The dataset does not include indicators of the quality of care and does not allow to assess whether changes associated with PBF are resource-driven or due to the incentive mechanism itself. The results are largely consistent with other impact evaluations conducