The article suggests that the strategy had weaknesses in certain areas that needed to be reviewed and reintroduced. The structure in place for delivering the reforms proved counterproductive, as it did not lend itself easily to the implementation of the reforms. Ultimately, several of the objectives of the reform were not achieved because the right systems and procedures to support the reform were not in place, such as regulation, efficient reimbursement mechanisms and an approach to Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023108 seemed to be from reduced utilization rather than the impact of just the reform. Another aim of the reform was to reduce fragmentation, but this did not happen. Other expectations were not met owing to weak regulation in the private health sector. The article suggests a need to review the reform in certain areas. deal with competition among the schemes. Lloyd- Sherlock, 2005 Health sector reform in Argentina: a cautionary tale Health financing and health services delivery This paper looks at health sector reforms in the 90's in Argentina specifically focusing on reforms in financing, hospital management and autonomy and decentralization of the health system. The financing reform's outcomes were not as good as expected because the strategy, which was based on neoliberal concepts, was not in tune and sync with the general thinking. At the same time, the regulation system and the structure of the organization involved in health financing also had minimum success, which was true also for the autonomy of hospital management. A major objective of the hospital reform was cost recovery, but this hardly happened owing to the strategic, structural and systems challenges in the implementation of the programme. Staffing control issues were responsible for the failure of the hospital reform. The pension fund reform was hardly successful owing to accountability issues. Fundamentally, the reform viewed the health sector in its separate components rather than in its totality, meaning that the problems that cut across the sector were overlooked. These included a big imbalance in resourcing, which showed As indicated in the scope of implementation, the strategy's faults had a role in the failure of both the financing and hospital reforms. In this case the content of the strategy, mainly based on neoliberal concepts, and the process of policy-making and implementation were responsible for the lack of success. The structure that was put in place did not take into consideration the context and the strategy and this, to some extent, was responsible for the failure. System deficits were responsible for the failure of the two reforms. For example, the possibility that private operators would not obey the law and therefore undermine the system was not taken into account. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 109 that, although the total health spending was relatively high, the share devoted to activities with high social returns such as public health programmes, public hospitals and public clinics remained disproportionately low. Buss and Gadelha, 1996 Health care systems in transition: Brazil: Part I: An outline of Brazil's health care system reforms Decentralization, health care governance Brazil's health care system underwent sweeping changes over the 10 years since the nation's return to democracy. The main reason behind these was the quest for universal health access, fair distribution of resources and improved quality, using decentralization of services as the core strategy. Although some progress was made in decentralizing the unified health care system, with most publicly funded health services already under state or municipal control, there were still many problems in universal access to services, fair distribution of resources and improved quality, owing to existing political priorities such as state and fiscal reform and their impact on the administration, social control, and financing. The reform strategy did not take into consideration the local realities. The fact that a strategy has worked somewhere does not mean it will work in another place. There were in place appropriate structures to deliver the reform, given that the system had been appropriately decentralized from the national to the regional and provincial levels. Ewig and Bello, 2009 Gender equity and health sector reform in Colombia: mixed state-market model yields mixed results Health financing and health services delivery This reform of health financing in Colombia aimed at ensuring gender equity in access to health care. Overall, the reform had promise in creating gender equity in health, but it did not meet its potential, in particular in achieving the original reform goals of providing universal coverage and a unified package of services for the contributory and subsidized schemes, including for all women's health needs. Elimination of co-pay in the subsidized scheme even minimally would have promoted gender equity. The system The strategy was straightforward and aimed at reforming the financing system to ensure greater access to health care by all The two-level structure put in place to achieve improved health access care was discriminatory and had counterproductive outcomes, jeopardizing the ability of the reform to achieve its objective. The structure unintentionally created a system dividing people into those who could pay and those who cannot pay, and that also contributed to the challenges of the reform. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023110 requires greater government oversight to ensure equity in quality for the two regimes, to ensure that insurers provide all that is guaranteed in the basic package and to prevent discriminatory fees that are imposed on women who purchase supplemental insurance. Paepe et al.,2009 Ecuador's silent health reform Health services delivery, service integration Ecuador was part of the countries instituting reforms in the health sector in Latin American countries. The goal of the reform was not expressly stated, and hence the reform was silent. This reform hardly changed the status quo and rather contributed to the deterioration of the services in the sector. A new leftist government decided to change the course from the neoliberal type of reform to one that ensured integration of services and reduced fragmentation in the sector, and that was backed by new constitutional rights, ensuring all had access to services. This was well received by the populace. However, institutional challenges, structural difficulties and the politics of self- interest challenged the ability of the new government to proceed with the reforms as envisaged. Some changes were made, though, but that hardly changed the status quo. A clear strategy was in place that was introduced after considering different alternatives and what was happening in other Latin American countries. The failure of the silent reform was partly due to the lack of appropriate structures to support the reforms. More importantly, the overt reforms suffered as the government struggled in establishing the structures to support the intended strategy The paper suggests that regulatory systems that ensured that the private sector was the fulcrum of reforms since it could better be supervised were weak and made private sector operators better off at the expense of the public sector, which did not see any improvements in health outcomes. The overt reforms faced basically the same challenges. Homedes and Ugalde, 2005 Human resources: the Cinderella of health sector reform in Latin America Health services delivery In 1980, several countries in the LAC region experienced an economic downturn. The International Monetary Fund and the World Bank took advantage of the situation to provide loans to the ministries of health and social security funds. However, the countries were required to reduce public spending. Together with the There was a strategy in place, but it failed. The principles underlying the World Bank- led reforms included the belief that the private sector was more efficient than the public sector and that decentralized administrative units were better equipped to There were structures in place to deliver the reform, however, they created several problems. For example, health providers catered for their own interests The reforms created a system where quality of care was compromised. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 111 loans, the Bank offered guidelines for the reorganization of the health services according to its economic ideological principles. The structural adjustment programmes affected health services adversely and made it difficult for the governments to maintain physical facilities, provide equipment and necessary supplies or maintain competitive salaries for the workforce. respond to the needs of the population than centralized governments. Hence, the role of the state was limited to that of a regulator of the health care market. instead of those of patients. Barrientos and Lloyd- Sherlock, 2000 Reforming health insurance in Argentina and Chile Health financing Health reforms in Chile and Argentina have sought to expand the scope for private sector participation in health insurance and to partially replace social health insurance. In Chile, reforms in the early 1980s opened up the way for ISAPREs to compete for affiliation with the social health insurance. In Argentina, reforms in the 1990s created the conditions for greater competition both among Obras Sociales and between then and private health insurance. In both countries, the overall access to health services remains high because the public health care sector continues to be the provider of last resort. Health reforms have reinforced segmentation in health insurance, with private insurance covering the well-off segment and social insurance and public providers covering lower income, high risk groups. The reforms further deepened inequalities in access to health care and the capacity of social insurance to pool risk. In both countries there was a well thought out strategy in place that was influenced by the Bretton Woods institutions and oiled by the wave of neoliberal ideas pivoted by the wave of conservatism around the world. A major ingredient that was needed for the success of the reforms was integration of financing and services, that is proper institutional alignment with the reform. This did not happen, but islands of institutions were created that, though they worked, they did not achieve what the reform envisaged. The lack of attention on regulation created a situation where the private sector grew at the expense of the public system and eventually undermined the objectives of the health sector reforms. Vargas-Zea et al., 2012 Colombian health system on its way to improve allocation Health financing, resource allocation This paper focuses on the actions by the Colombia government to lower health costs and strengthen the system's capacity to achieve efficiency The establishment of the Health Technology Assessment Agency was mainly meant to achieve The reform focused on mainly building structures and systems as a means to Putting in place robust systems was part of the entire agenda of Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023112 efficiency - transition from a health sector reform to the settlement of an HTA agency in resource allocation, with a health technology assessment agency created to achieve that. The case of the Colombian health system provides an example on how context, policy and political challenges and solutions could incrementally lead to a systematic use of evidence to inform health policy. The country's financial constraints, competing priorities, service fragmentation, and the citizens' tradition to challenge health care coverage, as well as the lack of institutional capacity, led the government to enact by law a new health technology assessment agency. efficiency. Even though the paper does not give a clear account of the end product of the reform, it is clear that a strategy was in place to deliver efficiency and it was based on what had happened in the evolution of the process. get the Health Technology Assessment Agency working well to make the system more efficient and to reduce its inefficiency. getting the Health Technology Assessment Agency working to reduce inefficiency. Almeida, 2006 Health sector reform in Latin America and the Caribbean: the role of international organizations in formulating agendas and implementing policies Health policy reform The structural adjustment reforms carried out in the 1980s and 1990s centred basically on privatization, making the economy more open (liberalization) and flexible, introducing competition mechanisms and more precarious labour relations in both the economy and the various sectors, including the health sector. The dominant economists' view, whether in the diagnoses or in the solutions recommended, had various harmful effects, probably the most serious being to mask the role of politics in the process of change. A second important mistake of this unilateral emphasis on the economic aspects is the belief that these reform processes obeyed a single, cast iron logic to which all would have to adjust. This reveals a deterministic outlook where the new world order is seen as subject to one inexorable and inescapable dynamic. National governments were treated as passive objects of forces that they Efforts to transform the institutional framework in which policy is formulated and implemented will be affected by the history of each society and by negotiations and conflicts among national and international lobbies, politicians and bureaucrats, many of whom draw substantial support from the institutional status quo. The issue of structures seems to be a major challenge in most of the reforms that took place in the 1980s and 1990s in the LAC region. New strategies are proposed through the There was the need for strong implementation and regulatory capacity to ensure the success of the reform. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 113 could not control, thus political action was nullified as a counterweight to the over-valued economic mechanisms, and governments' responsibility for the failures and successes of the policies applied were voided. reform but the institutions and structures to implement the reforms are often over-simplified and are therefore not put in place. Willis and Khan,2009 Health reform in Latin America and Africa: decentralisation, participation and inequalities Health governance and health care financing This paper compares the outcomes of neoliberal reforms in the LAC region to that of Africa. The paper outlines the key dimensions of health sector reform that are often bundled together under the heading of neoliberalism. The reform policies and processes experienced in both Latin America and sub-Saharan Africa share some characteristics, most notably a reduction in state provision of health care, growing private sector health care and health insurance services, and an increase in the charging of user fees to expand insurance schemes to the most marginalized. The paper argues that unlike the LAC region, in Africa the reforms, for instance on decentralization, resulted in progress in terms of efficiency and participation, even though this is not without opposition. For example, there was opposition of the reforms by health personnel, lack of qualified personnel to implement the reforms, inability of management committees to ensure efficient supervision over health centres, and scarcity of resources in the form of finances and skills transfer to the local levels to ensure effective delivery of PHC. These obstacles have wide resonance in West Africa, and studies have been conducted to see the impact of such schemes in several countries in the Region. In all these reforms, deliberate strategies were in place. Structure was basically an issue and, in the case of decentralization, it involved an attempt to put in place appropriate structures to enhance and encourage participation. Putting in place structures helped to improve inclusion and participation, but this was not enough, as skills and staff to manage the decentralized centres were issues. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023114 Table AP-5: Abstraction of data for software: WHO Regional Office for Africa Schneider et al., 2020 District governance Health Innovations in The triangle of Institutional constructs and improved governance governance could managers, clinicians of credible maternal, neonatal reforms add significant value and information officers commitment, and child health in to the district health coordination and South Africa: pathways system cooperation; and of change strengthening for collective sense improved MNCH making Achoki and Lesego, Implementing health Health The success of any In Angola, there is It is necessary to 2016 financing reforms in financing health financing training of CHWs, who carefully balance Africa: perspectives of reforms reform is dependent are known as access to health health system on embracing of community services with stewards sound policies, development and health appropriate regulations and agents. In Eritrea, accountability and accountability combining midwifery cost-curbing measures mechanisms. and nursing is used as a such as co-payments task-shifting strategy, as to discourage the well as using Cuban potential moral hazard doctors. In Ethiopia and leading to misuse of Mozambique, non- health services. physician clinicians are trained for emergency obstetrics. All five countries use CHWs to address shortages in the health workforce and to improve access to health services in geographically isolated regions. Chol et al., 2018 Health system reforms Health Restoring health Joint review of health in five sub-Saharan financing, systems after policies was carried African countries that HRH and disasters in out in Eritrea by MoH experienced major health countries that have and HMTs to ensure armed conflicts (wars) governance experienced wars community reforms participation. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 115 during 1990-2015: a literature review Devolution was mainly driven by the political commitment of the same leaders or parties and was responsible, at least in part, for the success of decentralization efforts in these countries. Mbau and Gilson, 2018 Influence of organisational culture on the implementation of health sector reforms in low- and middle- income countries: a qualitative interpretive review Health governance reforms Understanding culture can facilitate the development and negotiation of mutually agreeable approaches to conflict resolution, problem solving, decision-making, and management practices, all of which characterized the implementation of the reforms across the different settings in the reviewed literature. Demonstrated weaknesses in communication practices, delays and lack of feedback owing to heavy dependence on a top-down style of communication led to centralization of information among the public health managers and undermined health workers' knowledge of the reform and its objectives and slowed its implementation. In Brazil, the health secretariat and staff lacked autonomy and voice in decision- making, which led to the poor implementation of the reform policy. In Uganda, the paternalistic attitude of MoH staff towards the district health system and the attachment to the traditional way of managing programmes within MoH resulted into Health managers in Brazil's urban district health system were observed to be the most committed to the reform objectives in terms of the language used and adherence to the procedures outlined in the reforms when compared to the managers and health workers in the rural and metropolitan districts. In Nigeria, hospital level, commitment was inferred from the health workers' report that both public and mission hospital activities and images were consistent with the objectives of the reforms. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023116 poor ownership of the decentralization process. Reporting lines between Ghana's district health system and the regional departments formed barriers to decision- making and implementation of the decentralization policy. In Nigeria, participative management by hospital managers encouraged teamwork and participation of the staff in planning for the health sector reforms. In Brazil, consultative management led to the decentralization policy being judged as better implemented in the urban districts than in the rural and metropolitan districts. Petersen et al., 2020 Health systems strengthening to optimize scale-up in global mental health in low- and middle- income countries: lessons from the frontlines. A re- appraisal NCD, mental health reforms Health care provision needs to be responsive to people's needs and expectations, placing at the epicentre empowerment and engagement of individuals, families and communities to promote and protect their health Clinical decision-support tools are highlighted as helping to support providers with clinical expertise and skills to deliver the best possible care according to the latest evidence. In human resources, person-centred care, which is subsumed under people-centred care, is central to care provision at the meso- level. It focuses on the totality of the person from a holistic biopsychosocial perspective, with clinical communication skills as a helpful tool in understanding a person holistically. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 117 Senkubuge et al., 2014 Strengthening health systems by health sector reforms Health financing, HRH, health governance, health information reforms There is a growing recognition that the global health agenda needs to shift from an emphasis on disease-specific approaches to strengthening of health systems, including dealing with social, environmental and economic health determinants through multisectoral responses. There is a growing recognition of the role of non-state actors, such as the private sector, as an engine of growth and innovation, and also in the delivery of health service. These factors indicate the expected roles of the health system in regard to the health workforce, namely production, distribution and retention of health workers. Health sector reforms and health systems strengthening focused on recruitment of health workers, creation of a mid-level cadre, use of CHWs and changing of medical and nurse training. A number of governments have implemented a series of reforms to improve the distribution of health workers in rural and remote areas, through introduction of incentives such as allowances for housing, transportation, hardship and education. Furthermore, in many developing countries there has been movement to strengthen participation of health care users in decision making as part of the health sector reforms and health systems strengthening. Wishnia and Goudge, 2020 Impact of financial management centralisation in a health system under austerity: a qualitative Health financing Finance and clinical managers often do not have a shared vision of the goal of the health system and this drives The authoritarian management style created unnecessary work. The lack of a participatory environment The relational accountability theory points to the importance of positive supervisory relationships existing Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023118 study from South Africa tension and impacts negatively on relationships. This leads to an organizational culture that is competitive and dismissive of the needs of the collective and weakens the health system. demotivated staff. However, many clinical managers suggested that agile accountability mechanisms that identify and correct mistakes quickly could help reduce financial mismanagement. The district management team attributed some of their successes to the integration and communal action they had managed to foster. Several managers expressed a desire for a more collectivist culture. alongside accountability measures for the latter to be effective. If the supervisor has a good understanding of the challenges the supervisee is facing, a realistic compromise is possible. Relational accountability requires a participatory management style and coproduction. Ekenna et al., 2020 How ready is the system to deliver primary healthcare? Results of a primary health facility assessment in Enugu State, Nigeria Continuing medical education, funding and security were identified by health workers as key enablers of service delivery. Two-thirds of PHC centres had staff who had received pre-service or recent (within the last two years) in-service training in at least one of the following areas: immunization, HIV services, family planning and malaria services. A major enabler noted was sponsorship for training and workshops. A health worker noted that attendance increases zeal and knowledge. In rural areas PHC staff cadre constituted workers who were able to work in the location. CHWs (100%} and nurses/midwives (93%} were mostly available in urban PHC centres. Fetene et al., 2020 Experiences of managerial accountability in Ethiopia's primary healthcare system: a qualitative study Cultivating a culture of accountability in health care systems for improving quality of health care At the individual level, the paper advocates for teaching about legal and ethical accountability so that health care workers are aware of how medical The importance of cultivating a culture of accountability in health care systems is highlighted in role of improving quality healthcare that Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 119 mistakes are accounted for. community members play by holding government facilities accountable for provision of services. Haddad et al., 2006 Learning from health system reforms in Burkina Faso Health financing Within the reforms, the heaIth sector benefited from an important flow of resources. There were significant increases in public expenditures, health care staff, number of primary care facilities and the availability of generic drugs. Structural adjustment programmes entailed significant increases in health care staff. Unlike other ministries, MoH was able to embark upon an active recruitment process. Between 1990 and 1999, staffing in the public health sector increased. Burkina Faso differs from its neighbour, Mali, where the fact that health officers respond directly to local authorities has significantly altered power relationships between local actors and has resulted in greater responsiveness, efficiency and transparency in health services, as well as the emergence of local leadership. Witter et al., 2019 What, why and how do health systems learn from one another? Insights from eight low- and middle- income country case studies Health financing, HRH reforms, health governance, MNCH reforms The findings emphasize the agency of local actors and the importance of developing national and subnational institutions for gathering, filtering and sharing evidence. International study tours were the most commonly mentioned mechanism for international learning and were used across the eight sites, typically early in the policy development process and included a variety of constituencies (technical, parliamentary, etc.). Capacity building through formal training or on-the-job experience also played a role, with countries tending to initially train their staff abroad and gradually developing local capacity and institutions (for example in Rwanda and Growing government financing, confidence and leadership in setting parameters within which evidence is used were highlighted in Cambodia Country decision- makers and technical staff also use direct relationships with development partner staff to gain advice on topics of interest at all policy stages. Development partners share ideas and evidence in all settings and facilitate their access. Personal relationships with development partner staff are highly important, especially when their presence in a country is long term or the country has a Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023120 Cambodia) in order to better retain trained staff. The factors that tended to increase confidence in suppliers of evidence included that they had in- country staff with embedded knowledge of the health system (highlighted in Bangladesh and Ethiopia). In some cases, authority derives from international agency authority (e.g. for the WHO package), as well as from donor funding and endorsement (Nepal). small population. Regional networks also played a role, though these were less frequently mentioned. In the Solomon Islands, regional professional networks may have facilitated idea transfer, including through contractors working across countries, and regional training networks were highlighted as significant. In relation to demand, having a performance-oriented organizational culture within the government was mentioned as a key factor in Ethiopia, Solomon Islands and Rwanda. Regional factors were again less prominent but, within West Africa, shared regional identities may play a role, facilitating learning across countries (Burkina Faso). Nepal has consistently looked to India and Bangladesh for their experiences in community-based care. Shared languages also play a role, for example, francophone African countries share a policy. Teaching and Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 121 consulting networks were cited as influential in Rwanda. El-ShaI et al., 2021 Accreditation as a quality-improving policy tool: family planning, maternal health, and child health in Egypt MNCH reforms These results emphasize that a high and continued level of commitment, which is a reflection of strong political will, is indispensable for the success of quality improvement interventions in LMICs in the long run. The factors in quality improvement were continued policy support from the government, stable programme funding, assorted incentives promoting facilities' participation in accreditation, and constant improvement in accreditation agency'sareas of focus and programme delivery. A high level of political commitment for reform was evident in the preparation and early implementation phases. Fusheini and Eyles, 2016 Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of health care provision UHC reforms Local involvement is seen as central for in UHC, and thus the district health system is a key component in reform efforts at UHC The report notes progress in hospital reforms with the redesignation of district hospitals. Thus full- time CEOs are in their posts in 60% of all hospitals. Quality improvement mechanisms have been introduced in 10 of the 11 districts; facility improvement teams are said to be functioning, quality assurance plans are being monitored, and assessments by the Office of Standards Compliance are taking place in all the districts. Private GPs were to be contracted in the 2013/14 financial year. National health insurance teams are in their posts in nine districts, but only four districts have nationally appointed full-time national health insurance project managers, and the other districts making efforts to fill the various posts. Contracting of GPs to provide PHC services at clinics located within the pilot districts was implemented in the 2013/14 financial year. It has been estimated that over 302 GPs have been contracted since. Githendu et al., 2020 Transformation of the Tanzania medical stores department There is evidence that the Global Fund supported reform Training of human resources was augmented through the Global Fund For the Medical Stores Department to effectively meet its . Build effective procurement and supply chain systems. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023122 through Global Fund support: an impact assessment study resulted in positive improvements in the overall performance at the Medical Stores Department. This could be attributed to several factors related to the Global Fund support, notably the better quantification and forecasting capabilities (due to availability of data through EPICOR and training of staff), improved warehousing capacity to hold a wide portfolio of products and direct delivery to facilities through a modern fleet. support, and this has been a critical pillar in improving the performance of the Medical Stores Department. Majority of respondents among the department's staff reported that they were more aware of their roles and responsibilities since receiving the necessary training and sensitization. obligations and deliver on its mandate, it must be led by an accountable team focused on continually improving its performance. The existing governance framework comprising an independent board staffed by high calibre professionals and an experienced management team at the helm of the department provide an opportunity for further transformation. Sustained and multifaceted support is necessary as opposed to piecemeal and isolated undertakings. Effective supportive measures need to involve all the key health system stakeholders, including those involved in the financing, planning and implementation of health programmes. Kidia, 2018 The future of health in Zimbabwe Galvanizing local and global health communities to take action during these times has the potential for reprioritization of health and even pivotal health care reform (1) Encourage retention and motivation of current workers through better, safer work environments, (2) build leadership capacity in the workforce by mobilizing the Zimbabwean health diaspora to engage in training and skill building for the current workforce and (3) place greater reliance on mid- level and non-specialist There is need for strong social engagement and political will. A major political transition, such as the one Zimbabwe is currently experiencing is the perfect time to garner this type of energy. Fight corruption and cronyism in the health sector by working with international organizations to create strong accountability mechanisms at both the national and district levels. Prioritize community engagement, i.e. empowering citizens to promote and deliver health care in their own areas by focusing Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 123 providers and on community members. on local ideas, concerns and opportunities. Engage the community by working explicitly with district health offices rather than national level MoH departments. Also include income generating activities that promote financial independence among patients, and community awareness initiatives. Grow local leadership and ensure that interventions are socially and culturally sensitive. Giving the local community agency in setting health priorities, would lead to smaller budgets, built-in accountability and less room for corruption. Mbau et al., 2020 Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya Health financing Kenya has prioritized the attainment of UHC through the expansion of health insurance coverage by NHIF. In 2015 NHIF introduced reforms in premium contribution rates, benefit packages and provider payment methods. There was a lack of initiative by government health facilities to seek contracts with NHIF, as well as staff shortages within NHIF for active follow-up. There is need to engage health care providers in determining provider payment rates and to publicly avail information on how the rates are developed. The failure of the reforms was due to (1) inadequate communication on the upward revision of premiums, (2) use of complex language such as medical terms to describe the services offered, (3) vagueness of the benefit package, where services were presented in broad categories, making it The unequal distribution of entitlements in the new benefit packages across different population groups limited citizen's access to the entitlements. Services were more expensive in private- for-profit hospitals than in the public hospitals, which put patients at the risk of Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023124 This will improve provider acceptance. Actively educate health workers on the services offered in the benefit package, as they are the gatekeepers who provide access to health services. difficult for users to know the specific services they were entitled to, ( 4) limited geographical coverage of communication and sensitization campaigns and (5) limited knowledge and awareness among some health care providers who were gatekeepers of the access to these services. Weak financial accountability led to fraud by health care providers, NHIF officials and NHIF beneficiaries. NHIF should strengthen monitoring and supervision of health care providers and impose sanctions and rewards for quality care. having to make out-of- pocket payments. Mulupi et al. 2013 Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya UHC reforms As Kenya continues to prepare for UHC, it is important that communities be educated and engaged to ensure that NHIS is acceptable to the population it serves. Awareness levels on NHIFwere low and there were concerns about affordability of the premiums and benefit packages. Most people were of the opinion that only those working in the formal sector could belong to NHIF, owing to the expensive nature of the premiums, although it was reported that those working outside the formal sector were Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 125 increasingly getting to know about NHIF and choosing to be members to be supported during illness, that is through cross-subsidization, to be protected against the unpredictable costs of heaIth care and to get access to quality health care promptly. NHIF contracts more health care providers than community-based health insurance schemes. Kenya needs to take advantage of this trust and improve the care in the public health system before embarking on the implementation of NHIS. lmprovingthe public health system will be a major contribution towards acceptability of the financing mechanisms of health insurance and tax funding for UHC. Kane et al., 2019 Coming full circle: how health worker motivation and performance in resuIts-based financing arrangements hinges on strong and . The study demonstrates the importance of analysing existing institutional, management and governance arrangements and . Without coaching and mentoring on how to implement the RBF programme, facility managers are unlikely to be able to successfully navigate this and will struggle to implement the Capacities for good leadership and to stimulate teamwork are at the heart of good management practice. Managers can act to fulfil their management function provided they. Teamwork was uniquely fostered by the clear and shared benefits of working as a team to achieve targets and to earn higher incentives. Carefully designed Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023126 adaptive health systems capabilities and taking these into account when designing and implementing RBF interventions programme, particularly the aspects that require innovation, exercise of autonomy and team-based decision-making. have the leadership and management competencies, decision- making space and tools and support from their higher-ups. . processes that take into account the interest and willingness of various actors to change and that are aware of and constructively address potential bottlenecks and points of resistance are required to accompany changes in institutional arrangements. Tsofa et al., 2017 Devolution and its effects on health workforce and commodities management - early implementation experiences in Kilifi County, Kenya Health governance reforms HRH and EMMS management functions were rapidly transferred to counties before appropriate county- level structures and adequate capacity to undertake these functions were in place. Harnessing the full potential benefits of this increased autonomy requires targeted interventions to clarify the roles and responsibilities of different actors at all levels of the new system, and to build the capacity of the counties to undertake certain specific HRH and EMMS management tasks In the procurement and distribution of commodities in Kilifi County, the County Department of Health embarked on establishing a quantification and ordering process for EMMS from the end of 2013 amidst several challenges, including a lack of appropriate technical and infrastructural capacity at facility and county levels. From these findings, it is evident that the decision space of decentralized units can be compromised by lack of capacity to undertake the decentralized functions. Political interference and discrimination in HRH management began to be reported in some counties immediately the devolution process began. . Public participation and accountability in recruitment of senior public servants at both the national and county levels was seen by many as a public relations exercise, as many people felt that members of both the national and county assemblies did not have the required skills and capacity to undertake meaningful assessment and vetting of these public officers. The multiple challenges and uncertainties over the health workforce management highlighted above led to widespread fear and anxiety among many health care workers at the time. In the early days of the Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 127 implementation of the devolved government, a health sector intergovernmental relations forum was convened to facilitate dialogue and consensus around EMMS management issues and to develop an interim action plan to address a drug shortage crisis that was at the time being experienced in government health facilities across the country. Jenkins et al., 2013 Health system challenges to integration of mental health delivery in primary care in Kenya - perspectives of primary care health workers MNCH reforms Improvement of medicine supplies and information systems, explicit inclusion of mental health in district level targets, and management and supervision of primary care are likely to greatly improve PHC health worker effectiveness and enable training programmes to be followed by better use in the field of the newly acquired skills. Mental health programmes could do more to train their staff and the volunteer CHWs, and the district health management team also needs to be trained. The health workers were not clear about whether to order medicines or how to order them, and many health workers were not even aware of the new pull system being introduced. Despite their training in mental health care and their theoretical knowledge of PHC principles, they exhibited attitudes and practice in keeping with a more medical model of health care, emphasizing The high number of clients who attend health centres each day make it difficult for the health worker to review each adequately and discuss the problems comprehensively. Much time is taken up by other needs such as immunization and family planning. There is need for a mental health advocacy campaign at all levels, consideration of the use of mobile phones for supervision and implementation of management protocols, online consultation with district health workers, and more involvement and education of The skills learned in the training course were not easy to implement because the district medical team did not offer much support regarding mental health. Health workers, especially those in the intervention group, were able to reach the community through talks organized by the community chiefs. Poor compliance was a problem. The participants thought that this was due to the differences in the illness models used by the patients and the health workers. Stigma was a major problem, and mental illness was still more stigmatized than HIV/AIDS or leprosy. Patients were often neglected and were more likely to be taken to the health Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023128 pharmacological treatment approaches and expecting psychiatric patients to conform to the standard sick role. patients' relatives. There was only one psychiatrist in the whole of Nyanza Province and he was not able to visit and support all the hundreds of PHC facilities in the province. centres only when they were violent. Joseph and Maluka, 2017 Do management and leadership practices in the context of decentralisation influence performance of community health fund? Evidence from lramba and lringa districts in Tanzania Health governance reforms The study indicates that the performance of community-based health financing largely depends on the personal initiatives of the top district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team and the Ministry of Health and Social Welfare should strengthen the supportive supervision mechanisms for the district health managers and health facilities. In terms of training and managerial skills, the findings indicate that the vast majority of the district health managers in lramba district had attended some training on managerial skills. The monthly evaluation of the Community Health Fund (CHF), performance, formation of hypothetical households to join CHF, introduction of a mobile CHF and a referral system, overhauling of CHF and the user fee payment system, and community sensitization all aimed at making people join CHF. The supporting mechanisms that were said to be exerted on the health facilities included constant encouragement of Health sector reforms (HSF) who work in remote areas, continued coaching of HSF, regular visits of the district health managers to the health facilities, and frequent and friendly communication between district health managers and HSF. While the allowance paid was reportedly District health managers formed hypothetical households that were obliged to join CHF. Respondents reported that elders who were unable to pay CHF premiums were grouped in tens which formed one household and the village government paid on their behalf. An innovative and participatory sensitization process was introduced. In lramba sensitization was done by the members of the Council Health Management Team, Council Health Service Board or Health Facility Committees but also it encompassed all district council management team members led by the district commissioner Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 129 small, the vast majority of the committee members felt satisfied and motivated. In addition, the monthly meetings of the lramba committees to discuss issues pertaining to the performance of their health facility and CHF in general largely increased the uptake of CHF. District health managers and local leaders were able to exercise considerable discretion in the implementation of the CHF scheme. Additionally, availability of health services, effective supervision mechanisms and incentives for the Health Facility Committees and board members had significant impact on the performance of the districts. and the district executive director. Ireland et al., 2011 Can performance- based financing be used to reform health systems in developing countries? Health financing The success or failure of PBF as a comprehensive social intervention is entirely dependent on the context. The conditions necessary for the success of PBF include strong leadership and There is need to have management capacity at national and local levels for effective PBF implementation. Some of the main reasons for the Rwandan success are strong leadership and political will. The waning enthusiasm from health workers who have become accustomed to receiving financial incentives raises the question of their sustainability as a motivating factor. There was a significan.t Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023130 management support, accurate information and reporting systems, funding and training. methodological challenge of designing a reward system that is equitable and socially acceptable and that highly promotes quality and quantity in both targeted and non- targeted services. Better health outcomes are best achieved when service delivery is organized around people's needs and expectations, and putting people first should be the focus of reforms. Lehmann et al., 2009 Task shifting: the answer to the human resources crisis in Africa? HRH While task shifting holds great promise, its long-term success hinges on serious political and financial commitments. It requires a comprehensive and integrated reconfiguration of health teams, changed scopes of practice and regulatory frameworks, and enhanced training infrastructure, as well as availability of reliable medium- to long-term funding. Task shifting requires building of training and management capacity Task shifting requires integration into the mainstream health system of the concept and roles of new cadres, changing the scopes of practice and regulatory frameworks, enhanced training infrastructure, etc. and a systematic engagement with all the consequences. Successful task shifting requires a comprehensive and integrated reconfiguration of health teams, particularly at the community and primary care levels. Task shifting involves not just the recruitment and training of lay health workers but also changes to the roles, skills and workloads of nurses who have to coordinate and supervise them. The importance of commitment, the need to be clear about the levels and extent of participation, and the importance of resolving matters of representation must be recognized by the leadership from the national government. It is the national government's role to ensure the existence of A central component of a broad and well- funded health policy and is the embedding of task shifting within a comprehensive approach at the area level that also involves community-based organizations in decision-making about allocation of resources and in actions that address some upstream determinants of health at the local level. The approach should require the ownership and active participation of communities as a non- negotiable Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 131 an enabling regulatory framework and credentialing system to drive the implementation of relevant policies. precondition. The national government must harness the support of the multiple stakeholders who affect and are affected by the reconfiguration of tasks, such as professional bodies and associations; trade unions; ministries of health, education, finance and public service; NGOs; community organizations; and local health structures. Witter et al., 2019 The political economy of results-based financing: the experience of the health system in Zimbabwe Health financing RBF adoption was aided by its ideological retro- fitting into an earlier government performance management policy. The main beneficiaries of RBF were front-line providers, who gained small but critical additional resources, but these were subject to high degrees of control and sanctions. Organizations that can bring technical and financial capacity to bear, for example by supporting RBF implementation, can play a very significant role in the emergence and development of reforms. RBF was framed in different ways at different stages, including as an approach to motivate staff, as a way of resourcing the sector, as part of a wider transformation to a results orientation in the public system, and as a minor variation of a familiar fee-for-service payment mechanism. Staff in primary health units have generally benefited from having the funds and materials to work with, as well as the bonuses. This was reflected in the impact evaluation, which found higher levels of job satisfaction and The provincial medical directors were seen as a key interface between policy and practice. The RBF programme worked closely with them from the start. The RBF programme is co- chaired by the Ministry of Health and Child Care (principal director, preventive services) and a lead development partner, and includes the Ministry of Local Government, which manages all public infrastructure; civil society; Ministry of Finance; mission institutions; and development partners. The Ministry of Finance was said to be a key RBF is embedded in a Ministry of Health and Child Care hierarchy that is well respected, with communications going from the ministry to provincial medical directors and then to the district health executives. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023132 autonomy in RBF than non-RBF facilities. champion from the start, perhaps because RBF allowed for some level of testing of the RBM concept previously introduced but not implemented due to the lack of resources. Munshi et al., 2019 Sub-national perspectives on the implementation of a national community health worker programme in Gauteng, South Africa Health human resources This paper explores ward-based primary health care outreach teams' and managers' perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of its implementation. The district contracted an NGO to train CHWs and team leaders. Participants reported attending the 10- day training but complained that it was too short to cover the manual content and to adequately prepare them for the health issues they saw during household visits. The implementation planning and operationalizing was left to the capacity and inclination of the provinces or districts. The competency of CHWs and team leaders to perform as expected was compromised by training deficiencies and absence of ongoing supportive supervision. There was inadequate district preparation to ensure readiness at the institutional and community levels. Learning occurred beyond the formal training through peer support. CHWs completed some Midway through the study, the public health specialist appointed professional nurses as subdistrict managers specifically responsible for the CHW programme. These appointments increased the support to the teams and the liaison with stakeholders to get more buy-in from within the health facilities and communities. All team leaders reported having clinical responsibilities that prevented them from fulfilling all their ward-based PHC outreach teams responsibilities. The failure to formally appoint CHWs resulted from the lack of establishment of the cadre within the human resources policy of the National Department of Health. The relationships between CHWs and team leaders developed over time and were viewed as positive and based on mutual respect by participants. The complex history of having two jurisdictions responsible for PHC delivery in the district created two lines of authority and resulted in some confusion among managers. Leadership by facility managers was limited. It was linked to a top- down policy that did not take into account the complexities of the health system, such as the dual structure of provincial and local government authority with facility managers being accountable to local government authorities and district managers to provincial structures. Some teams reported assisting each other to fill out the household registration forms, as the task was challenging for some members. CHWs still felt motivated and committed to the job. CHWs discussed their role with pride and valued the opportunity to make a difference in their communities. Other studies have shown that forging a collective vision and having a champion at the very local level can be an enabler in the implementation process. The consequence of the rushed implementation was that insufficient time was spent in building trust and a shared vision with local community leaders in order to create partnerships Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 133 tasks collectively, which allowed those with more capacity to share skills with those who had less competence. This contributed to the programme's implementation. supportive of the CHW programme. Maiga and Eaton, 2014 A survey of the mentaI healthcare systems in five Francophone countries in West Africa: Benin, Burkina Faso, Cote d'Ivoire, Niger and Togo Mental health reforms Assessment of aspects of mental heaIth care in five francophone countries and how they are reforming services to make them more accessible In Benin, despite training specialists in mental health since 1985, their levels remain low owing to the length of the training and because there is little interest in this specialty due to the stigma attached to mental diseases. Niger and Togo have offered training in mental health nursing since 2007 and 2012, respectively. Placing a greater emphasis on non-specialists providing care, or task sharing, with specialists mainly supervising, would alleviate this problem. There is a relatively large number of psychology graduates, but they are not appropriately trained or employed for clinical work. International partners have primed and helped implement these pilots. In the current economic environment, such private-public partnership is essential in leveraging at least some of the resources necessary for scaling up. Resource allocation for mental health is inadequate, the policies and strategic plans developed are hardly ever budgeted for beyond the maintenance of existing core (hospital) services and staff salaries. Increased interest from the international community, including agencies such as WHO, which launched a global mental health action plan in 2013, is starting to change this. Lapao,2015 Seriously implementing health capacity strengthening programs in Africa Health human resources Deeper involvement of health authorities and more rigorous approaches are desirable for the proper development of health capacity strengthening programmes in Africa. Besides management, research and policy need capacity strengthening if change and quality improvements are to be promoted. It is important to understand (and further study) the behaviour of managers and other professionals and the challenge of strengthening their capacities to enable them to tackle reform. It is particularly challenging for The better the integration of services, and adequate and balanced the HR distribution, the better the service efficiency. Constant monitoring, or mentoring is necessary from MoH. Often an action-training programme itself is not enough and more government involvement is required. A diversity of lecturers to support multidisciplinary training is critical. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023134 these professionals to be engaged in confronting a complex context that continually changes, and often is not predictable. Unlike clinical area professionals, managers cannot rely on good practices replicable in any context to guide their decisions. There are good practices, that is examples of management practices, known (and with evidence) to favour the reform process, but they are always linked to a context, so they are often are not replicable. The main health care management challenges include supervising health care professionals most of whom have high level of qualifications, making it difficult, or impossible even, to use the traditional hierarchical supervision. Being that the hospital is a very different organization vertically and horizontally, its production is mainly located in the operating centre (emergency, surgery, consultations, etc.). In this case, support services primarily serve to assist the operations centre. Health management should promote good use of Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 135 instruments (planning, evaluation, etc.) that allow support the decision on the allocation of resources (HR, technology, financial, etc.) in line with the organization's objectives. Action-training should be encouraged as a way of providing activities related to the reality of work, as they are focused on solving concrete problems. Petersen et al., 2019 Scaling up integrated primary mental health in six low- and middle- income countries: obstacles, synergies and implications for systems reform PHC strengthenin g and expansion Organizational incentives and rewards that were found to promote service delivery in relation to integrated care included training and specialist support from the Programme for Improving Mental Healthcare teams, particularly in India and Nepal. Mental health specialist cadres were generally supportive of task sharing. Persistent shortages in specialist human resources for mental health emerged as an enduring the challenge. Participants in most countries reported relatively acceptable internal relationships and communications at the PHC level, for instance between CHWs and nurses in South Africa, between prescribers and non- prescribers in Nepal and between nurses and psychiatrists in India. The weak feedback systems between secondary and primary levels of care were reported to impair continuity of care at the PHC level, particularly in South Africa. Self- efficacy to deal with patients with mental disorders as a result of the interventions was reported among the PHC providers. The interventions were regarded as being contextually appropriate across the board. This was attributed to the intensive collaborative process undertaken during the formative phase of the training. In respect of people, who are often cited as the seventh building block of health care and referred to as individuals, households and communities, being caught in the poverty- mental illness cycle, as well as stigma, was reported to impede access to care and recovery. A hierarchical culture characterized by internal maintenance with a need for Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023136 stability and control was especially dominant across most of the countries, although it promoted control and standardization in the provision of mental health care. Ward, 2010 Implementing a gatekeeper system to strengthen primary care in Egypt PHC strengthenin gand expansion A marketing campaign was conducted to increase awareness on the services offered at family health model clinics and to attract patients. Marketing methods included door- to-door visits, flyers, posters and announcements in mosques. Muthathi et al., 2020 Decision space and participation of primary healthcare facility managers in the Ideal Clinic Realisation and Maintenance Programme in two South African provinces Health governance reforms The study found that PHC facility managers reported not being involved in the conceptualization of the Ideal Clinic Realisation and Maintenance (ICRM) Programme and highly participating in the programme implementation. The programme participants reported having had a narrow decision space on the critical areas of the availability of In the study, at least one week of training was a significant predictor of the decision space, but training alone was an inadequate mechanism to capacitate the programme implementers if adequate resources were not provided. Most participants, who were PHC facility managers, felt that they were not equipped with the necessary resources by the national or relevant provincial department of health. They voiced their frustrations over the lack of control over the budget and supply chain management, which constrained their ability to ensure the availability of medicines and basic resuscitation equipment in their facilities. The absence of essential medicines and The PHC facility managers felt that they lacked control over the facility budget, staff and supply chain management. Some of the, reported that they were penalized for inefficiencies in areas beyond their control. They had no power to influence procurement processes and turnaround times. Their decision-making power over the provision of equipment for vital functions was limited, since delivery of equipment depended Most participants were of the opinion that policy-makers planned the ICRM programme without their involvement. They expressed concern about their lack of involvement in the conceptualization and the planning of the ICRM programme and pointed to their exclusion from providing inputs into the ICRM policy document. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 137 essential medicines and on basic resuscitation equipment. medical equipment leads to distrust of the health care system by the public and decreases utilization of a health care facility by the public. on the supply chain department. Achieving the ideal clinic status was strenuous, frustrating and a burden. The pressure and urgency to be compliant with the demands of the programme led at times to the faking of compliance. There should be special efforts to involve front-line managers and staff in discussions on future health reforms both at their workplaces and through their representative organization. Shiroya et al., 2019 Challenges in policy reforms for non- communicable diseases: the case of diabetes in Kenya NCD, mental health reforms The policy implementation process was largely heaIth-sector driven. The non- health sector remained largely uninvolved, contrary to global recommendations. This, in addition to the fragmented health governance and weak monitoring systems, continues to undermine existing gains and efforts to fight diabetes and The establishment of centres of excellence for diabetes management and care, and capacity building for in-service and pre- service human resources remain essential for secondary and tertiary diabetes prevention efforts across the country. The influence of civil society, including patient support groups, and MoH leadership has been essential in leveraging efforts for diabetes prevention. In addition to the vested political and professional interests, the low level of awareness among policy-makers towards diabetes is a challenge. An inter-agency coordinating committee has been created at MoH that engaged with stakeholders, and it is hoped that this will Patient empowerment is evident through the involvement of patient associations in policy development. The inclusion of patients with diabetes in various levels of policy development processes has been important in shaping national interventions against NCDs. Notably, these engagements have translated into successful advocacy and lobbying efforts by civil society and patient support groups within the national Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023138 NCDs on a wider scale. translate into a more multisectoral engagement for NCDs. Implementing new strategies requires a comprehensive approach with a given flexible framework at the ministerial level and data generation at the ground key for tailored solutions and feedback for informed decision- making. discourse. As confirmed by the key informants, the MoH interagency coordination committee on NCDs recently incorporated players such as the manufacturing sector. Dossou et al., 2020 Opening the 'implementation black-box' of the user fee exemption policy for caesarean section in Benin: a realist evaluation MNCH reforms Trust, perceived coercion, adherence to policy goals and perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self- efficacy at the operational level to generate policy implementation outcomes. The managers in the facility are civil servants who are recruited, appointed and paid by the government. They spoke on how the power of hierarchy within MoH made them implement the policy. Providers expressed the feeling that their managers had a laissez- faire attitude towards the policy. They said that they received little organizational or supervision support. The supervision visits from the implementing agency were irregular and were perceived by the health providers as merely a way of controlling prescription of drugs and use of consumables. Poor communication, poor organizational and supervision support, and a laissez-faire attitude contributed to health professionals exploiting opportunities to charge fees, which impacted negatively on the policy. The district The managers of this facility felt they were not properly engaged in the policy design process and that their concerns were not properly addressed. The community representatives in the district health committee (Comite de Sante) reported in interviews that they had little knowledge about the policy and were not much engaged in it. The managers adopted five out of the eight items of the policy package. They were motivated by their involvement in the development of the policy and by its alignment with their values and principles, but as civil servants, Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 139 health committee includes community representatives who play a leadership role in the management of the hospital, which is considered by the local communities as their hospital. The policy was implemented better where the perceived pressure,generated either through the top- down bureaucratic hierarchy or bottom-up community voice, was high. The management team can play a critical role by ensuring a good fit between the policy and the organizational context. The team's commitment to the policy can be triggered by persuasion. Persuasion as a governance instrument is extensively documented in political sciences. Compliance is achieved by the perceived pressure that derives from the enforcement of authority. Hierarchy is an important factor for enforcement and can be enacted through direct command, supervision, control, auditing or the they also felt forced to implement the policy. They actively informed the public and made efforts to support their providers in the policy implementation. In the faith-based hospital, there was mistrust of government before the introduction of the policy, which resulted from previous negative engagements. Others have reported that organizational trust is a soft component of systems that policy- makers usually overlook but that it influences policy implementation. Beyond effectively informing the key stakeholders, including the public, and providing formal access to complaint channels, public accountability has tackled its specific challenges, that is the fragmentation of actions and actors, conflict of interest, diverging values and different management and accountability practices. Policies that increase personal or institutional financial Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023140 overall accountability requirements. gains are more likely to be adopted, but perceived fairness in the allocation of the resources between the parties beyond the net personal financial gains can play a role, too. Compliance can be enforced by the community and users through two ways: having voice (being informed and having effective channels to express that voice) and using that voice (actively expressing voice). Rao et al., 2014 Progress towards universal health coverage in BRICS: translating economic growth into better health UHC reforms Although national governments have played a prominent role in the reforms, private financing constitutes a major share of health spending in BRICS. Brazil is yet to achieve complete UHC coverage because it is difficult to attract qualified health workers. In China, the reforms have not adequately addressed the provision of adequate salaries for health care professionals, resulting in a continued reliance on payments from patients. Governance of the health sector often needs strengthening to ensure that mandatory prepayment or public funding becomes the main mechanism for financing health services. Health sector reform in Brazil was largely driven by civil society rather than by the government, political parties or international organizations. Civil society demanded a health system that was responsive to - and was controlled by - the public. It also demanded that health be considered a fundamental right. These values were reflected in the constitution adopted in 1988, which paved the way for far- reaching reforms of the health system and Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 141 formally established the Unified Health System. In India, out- of-pocket payments to private providers and the rising medical costs had placed a large burden on poor households and become an important cause of impoverishment. In 2009 China began reforming its health sector in response to public concerns over the high cost of health care, the growing impoverishment experienced by households as a result of health spending and the large heaIth inequalities observed between the provinces and between urban and rural areas. Concerns over inequity in the health sector are also driving South Africa's efforts to reform its health system. The burden posed by HIV/AIDs, tuberculosis and other communicable diseases, plus noncommunicable diseases and injuries has disproportionately affected South Africa's Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023142 Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 143 health workers were adequately paid and motivated to handle increased workload. combination of political momentum, donor buy-in and deployment of rapid technical as staffing across districts, the need for a revised training policy, and for a more systematic package offinancial and non- financial incentives, especially for those working in rural areas. long hours and had to be available 24 hours a day. This sometimes leads to complications with care, as some health facilities cannot cope effectively with the number of patients coming through. Managing with too few staff has negative effects on patients, who might need to visit the facility repeatedly to seek free drugs. The workers themselves would not have time to pursue other activities, like private matters. The measures to encourage and retain staff in rural areas require to be comprehensive packages that include housing and promotion and training opportunities. Revision of training and measures to boost the quality of care are all part of the unfinished agenda. There are still too few of some key cadres such as midwives, and attrition remains high and was 13% in 2011 across all cadres. management contracts for higher level managers have not been made fully effective. differential that grows when other sources of remuneration are considered. Evaluations have generally found staff supportive of the fee removal policies in principle, while also resentful in some cases of being taken for granted by users who now expect all services to be fully free. Zulu et al., 2013 Developing the national community HRH reforms There is need to recognize that actors' power or A reason the government's proposal to introduce a new The Directorate of Human Resources and Administration at MoH Some of the members of the strategic team complained that they Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023144 health assistant strategy in Zambia position in the political hierarchy, more than their knowledge and understanding of the issue, may play a disproportionate role in shaping the process as well as the content of a health policy reform. group of non-clinical health workers was rejected was the argument that the government was facing challenges in improving the conditions of service for the existing health workers and that creating a new category would strain its finances further. The other concern was about the lack of a clear plan on how to address staff attrition once the target ofabout5200 community health assistants was attained in the final phase of the programme. headquarters played a key role in placing the issue on the policy agenda. were not requested to review or comment on the strategy before it was launched. Regarding the unclear involvement of civil society and CHWs in the process of formulating the strategy, informants from the Human Resources Department at MoH said that some stakeholders could not have been fully involved because the work was done on a voluntary basis. The lack of involvement of CHWs in formulating, finalizing and launching the strategy showed the lack of voice and power of the CHW workforce in the contemporary policy development process and reform. Afriyie et al., 2021 Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders' perspectives Health governance reforms Governance factors that emerged from participants as facilitators of health included a shared strategic vision for a single mandatory health insurance, community engagement and collaboration with diverse stakeholders in the Community members who were involved in health facility governing committees mentioned that they had received a few orientation sessions about health insurance schemes but they had not participated in specific training about health financing. Participants perceived that there was strong collaboration between implementers of iCHF and other stakeholders such as politicians, religious leaders and NGOs, with each stakeholder having specific roles. The stakeholders mentioned that the role of the private sector was Stakeholders mentioned the existence of a misunderstanding about health insurance schemes among community members. They explained that this was due to the limited transparency about the benefit packages of the health insurance scheme. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 145 implementation of health financing policies and enhanced monitoring of the enrolment in the improved Community Health Fund (iCHF) owing to the digitization of the registration process. Governance factors that emerged as barriers to the implementation were a lack of transparency, limited involvement of the private sector in service delivery, weak accountability for revenues generated from the community level and resource limitations due to the iCHF design. limited in the implementation of iCHF. They noted that the government could collaborate with private health facilities to provide health care or diagnostic services in case the services were unavailable in the public health facilities. Evidence shows that routine practices of implementing health financing reforms can be bear results when multiple actors engage in delivering health insurance outputs and share a coherent view of their roles and purpose. Participants further mentioned that the limited information about vulnerable groups eligible for exemption under iCHF was another implementation challenge. Taderera, 2016 Do national human resources for heaIth policy interventions impact successfully on local human resources for health systems: a case study of Epworth, Zimbabwe HRH Moderate decision space allowed the agent to help mitigate financial and technical constraints of devolution in low- income peri-urban areas and may help revive HRH planning and budgeting. Local key informants revealed that support for post-basic training included facilitated enrolment, paid study leave and tuition fee waivers. However, whilst some health care workers appreciated this, others complained of the limited post-basic training opportunities and unavailability of funding Human resource planning and budgeting were undertaken through collaborative and complementary decision space between the Epworth local board and MoH to project the demand and supply of health personnel for the two municipal clinics and one mission clinic. This resulted from an The principal's (MoH) engagement of international health partners resulted in a narrower decision space for the agent. This helped provide technical and financial support to help revive the HRH reform policy intervention in low- income peri-urban areas. Narrow decision Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023146 Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 147 effectiveness of the community health strategy on health outcomes in Kenya available at baseline and endline periods and had been trained on various topics as stipulated in the community health strategy guideline. programme planners, and managers in establishing, maintaining and sustaining effective and functional community health units in different sociodemographic contexts are complex. and were actively involved in the implementation of the community health strategy, as demonstrated by the frequency of their meetings. Based on evidence, attitude change by communities facilitates behaviour change, which in this case improved pregnancy outcomes for women and health outcomes for newborns and infants. Maimela et al., 2018 Interventions for improving management of chronic non- communicable diseases in Dikgale, a rural area in Limpopo Province, South Africa Integration of health services A model focusing on integrating nursing services, CHWs and traditional health practitioners, including a well- established clinical information system for heaIth care providers, is the subject of this literature. A novel aspect of the model is the inclusion of community ambassadors who are on treatment for NCDs and are, thus, repositories of knowledge and can serve as a bridge between health care workers and Health care practitioners' readiness can be improved by conducting training, which can impart knowledge to them and prepare them. Therefore, strengthening of collaboration and integration of health care practitioner services are needed to serve poor communities. Awareness campaigns should use approaches such as community radio stations, community dialogue and mass campaigns to reach more community members. The involvement of the people themselves, families and community members was seen as a critical aspect that can be undertaken through the establishment of chronic NCD management and health promotion centres. Patients may be used as ambassadors to inform others and to play a role to motivate other patients in the communities going through health problems. As the ambassadors will be drawn from community members Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023148 community members. who are suffering from chronic diseases themselves but have managed their chronic illness well, it will be good for chronic disease patients to learn from the best practices of those who have managed their conditions well. Bvumbwe and Mtshali, 2018 A middle-range model for improving quality of nursing education in Malawi HRH Transforming and scaling up of nursing education emerged as the main concept of the model. The main strategies in the model included curriculum reforms, regulation, transformative learning, provision of infrastructure and resources and capacity building. There are problems with capacity among nursing faculty in terms of clinical competences. Participants noted that over time, faculty members lose their practice competences. The findings show that there should be deliberate continuous professional development for nurse educators. The participants highlighted the fact that improving educational capacity through nursing faculty development could be one of the severaI strategies to address a complex human resource problem. lnterprofessional education has been recognized worldwide as a key component in strengthening health care and overcoming practice challenges by teaching students the necessary skills to become part of the National, institutional and programme leadership commitment drives positive transformation when implemented using a collaborative and partnership approach. Academic-practice partnerships enhance the learning culture, as both academics and practitioners take upon themselves to ensure that the graduates are well trained and socialized. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 149 Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023150 Decision space was significantly positively associated with some managerial performance indicators such as essential drug availability, but not others such as our performance management and quality improvement measures. constraints compared with discipline. Disciplining or firing of health workers would result in a decrease in a health system's financial burden, as opposed to recruitment and promotion, which would require input of financial or logistical resources. The authors hypothesized that this difference may be explained by other factors that mediate the relationship between decision space and performance, such as managerial competence and responsiveness. Liwanag and Wyss (2018) found that in the Philippines, which has been undergoing devolution for the past 25 years, most local level public health decisions are made by elected local officials, mostly politicians who may not have expertise in health system administration, instead of local health officers, that is physicians who arethedejure authorities on the health sector. The findings may reinforce the importance of Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 151 factors specific to managerial functions, such as the ability to respond to changes in essential drug need, in mediating the association between decision space and performance of managerial functions. Scheneider et al., 2014 Whole-system change: case study of factors facilitating early implementation of a primary health care reform in a South African province PHC strengthenin g and expansion The factors that led to the successful use of CHWs in the pilot sites of the North West Province were: (1) alignment of scopes of work, training and M&E systems, with, for example, structured processes of household screening such that teams were able to begin their work with a sense of self- efficacy, (2) community dialogues that facilitated entry into the communities, (3) support and mediating roles of the team leader and (4) support and oversight from the subdistrict or district management and the Health Systems Trust. The involvement of the support cadres (human resources, finance, information) in the task team enabled the development of new systems, for example for more reliable payments of stipends and approval of transport and mobile phone allowances, and integration of the outreach team monitoring and evaluation system into the routine information system. During the evaluation it became clear that that facility managers were a key cadre of health workers that should have been targeted with more direct communication on the new PHC strategy. The case study highlights the crucial role of street level bureaucrats in policy processes and the discretionary spaces they exercise. There was also a high level of knowledge and ownership of the new policy by district and subdistrict managers. The ready acceptance of the policy by these managers was significantly influenced by the fact that they saw the policy from the start as both reflecting and reaffirming what was already present. The distributed ownership and leadership of the policy by district and subdistrict managers was central to the change process, which they drove through the task team and well- established district and subdistrict structures. The commitment of these senior and middle managers emerged from a collective vision that framed the policy Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023152 in continuity with the past and as reaffirming long-held values in the province. This showed how inadequate attention to design and consultation and the privileging of powerful actors, including donors, produced a policy outcomes that had low buy-in and limited chances of implementation. Shemdoe et al., 2016 Explaining retention of healthcare workers in Tanzania: moving on, coming to 'look, see and go', or stay? HRH Perceptions of personal safety and feeling that patient outcomes were compromised by poor care or as a resuIt of perceived failed promises were cited as the reasons for wanting to leave. Staying and coping with unsatisfactory conditions was often about being settled into a community rather than into the post. Poor retention was driven by wider issues related to staff shortages: For examples when health workers are recruited, they are instructed that they must work for 3 years then go for further training. However, the chances of attending training remain low because when the health worker remains alone at a facility, they cant leave for training as it means that health facility will have to be closed. The traditional system recruited health staff as civil servants, deploying them on annual quotas. These workers did not know where they would end up or for how long. The new, flexible system recruits staff for a specific post, in a known location and for a specified length of time. This is coupled with good housing and short term incentives. Poor management and communication between workers and their seniors, such as heads of departments, were noted in both rural and urban settings as key areas that were behind workers feeling pushed to leave. Lack of mentorship and managerial support was described as one of the biggest issues faced by workers in both urban and rural settings. Having limited access to further education was seen as worsened by lack of mentorship. Most valued workers were seen to leave to join more prestigious organizations such as NGOs. Those who moved on were often described as seeking clerical roles, basically moving to seek safer jobs. These were described as jobs that did not include contact with blood. For those who stayed, having a good relationship with the local community was mentioned as the most important motivating factor. We observed uncomfortable tension of staff wanting to attend to the needs of their patients and while ignoring their own safety and well- being or preserving Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 153 their safety at the expense of caring for their patients. Schneider et al., 2015 The challenges of reshaping disease specific and care oriented community based services towards comprehensive goals: a situation appraisal in the Western Cape Province, South Africa NCDs, mental health conditions Reorienting community-based services that have origins in care responses to HIV/AIDS and tuberculosis presents an inter- related set of resource mobilization, system design and governance challenges. These include not only formalizing community-based teams but also forging new roles, relationships and mind-sets within the PHC system, and creating greater capacity for contracting and engaging a plural set of actors, that is government, NGOs and the communities at district and subdistrict levels. CHWs' roles, particularly in households, were often vague and lacking a definition, tending to follow a limited number of locally mandated routines and being heavily focused on meeting daily visit quotas. A key consequence of the high turnover was that 51% the CHWs were at the entry level, that is they had not had an opportunity to be trained through the nationally accredited and laddered, four- year training system developed for community carers. Apart from the additional training provided by the provincial government for tuberculosis and HIV/AIDS adherence workers, in- service and induction training systems were the responsibility of the individual NGOs. Skills, and therefore quality of services, were highly uneven across the board. An NGO partnership system requires capacity for managing contractual relationships that include not only financial accounting and performance monitoring but also the trust relationships necessary for effective cooperation in a plural environment. A strengthened community-based system also entails coordinating of actors who do not exist in formal hierarchical or contractual relationships with health services, such as providers from other sectors and community structures. Being able to build norms of responsiveness and answerability between these local players, despite the absence of formal lines of accountability, is a key element of local governance of community-based systems. It requires the capacity to shift from modes of command- and-control (managing Stakeholders across the board were in favour of a revised definition of roles for CHWs in line with Health care 2030 and believed that CBS held considerable potential for addressing disease burdens Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023154 up and down) that are the dominant cultures within front-line service provision towards new relationships across organizational boundaries based on networking, cooperation and reciprocity (managing out). Akhnif et al., 2018 Are our 'UHC systems' learning systems? Piloting an assessment tool and process in six African countries UHC reforms This paper assesses the extent to which UHC systems and processes at the country level operate as learning systems. The relative high number of health research institutes (with at least five in the public sector) that produce considerable scientific knowledge, and in the recent past significant research in the field of UHC is fostering knowledge sharing and strengthening the coordination for the 'UHC system'. The existence of highly qualified executives within the ministries and departments involved in UHC has led to the emergence of a whole supportive ecosystem. There is poor coordination among ministries, especially on communication about UHC, and the insufficient involvement of national technical experts, with several key positions being entrusted to persons with political profiles. Coordination among UHC actors could be improved, and better use of knowledge by the lower levels of the system is required to get concrete results. Progress towards UHC will require that national actors work together and develop enough collective intelligence to ensure that strategic decisions are grounded in knowledge. This vision implies a new culture and other ways of organizing health It is important that system actors create practical processes for a learning cycle that stretches from the production of knowledge to its storage, sharing and use in action and problem solving. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 155 systems. The ambition should be to create environments, practical processes and a leadership supportive of systemic learning. Ye et al., 2014 Establishing sustainable performance-based incentive schemes: views of rural health workers from qualitative research in three sub-Saharan African countries HRH reforms The study showed that health workers have considerable interest in performance-based incentive schemes and are concerned about their sustainability. There is a need to further explore the use of non-financial incentives in performance-based incentive schemes, as such incentives were considered to stand a greater chance of being integrated into local budgets. Ensuring participation of health care providers in the design of such schemes is likely to achieve buy-in and endorsement from the health workers involved. Most of the respondents had no previous experience with such schemes, and several concerns about how they would be managed were raised. Most notably the district managers feared that the management of such schemes could result in a heavy workload at their level. The issue of equity and fairness would be a major challenge in the management of such schemes, including the non-financial incentives. The district managers were particularly concerned about their sustainability and what would happen if the scheme had to stop. Taderera et al., 2017 Human resource for health reform in peri- urban areas: a cross- sectional study of the HRH reforms The impact of post- 2008 human HRH policy interventions on health care workers in Epworth, It was revealed that there were some safety concerns, particularly amongst nurse aids who appeared to have limited CHWs were recruited and deployed in two main subgroups, one for peer educators and the other one for Peer educators often experienced stigma from some community members. They revealed that this Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023156 impact of policy interventions on healthcare workers in Epworth, Zimbabwe a peri-urban community in Harare, Zimbabwe, and the implications towards health sector reform policy in peri-urban areas knowledge about how to use the safety protocol in the event of an accident or emergency. Whilst the lack of a salary was the main reason some people either decided to not become CHWs or resigned from that role, CHWs cited the receipt of stipends to attend training as a motivator that eased the burden of volunteer work and also helped generate support from family members on the work. This might have emanated from the exclusion of nurse aids from regular training workshops often attended by nurses where safety protocols were taught. community health volunteers/village health workers. The deployment of CHWs helped mitigate the shortage of health care workers at the three public clinics and in the community. stigma emanated from their HIV status and resulted in name calling by some people who attended clinics where they were deployed. Kebede et al., 2010 Educating leaders in hospital management: a new model in sub- Saharan Africa HRH reforms The lessons learned included the need to (1) balance education in applied technical skills with more abstract thinking and problem solving, (2) recognize the interplay between management education and policy reform, (3) remain flexible, as policy changes have direct impact on the project, (4) be realistic about resource constraints recognize the interplay between management education and policy reform; manage the transfer of knowledge for longer term sustainability Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 157 in low-income settings, particularly information technology limitations, and (5) manage the transfer of knowledge for longer term sustainability. Bertone et al., 2018 The bumpy trajectory of performance-based financing for healthcare in Sierra Leone: agency, structure and frames shaping the policy process Health financing Adopting shared frames to ensure a common and inclusive understanding of technical concepts such as PBF may be useful to ensure the political sustainability of reforms. Also, the actual frames that define negotiation and implementation should remain flexible, allowing for disrupting events (e.g., the Ebola epidemic in Sierra Leone), as well as for time to develop national capacity and ownership in order to ensure longer term political support and better health system integration. There is lack of capacity within the Ministry of Health and Sanitation, the Directorate for Policy, Planning and Information and in particular the Health Financing Unit, in terms of both the number of staff and skill sets, as there are very few health economists or health financing experts in the country. Also, the technical capacity on health financing issues available in country is rather limited even among donors and international organizations. Indeed, no government partner, including the World Bank, had full-time staff based in Sierra Leone who are health financing experts. There is lack of opportunities for education and even more for specialized education, which leads to weak technical capacity. As a consequence, there is a lack of understanding of The high turnover of staff at the Ministry of Health and Sanitation and donors, the top- down nature of the introduction of PBF championed by the World Bank, the non- inclusive implementation processes, and the lack of technical skills at the national level resulted in weak ownership of PBF and eventually its discontinuation, despite availability of funding. The removal of experienced staff from the Directorate of Policy, Planning and Information resulted in weakened PBF implementation, created tensions and discontent from other directorates and led to the loss of political support for PBF. The Ministry of Health and Sanitation certainly was a central actor in the policy process, although it is clear that decisions were for a large part driven by external actors. Among these actors, the World Bank appeared to be the main driver of PBF's adoption and implementation, by introducing the concept in Sierra Leone, promoting it and providing technical and financial assistance, in line with its prominent role in supporting and funding PBF at the global level, usually through the Health Results Innovation Trust Fund. In addition, the team leaders in charge of the health sector projects for the World Bank changed over the period analysed with a particularly high turnover. Our view, Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023158 technically complex concepts and reforms such as PBF, not only in terms of the nuances of its role within the broader health financing architecture, but also in terms of its basic functioning (especially at the subnational level, among district health management teams and in primary health units). Donors also control the timing of the resources to run programmes, thus influencing policy implementation and causing sudden starts and stops in some cases. based on direct observation, is that there were at least four team leaders over 2010- 2017 and none was based in Freetown permanently. One of the emerging driving factors is the strong influence of external actors, and, in particular, project funders, which we found was exercised across the elements of the analytical framework that was adopted to understand PBF implementation. Sayinzoga and Bijlmakers, 2016 Drivers of improved health sector performance in Rwanda: a qualitative view from within Health governance reforms There is need for policy-makers and scholars to acknowledge the complexity of health systems, and the fact that they are dynamic and influenced by society's fabric, including the overall culture of performance management in the public sector. The widespread presence of CHWs and health insurance are the main factors that have led to Rwanda's improved health sector performance. The drivers of health sector performance were presence of well- trained staff, the proximity of health facilities that provide basic obstetric care and the availability of ambulances. Some participants emphasized the increased numbers of trained professionals, while others referred to higher levels of technical capacity, motivation and commitment. There was good collaboration among district, sector administration, CHWs and health facility staff. There was strong commitment of CHWs to register all pregnant women and encourage them to attend antenatal care. A very high level of commitment and strong leadership were observed among health staff. The government's political commitment, the strong leadership and governance factors (improved policies and guidelines) were factors that had made progress Cognitive behavioural factors such as the general public's increased awareness of health risks, improved literacy levels (in particular among women), increased child spacing (lower levels offertility), and more conducive individual behaviour and personal protection against health hazards also were important. Other factors were the involvement of mid- level health care providers and CHWs, and strong involvement of women Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 159 possible. These included improved managerial skills and a monitoring and evaluation culture nurtured by a widespread and multi- level determination to increase performance, which is not solely driven by individuals' financial interest. Also In place were mechanisms for close oversight and control of the performance of health institutions and individual health workers, primarily through performance contracts that stipulate certain financial rewards and punitive measures. in collective health actions within local communities for around reproductive health and safe delivery, often working in close collaboration with local health workers. Meier et al., 2012 Implementing community participation through legislative reform: a study of the policy framework for community participation in the Western Cape province of South Africa PHC strengthenin gand expansion Supporting health committees through a participatory policy would require investment in mobilizing communities to select representatives, ensuring that health committees meet regularly, engaging health services management, and coordinating communities with management at the local clinic level Health committee members often noted the need for administrative training that is defined by the communities themselves, but including, at a minimum, basic computer skills, administrative committee procedures,accessto information on prevailing health issues, department of health services bureaucratic functions, and health committees' participation responsibilities. Many of the provincial stakeholders feel stuck in the old system and are operating as if no change has taken place. Effectively shifting from a paternalistic medical model to a participation-based model requires a significantly different approach to health and health care that has not been addressed in provincial policy. The relationship between the health system and community representatives and policy-makers must outline specifically defined objectives, roles and responsibilities to create mutually accepted, effective, and legitimate institutions to represent the community's needs. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023160 Argaw et al., 2019 Improved performance of district health systems through implementing health center clinical and administrative standards in the Amhara Region of Ethiopia PHC strengthenin g and expansion The majority of district health system performance management scores were significantly improved in four areas, i.e. leadership and governance, health centre- health post linkage, clean and safe health facility, and quality improvement and health information systems. This result could have been due to the technical and financial support provided to successfully implement change packages. Implementation of the standards improved the work culture in teams, created shared visions and understanding of the mission of the organization, and helped in mobilizing and aligning the necessary resources, as well as implementing and following up with monitoring the performance of district health systems. The technical competency of health care providers was enhanced through coaching and arranging several experience-sharing and learning collaborative workshops. With regard to the professional mix of the trainees, 395 (30.2%} were health information technicians, 344 (26.4%} were diploma nurses and 5 (0.4%} possessed a BSc in midwifery. The leadership of Amhara regional state's health bureau took the initiative to apply the standards and use the performance measurement scores for recognition and rewarding staff during semi-annual, result presentation workshops. Action plans were developed on identified priority activities indicating the person responsible, timeline and the resources allotted. Kyomugisha et al., 2009 Strategies for sustainability and equity of prepayment health schemes in Uganda Health financing The perception of fairness was associated with very low payments for the services received, with members paying less than non- members but both getting the same treatment and with no patient discriminated based on gender, age or social status. Schemes are not sustainable because they operate on Focus group participants felt that the schemes could run on their own if they had good leadership that could support them to start income generation activities and attract more members. If attitudes of health workers towards scheme members improved, more members would join the join the schemes. Members' involvement in planning and decision-making was The most vulnerable and needy in society members such as orphans, the elderly and people with disabilities were not exempt from payment, even though they usually had greater health needs than the rest of the population. The practice of providing treatment to non-members first before members was unfair, according to members, but this was more of a problem Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 161 Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023162 an outbreak': barriers to disease prevention and health promotion at the community level in Kongwa District, Tanzania gand expansion district levels lack the necessary political will to prioritize disease prevention and health promotion. The gravity of disease prevention and health promotion stated in the national health policy is not reflected in the district health plans, there is gross underfunding of community-level disease prevention and health promotion activities, and limited community participation. community health programmes are lacking. or hamlet, are people who are selected by their fellow villagers through their government. Their role is to work in collaboration with a primary level health facility such as dispensary or health centre to facilitate the implementation of disease prevention and health promotion interventions. They do so through sensitization of community members and taking part themselves in administering such interventions. responsibility to provide environmental sanitation services to the private sector and CSOs. Although this is an opportunity for a public-private partnership in service provision, in a poor country a such a partnership presents a risk of having the larger part of the population unattended to. stakeholders at the community level in planning for disease prevention and health promotion activities, and insufficient participation of villagers in defining local problems requiring prevention and health promotion interventions. Sanogo et al., 2019 Universal health coverage and facilitation of equitable access to care in Africa UHC reforms Although UHC seems to increase the use of health services, shortages in human resources and medical supplies; sociocultural barriers; physical inaccessibility of health facilities; lack of education, information, decision-making power and gender- based autonomy; failure to attend prenatal visits; The relationship between UHC and equity is evident to the extent that it allows for an increase in health care coverage and improved health outcomes, but it depends on the availability, accessibility and capacity of health workers to deliver quality, people- centred integrated care. Underinvestment in the production of sufficient health workers, inadequate capacity of HRH departments to carry out the main HRH functions, and low implementation of most of the existing plans were identified as the main causes of the present situation, which constitutes a key impediment to meeting the needs of health care delivery for all. It is important for countries to continue to engage in policy dialogue to improve the efficiency and inclusiveness of service delivery, building on on- going operations and gains of the Value for Money Programme. The private sector, through public-private partnerships, could be involved to address quality, efficiency and financing issues in the health infrastructure and service delivery. Other important factors to consider in order to ensure equity and performance of health systems include ethnicity, religion, health service physical accessibility, decision- making, gender and autonomy, information, and education. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 163 previous experiences; and fear of caesarean section delivery were found to deter access to, and use of, health services. Lutwama et al., 2012 A descriptive study on health workforce performance after decentralisation of health services in Uganda Health governance While the study shows that health workers are productive, 50.4% of them reported that their organizations did not have indicators to measure their individual performance. The findings indicate that the health workers were skilled and competent to perform their duties. In general, the results show that health workers were proficient, adaptive, proactive and client oriented. All the health workers indicated that they had mastered the skills necessary to do their work and were confident about their prescribing practices. They all said that they improved their knowledge and skills through continuous professional education. The all agreed that they adjusted well to changes in their core tasks and had learned new skills to help them adjust to change. Most health workers (89.9%) indicated that they were flexible with regard to the overall changes within their organizations. A large proportion of health workers (80.1%) disagreed that the rural facilities were as well staffed as the urban ones. All the health workers agreed that they communicated openly with each other, coordinated their work amongst themselves and supported their co- workers when requested. Most health workers (80.1%) indicated that they used standard procedures to ensure that their core tasks were done properly. All the health workers were aware of their task of serving clients, had clients' interest in mind and respected their clients' opinions. All the health workers indicated that they always behaved professionally, took a problem-solving approach to client care and gave their clients' the opportunity to express their needs. The majority of the health workers (99.3%) agreed that they tried to assess their clients' needs, and 90.2% had respect for their clients. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023164 Table AP-6: Abstraction of data for software: Asia Mahipala, 2016 Reorienting the focus Health system reform Development of Increased towards the Sustainable measurements for UHC density of Development Goals: using coverage index and doctors, nurses challenges and incidence of catastrophic at the opportunities for Sri spending (four quadrants) community Lanka level Som and The road from Mental health Inclusive planning, Inclusiveness, data Mohanty, 2018 Millennium including for psychosocial sharing Development Goals to health Sustainable Development Goals: a transition in need hierarchy Ved et al., 2019 India's health and Health system Reform towards Training non- Accountability wellness centres: reform, HRH reform, comprehensive PHC physician cadres realizing universal financing reform, through reforms in HRH and health coverage through pharmaceutical financing, free dispensing of comprehensive primary reforms, digital medicines at the health care technology and ICT community level, and use of digital technology, and information management systems Agarwal et al., Bringing health care Health information Use of telemedicine to Digital health Common data 2020 closer to people - a reforms expand coverage of health systems elements and data review of various services at the primary care sharing telemedicine models level under the national health mission in India Taneja, 2005 National rural health PHC reforms Decentralizing village and Non-health mission -a critical district level health professional review planning and management, cadre introducing a non-health introduced at professional cadre at the the community community level level Bezbaruah et al., 2021 Roles of community health workers in advancing health Human resources reform Use of CHWs to respond to emerging health security issues Ethics, professionalism Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 165 security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region Mahendradhata The Republic of Decentralization and Decentralization, Limited skills in Technical staff Public sector Community et al., 2017 Indonesia health system health financing introduction of greater planning, at the district operates differently empowerment, local review autonomy, improving management level, policy and from private sector, ownership quality of medical and leadership planning staff at and private sector is education, introduction of at the district the national not decentralized national health insurance level level World Health Organization, 2013 Health in all policies: report on perspectives and intersectoral actions in the South-East Asia PHC strengthening Decentralization, integration and multisectoral collaboration Multisector collaboration . Region MoH Nepal, 2019 National health policy Health system Professionalism, Nepal, 2019 reforms integrity, ethics, people centredness, efficiency, sustainability, respect of rights, decentralization, inclusive partnerships, equity, dynamism and . adaptiveness Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023166 Table AP-7: Abstraction of data for software: Europe Dominis et al.,2018 Keys to health system strengthening success: lessons from 25 years of health system reforms and external technical support in Central Asia General health system strengthening Change around three control knobs: financing (pooled budgeting), regulatory, and organization (health information system, improved HR) Different skills are required throughout. Capacity building at all levels of government for the design, piloting and implementation phases of reforms Change requires a mix of staff who are both doers and thinkers Latifi et al., 2016 Access to specialized care through telemedicine in limited-resource country: initial 1,065 teleconsultations in Albania Service delivery and health information systems . Change is introduced in phases, that is development of policies and procedures, building of network systems and infrastructure, and training Dedicated trained telemedicine personnel, lack of some specialist cadres in regional hospitals . Local champions in each hospital appointed and used as trainers, and nurses and doctors are involved early in the planning process Nicholson et al., 2013 A governance model for integrated primary/secondary care for the health- reforming first world - resuIts of a systematic review Health system delivery, integrating care Policies and restructuring Continuing professional development, supporting joint working Strong and committed executive and clinical leadership Culture that focuses on high quality care. Linking change to attainment of this is important. Avby et al., Tending to innovate PHC Introduction of policies Use of multidisciplinary Task shifting was The leaders strived to A learning-oriented 2019 in Swedish primary and financial reforms teams. The crossing of undertaken using the provide good conditions culture involving health care: a professional less expensive staff. for creativity and conscious qualitative study boundaries was Staff engagement was readiness to encourage deliberation of evident in practice. reinforced in different experimentation. The performance and activities, such as leaders ensured their goal achievement. arranging summer accessibility, for example High demands were parties. Financial by allocating made on the staff to incentives were consultation time for staff take professional translated to attract members'questions responsibility and professional values. during the workday. The contribute to the leaders were highly goal quality of health oriented and care services. communicative about their vision. All the Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 167 leaders had entrepreneurial characteristics. Denis et al., Medical doctors in Mixed- financial, Introduction of Medical leadership and Engagement of 2016 healthcare service delivery legislation, financial engagement in roles medical doctors in leadership: and reforms, market-based that go beyond leadership roles in theoretical and organizational reforms individual doctor direct patient care and practical challenges reforms excellence are beyond may require important assets for additional initiatives the performance and that are closer to their the future of a health professional values care system. and interests. Compensating physicians for leadership development activities such as training and capacity building to ensure doctors are engaged in managerial roles is important. Fraser et al., 'Holding the line': a System-wide Implementation of policy Clinicians were used as The approach of the 2017 qualitative study of reconfiguration change, power key messengers to Strategic Health the role of evidence mobilization by senior drive change, along Authority was not in early phase managers in order to with communication consensual or decision-making in hold the line experts. deliberative around the the reconfiguration question of site numbers, of stroke services in but it was firm, London dictatorial, hands on and active organizational control through setting explicit standards and performance measures. A new public management style of top-down decision-making was introduced in phase two. Wedel, 2007 Turning vision into reality: successful integration of Healthcare services delivery Policy development and reconfiguring of service delivery were undertaken, including Task shifting A collaborative partnership model was used to include an interdisciplinary team. The distinct cultures of the regional health care programme offices Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023168 primary healthcare in utilizing population An alternative payment and the PHC office Taber, Canada health research, plan was devised for were recognized, integrating health care physicians, and team- validated and then services delivery, building strategies aligned using the creating sustainable such as visioning common focus on collaborative exercises were used to patient-centred partnerships and build trust among care. practices, improving team members. cost-efficiency within the health care system and developing and implementing social and . health care policies. Smyth, 2009 Making integration Health service Organization and clinical Increased Making integration Strong leadership was A culture of work requires more delivery setup changes specialization and work requires more required to enable the commitment than goodwill integration and distribution of than goodwill partners to participate in towards patient- governance knowledge has decision-making centred care and increased the need for lack of collaboration individualism, collective decision- making Suter et al., Ten key principles for Health service Committed and visible 2009 successful health delivery leadership with clear systems integration communication processes, leadership with vision van der Integrating staff well- Integration of Acknowledgment of There were changes Veen et al., being into the mental health staff well-being could in the mindset of 2015 primary health care be a key ingredient in beneficiaries, system: a case study the motivation of staff recognizing that in post-conflict and the quality of stress management Kosovo services, many of the was not a luxury but main stressors such as a necessary tool to level of workload and improve low salaries were effectiveness of reported uniformly. work, including patient care, teamwork and personal life. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 169 Almajali et al.,2016 Antecedents of ERP systems implementation success: a study on Jordanian healthcare sector Health service management and governance Training, supportive leadership, ease of use, user satisfaction, and ERP implementation success ERP system users must have useful training inside or outside the organization before starting operations. Supportive leadership was crucial. Van Veghel Organization of Service delivery The basic expertise to Physicians have limited A culture exists to et al., 2020 outcome-based measure and analyse or no dedicated time to openly discuss quality improvement outcome data is discuss and analyse outcomes within in Dutch heart available. outcome data. each specialty. centres Much less openness exists to discuss outcomes. A culture exists among all specialties to continuously improve health care. Atun et al., Diffusion of complex Service delivery Organizational Doctors sought to Autonomous family Improved 2007 health innovations - (decentralization), improve their medicine teams, communication implementation of financial (budget knowledge and skills comprising a family between health primary health care funding), clinical and develop their physician and one or professionals and reforms in Bosnia (creation of family competencies, which in two family medicine the promotion of and Herzegovina medicine teams, turn, helped them feel nurses, could be cooperation and establishment of more valuable. engaged by the team development, specialist training and municipality health helped to enhance management centres through a the quality and programmes) and direct contract or efficiency of relational changes through them by the services. newly created health insurance organizations, which was a shift from salaried employment. Atun et al., Introducing a Health Changes in organization, Creation of a new Family physicians There was 2006 complex health financing, regulation, financing, specialty that was working as contracted willingness to learn innovation - primary service delivery, resource allocation, and widely accepted. This private practitioners. and enthusiasm to health care reforms governance provider payment required training. Empowering family change the old in Estonia systems and service physicians and nurses health system. (multimethods provision increased their evaluation) independence and professionalism, Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023170 expanded the scope of their work and increased their involvement in management functions. Hernandez- Quevedo et al.,2018 20 years of health system reforms in Europe: what's new? Heath financing, device delivery, HR Enacting various laws and policies, changing payment systems, introducing quality of Lacking a policy and managerial capacity to effectively run a reform will blunt the Changes in staffing with a move towards the use of specialists and multidisciplinary Strong leadership and operational planning are needed to keep reforms on track. care committees implementation efforts. If health services need to be provided in a different teams way, then health workers need the necessary training to implement the required changes. Ham, 2010 Working together for Service delivery Service delivery Training and The use was made of Reaffirming the health: achievements innovations, telephone- development are psychometric and commitment to the and challenges in the based service that particularly needed in capability tests in the principles of Kaiser NHS beacon provides proactive care methodologies for appointment of working together for Sites Programme to patients with long- clinical system consultants and health and seeing term conditions in redesign using lean establishment of the this as a priority for Birmingham, closer thinking. Use is made Trust's business unit all the organizations integration of health and of general physicians structure and the involved social care via Care known as hospitalists Clinical Policy Group to Trusts in Solihull and to work in only the develop care pathways Torbay, and a focus on inpatient environment long-term conditions and to ensure that and leadership patients receive the development appropriate level of care Harris, 2012 The North West Service delivery Implementation of the Creation of a A collaborative London Integrated and HR Integrated Care Pilot multidisciplinary group approach allowing Care Pilot: innovative coordination programme that newly that meets regularly interests and strategies to improve developed and concerns to be care coordination for established financial and shared in an open older adults and governance and transparent people with diabetes arrangements forum has been Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 171 adopted. The composition of the board permits mutual accountability and collective decision- making. Jackson et al.,2008 The primary care amplification model: taking the best of primary care forward Health service delivery The development of a formal partnership between the University ofQueens nd(UQ)and Queensland Health enabled the development and piloting of the primary care amplification model at Inala Primary Care The annual performance appraisal for all staff reflects an organizational commitment to career development. The training activities enable all staff to have expanded clinical roles, thereby increasing job satisfaction. A culture of continuous quality improvement Jackson and Nicholson 2008 Making integrated healthcare delivery happen - a framework for success Health service delivery Introducing service integration framework- change management and clinical practice, training and professional development, ICT and appropriate clinical and organizational governance Clinician leadership and a strong patient focus were pivotal in operationalizing key initiatives. Executive leaders from the key organizations who committed to working together and creating a sense of urgency to achieve shared outcomes Suter et al., Ten key principles for Service delivery Multiple aspects Implementation and Implementation and 2009 successful health integration highlight 10 essential operation of an operation of an systems integration areas to change in the integrated health system integrated health health system requires leadership with a system require an vision. Bringing different organizational cultures together culture that is demands committed and congruent with the visible leadership. vision. Clashing Successful leaders cultures is one of recognize the importance the barrier to of learning and how it integration acute contributes to the overall care efforts integration goal. They ensure opportunities, resources, incentives and Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023172 rewards for staff learning and enable providers to take the time to obtain additional training. Sokol et al., A change Health system Routine monitoring of Training and A team-based, patient- A participative leadership 2020 management case delivery, health patients, such as certification of all centred clinical model that encourages study for safe opioid products and checking urine physicians. Medical approach providing the participation of all prescribing and technology toxicology, setting up assistants were trained medical care at home members of the practice, opioid use disorder controlled substance to complete the is used. A core group of with charismatic treatment agreements and using prework of a visit and clinical and leadership provided by a the state's prescription on the curriculum to administrative staff key opinion leader and drug monitoring disseminate evidence- members who the final decision made programme based guidelines and expressed an interest by those in official clinic-specific policies. and passion to work leadership positions. collaboratively in helping patients with opioid use disorder was identified. Hospodkova Change management Digital health Setting national laws to Training of health care Motivation (need for Efforts to enforce et al., 2021 and digital enforce mandatory use staff in systemic change) and employee changes in a top-down innovations in of an IT system thinking and provision attitudes (adaptability) manner are rarely met hospitals of five of knowledge and the are key. with enthusiasm from European countries skills necessary for the front-line health care implementation of professionals. changes, but the different levels in digital literacy and/or approach to technologies among patients posed a threat to success. Nilsen et al., Characteristics of General health Change in general If employees are A bottom-up approach is 2020 successful changes in system involved from the more desirable. health care strengthening beginning and believe organizations: an the change is interview study with interesting, then there physicians, is a chance for the registered nurses and change to succeed. assistant nurses Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 173 Belias et al., 2019 Change management - obstacles and perspectives for the integration of changes in Greek public hospitals General health system strengthening Change in general Employees seek motivation, education, availability of aids, provision of information and some kind of pay. Each change can benefit a group of workers and overload another. The manager has to support changes in general and to have a strong supportive team of supervisors who will lead the changes and also believe in them. WHO Euro, 2016 Catalogue of resources to support health services delivery transformations Health service delivery Develop collaborative capacity Network across actors Foster shared leadership Facilitate team and effective group work. WHO Euro, 2016 Strengthening people-centred health systems in the WHO European Region: framework for action on integrated health systems delivery Health systems delivery Multiple Strong leadership and vision and adopting a bottom-up, grassroots approach build trust, interest and a shared sense of responsibility for a team dynamic to underpin the process. Development of an organizational culture that supports monitoring and evaluation, knowledge sharing and demand for data in decision- making. WHO, 2015 WHO global strategy Integrated, Multiple Transformational and Development of an on integrated people-centred distributed leadership organizational people-centred service delivery culture that health services 2016- 2026 supports monitoring and evaluation, knowledge sharing and a demand for data in decision- making is also a prerequisite for transformation. WHO Euro, Primary health care Health service Recruiting and training Matching provider 2019 organization, delivery primary care staff and incentives to services performance and determining the mix of quality in North disciplines of staff Macedonia members Ministry of Outcome based Outcome-based Financial and content- Learning from each Attention to pioneers Improving the health, Netherlands healthcare 2018- 2022 health care level agreements with various stakeholders other in daily practice and followers, both within and between quality registry landscape care organizations Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023174 Table AP-8: Abstraction of data on software for Latin American and the Caribbean Pozo et al., 2015 Improving adolescent sexual and reproductive health in Latin America: reflections from an international congress Health services, adolescent reproductive health The research presented at the congress reiterated that individually targeted adolescent sexual and reproductive health interventions were not sufficient to bring about change in adolescents' sexual behaviours, but rather that extended family networks, communities and local and regional actors must also be involved. This idea corresponds with the Andean plan to prevent teen pregnancy (PLaNEA), an initiative of the ministries of health of Bolivia, Chile, Colombia, Ecuador, Peru and Venezuela that indicates that establishing strong bonds between young people and their teachers, health professionals, parents and friends can contribute to effective programmes. Relationships that boarder on style were emphasized by the congress as very important in securing the trust of young people who are the key stakeholders in the development and scaling up of interventions to deal with adolescent reproductive health. Shared values between providers of services and more importantly receivers, as well as all important stakeholders in the adolescent reproductive health ecosystem, is seen to be very important in delivering the opportunity to scale up an intervention. Vargas et al., 2020 Understanding the factors influencing the implementation of participatory interventions to improve care coordination. An analytical framework based on an evaluation in Latin America Health services, clinical coordination . Health care coordination is considered key to improving care quality. Although participatory action research (PAR) has been used effectively to bridge the gap between evidence and practice in other areas, little is known about the key success factors of its use in health care institutions. This article analyses the factors influencing the implementation of PAR interventions to improve clinical coordination from the perspective of the actors in public health care networks of Brazil, Chile, Colombia, Mexico and Uruguay. Interventions The paper suggests that the willingness of professionals and managers to participate in the process constituted an important contextual factor that explained the success of the implementation of PAR interventions. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 175 were implemented to improve communication and clinical agreement between primary and secondary care. The results reveal that contextual factors, the PAR process and the interventions' content influenced their implementation, interacting across time. First, institutional support, providing necessary resources, and professionals' and managers' willingness to participate emerged as contextual pivotal factors, influenced by other factors related to the system (alignment with policy and political cycle), networks (lack of time due to work overload and inadequate working conditions) and individuals (not knowing each other and mutual mistrust). The different characteristics of the PAR process have a bearing on institutional support and professionals' motivation: participation, flexibility, consensual decision-making, the local steering committee's leadership, and the facilitating role of researchers. Evidence is provided that indicates that implementation through an adequate PAR process can become a factor of motivation and cohesion that is crucial to the adoption of care coordination interventions, leading to better results when certain contextual factors converge. Cash-Gibson et al., 2015 SDH-NET: a South-North- South collaboration to build sustainable Health services, research capacity building on social This article describes how a collaborative project (SDH-net) funded by the European Commission has successfully designed a study protocol and an S- The paper suggests that a lot of effort was put in place to build the capacity of the participants, as well as the tools and Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023176 research capacities on social determinants of health in low- and middle- income countries determinants of health N-S collaborative network to effectively support research capacity building in LMICS, specifically in the area of social determinants of health (SDH). This project seeks to elaborate on the vital role of global collaborative networks in strengthening this practice. guidelines that were needed. Farach et al., 2015 Stories from the field: the use of information and communication technologies to address the health needs of underserved populations in Latin America and the Caribbean Health information system As availability of ICTs grew exponentially in the last 20 years, their use in health has been widely espoused, with many emphasizing their potential to decrease health inequities. Nonetheless, there is scarce availability of information regarding ICTs as tools to further equity in health, specifically in LAC settings. The aims were to identify initiatives that used ICTs to address the health needs of underserved populations in LAC and among these projects explore the rationale behind the selection of ICTs as a key component, probe the perceptions regarding their contributions to health equity, and describe the challenges faced during their implementation. Capacity building was identified as an area of concern that needs attention to ensure that e- health can be used successfully to address gaps in the health of vulnerable population groups. The need for broader partnerships to guarantee project survival beyond pilot phases has been evidenced, and there are aspects that need to be addressed in equity-focused health interventions. Although this has been captured under shared values, it can also be looked at as part of the structures needed to create the right environment for collaboration. do Carmo Caccia-Bava et al.,2009 Testing some major determinants for hospital innovation success Hospital level Hospitals have adopted new policies, methods and technologies to change their processes, improve services and support other organizational changes necessary for better performance. The literature regarding the four major areas of strategic leadership, competitive intelligence, management of technology, and specific characteristics of the organization's change process highlight their importance in The study suggests that effective leadership is an important ingredient of organizational change. In this sense the study suggests that leadership could be transactional and, in this context, will focus on strengthening existing organizational processes, structures, strategies and culture. Leadership can be The study emphasizes that as part of the change, in the characteristics of the change process is the issue of culture, which boarders on shared values of the members of the organization. This is equally emphasized in the management literature, where a Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 177 successfully implementing organizational innovation. While these factors may indeed be important to enhance hospital performance, the existing literature contains limited empirical evidence supporting their relationship with successfully implemented innovations in hospitals. This study aims to empirically test these relationships proposed in the literature by researchers in separate knowledge areas. The results provide clear evidence regarding the importance of competitive intelligence, strategic leadership, management of technology and specific characteristics of the hospital's change process for the success of business innovation of products, business processes, organizational structure, and organizational culture. Given the importance of effectively implementing business innovation inthesedaysofhype competitiveness, it behoves top managers to do whatever they can to improve their hospitals in these areas. transformational, and in this sense the leader will articulate a vision and sense of a mission, showing determination and communicating high performance expectations. In addition, the leader will show persistence and enthusiasm in pursuing goals and be demanding of others through the communication high performance expectations. change process is supposed to be situated in a culture that is aligned to the strategy, structure and system being deployed for the change. Spigel et al., 2020 Implementing sustainable primary healthcare reforms: strategies from Costa Rica Health services delivery, PHC Costa Rica is an example of a country that has taken concrete steps towards successfully improving PHC over the last two decades. in the 1990s, Costa Rica implemented three key reforms: governance restructuring, geographic empanelment, and use of multidisciplinary teams. To understand how Costa Rica implemented these reforms, we Strong leadership allowed reformers to implement their vision. For example, to consolidate PHC functions under a single Costa Rica Social Security Administration entity, leaders committed human and financial resources, including re- allocating staff to the We found that Costa Rican health leadership undertook each EPIS phase with intention, ensuring that the model reflected their core values. This means that the implementation took into consideration the Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023178 conducted a process evaluation based on a validated implementation science framework. We found that Costa Rica implemented PHC reforms through strong leadership, a compelling vision and deliberate implementation strategies such as building on existing knowledge, resources and infrastructure, bringing together key stakeholders and engaging deeply with communities. These reforms have led to dramatic improvements in health outcomes in the past 25 years. In-depth analysis of Costa Rica's specific implementation strategies offers tangible lessons and examples for other countries as they navigate the important but difficult work of strengthening PHC. technical working groups from their routine work. This monumental task could not have been accomplished without strong leadership. To overcome initial resistance, leaders applied methods described in change management literature, such as providing in- service and preservice training, engaging stakeholders in technical working groups, facilitating collaborative workshops and negotiating with unions regarding benefits. Literature shows that involving multiple stakeholders in this way can diminish resistance between groups and strengthen support. core values of the key actors, and that acted to cement their commitment to the reform programme. The paper further suggests that Cost Rican leaders adapted regional and global promising practices to their specific cultural and political and economic contexts. We found that this careful work during the first three exploration, preparation, implementation and sustainment phases contributed to Costa Rica's ability to sustain the PHC model for over 25 years. Gericke, 2005 Comparison of health care financing in Egypt and Cuba: lessons for health reform in Egypt Health financing Egypt and Cuba are both lower- middle-income countries with a history of socialist rule, that have embarked on economic liberalization since the 1990s. Cuba has achieved an exemplary health status, whereas the health status in Egypt is lower than could be expected for its level of income. In this article, health care financing mechanisms in both countries are analysed on their effectiveness, efficiency and equity, with the objective of identifying the determinants of success in the Health care reforms cannot be looked at in isolation. Equitable investment in other sectors, in particular education, housing, water and sanitation, and improved traffic regulation are certainly equally important to improve population health in Egypt and in other countries in the Eastern Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 179 Cuban health system from which valuable lessons for the current health reforms in Egypt may be derived. Mediterranean Region. This speaks to the issue of shared values of what is being done and how the society conceptualizes the issue. Shared understanding in reform conceptualization can enhance problem definition and, therefore, the interventions and success. Massuda et al., 2018 Remembering Alma-Ata: challenges and innovations in primary health care in a middle- income city in Latin America Health services delivery, PHC This report identifies the challenges andinnovationsofPHC implementation in Curitiba, beginning with a brief history of the city's health system development. The city was a pioneer in linking urban planning with health system design, improving access to health care, and obtaining better health outcomes over the past 30 years. This report covers those years, as well as the challenges and strategies implemented during the most recent political cycle (2013 - 2016). There are substantial lessons that can be garnered from the experience of this middle-income city in Latin America, lessons that may be useful as the region moves toward the Sustainable Development Goal of UHC by 2030. The investment in improving professional clinical skills and the ability to work through multiprotection teams in health networks that interact with the various specialized care services were some of the more successful measures taken. This suggests that the development of appropriate skills was important in achieving the results documented in the paper. More than organizational changes, transformation of people and cultures is part of health systems innovation and it demands time and continuity to become well established. This means that in Curitiba skills had to be developed in a manner that addressed those needs of the reform. The issue of skill developed was undertaken in the context of the local culture, which the paper argues was a factor in the successful implementation of the reform. This goes to buttress the fact that shared values constitute an important ingredient in pursuing change programmes. Barrientos, 2002 Health policy in Chile: the return of the public sector? Health financing and health services delivery This paper looked at health reforms in Chile in the context of what happened in other Latin American countries. The reforms pushed for There seemed to be a general agreement over the reform and Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023180 private sector involvement in health, which happened mostly in private insurance, as well as private provision of health services. Though the reforms resulted in larger fragmentation of insurance funds with the better off, healthier and richer moving to private funds, attempts were made to cover those with insurance in a public system through a further reconstruction of the public system to make it more responsive. where things were supposed to go. Clark, 2015 The new left and health care reform in El Salvador Health financing and health services delivery El Salvador is the only Latin American country in which a new left administration has designed, initiated and made substantial headway in a national, expansionary health reform. The paper addresses the question in the area of public health care. An alliance of health sector leaders with both technocratic and diplomatic abilities capitalized on the policy window opened by the FMLN'S electoral victory and worked within the parameters set by president Mauricio Funes, the FMLN and civil society to universalize health care. The new minister of health, a professional highly esteemed inside and outside the country, was able to engage both a large social movement protesting neoliberal policy and an energetic health diplomat sent by the Pan-American Health Organization. In designing the reform, this alliance benefited from international as well as bottom-up policy diffusion. An alliance of health sector leaders with both technocratic and diplomatic abilities capitalized on the policy window opened by the FMLN's 2009 electoral victory and worked within the parameters set by President Funes, the FMLN and civil society. This to a large extent was responsible for the progress that was made in El Salvador. Inclusion and a bottom-up style were also important in driving the reform. The party in power, technocrats and civil society's movements all believed that the neoliberal attempts had failed and that the approach taken by the government was the way to go. Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 181 Huicho et al., 2020 Drivers of stunting reduction in Peru: a country case study Health services, maternal and child health Peru reduced its under-five child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016. This study aimed to understand the drivers of the success in the implementation of the interventions that led to the dramatic progress. The results suggest that the drivers of change included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy since the early 2000s and the acknowledgement that stunting reduction needed much more than food supplementation. The results were achieved through efforts driven through a multisectoral approach, strong civil society advocacy and keen political leadership. Peru's experience offers useful lessons on how to tackle the problem of stunting under differing scenarios and with the participation of multiple sectors. Style played an important role in the success of reducing under-five child stunting in Peru in the period under consideration. The approach of implementing the intervention was different in that pressure from civil society, galvanized by buy-in from political leadership at all levels where reduction of under-five child stunting was seen as a national priority, and so at all levels the needed financial resources were provided to implement the intervention. There was a major paradigm shift in problem framing, where stunting was redefined as a problem not just related to feeding but one that needed a multisectoral preventative action executed in an integrated manner by all the stakeholders. The suggestion here is that the narrative was changed based on the shared values of the actors and how they understood and framed the problem. Moreno-Serra, 2019 Potential determinants of health system efficiency: Evidence from Latin America Health system governance and efficiency This paper examines the levels of health system efficiency and their possible determinants across LAC countries using national-level data for those countries, as well as for other emerging and developed The paper suggests that personnel remuneration and evaluation systems that incentivize workforce results are also associated with efficiency gains in Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023182 and the Caribbean countries. The study found that efforts to increase health system efficiency could be focused in a few key policy areas associated with broader access to health services and better outcomes. These areas included general governance aspects, in addition to improvements in specific dimensions of the quality of health system institutions, notably stronger reliance on results-based management in the production of health care goods and services. health systems. The paper cites the examples of Chile and Uruguay, two of the most efficient LAC health systems, both of which have adopted some degree of pay-for- performa nce, notably for the reimbursement of primary care personnel in the public sector. For example, Uruguay has risk-adjusted capitation complemented by performance-based payments. Minoletti et al.,2012 Twenty years of mental health policies in Chile: lessons and challenges Health system, mental health Over the last 20 years, Chile has increased mental health's share of its public health budget and implemented policies that have radically transformed psychiatric services in the country. Both national and international factors have contributed to this process. The implementation of two national mental health plans has led to downsizing of mental hospitals and development of community alternatives such as PHC, community mental health teams, day hospitals, acute psychiatric beds in general hospitals and group homes. The annual number of new persons starting treatment for mental disorders in the public sector increased by 343% between 2004 and 2007, with depression as the condition responsible for most visits. The Chilean experience has been successful in increasing availability and accessibility of The paper suggests that MoH, in putting together both the first and second national mental health plans, had a wide level of consultation of stakeholders for inputs into the plans. In addition to that, the paper suggests that people with mental health disorders and their families were included in planning and evaluation at both the national and local levels. Additionally, there was augmentation of mental health expertise of primary care teams, where all urban primary care centres would have at least one full-time psychologist and receive support from psychiatrists, Managing change towards universal health coverage: service provision in Africa I Technical Brief I November 2023 183 services and demonstrating that with a modicum of political support, it is possible to implement an effective and efficient community- based network of primary and secondary care facilities. psychologists, or other mental health specialists through monthly visits primarily aimed at supporting the teams in their management of difficult patients. WHO, 2015 Accelerating progress on HIV, tuberculosis, malaria, hepatitis and neglected tropical diseases: a new agenda for 2016-2030 Health services delivery, infectious diseases This report assesses the progress and achievements related to the Millennium Development Goal (MDG) 6, which aims to combat HIV/AIDS, malaria and other major diseases. It looks at the key factors behind the achievements in reducing the burden of HIV/AIDS, tuberculosis, malaria, viral hepatitis and neglected tropical diseases, and the role played by WHO in those achievements. It also discusses the new post-2015 global WHO strategies, many of which have been endorsed by the World Health Assembly. In particular, the report discusses the key cross-cutting elements required to drive the ending of major infectious disease epidemics to achieve the health- related Sustainable Development Goal (SDG) 3 and specifically Target 3.3 of that goal. The report attributes the progress made with respect to the MDG 6 targets with the building and strengthening of laboratory capacity and networks and expansion, and training of the health workforce.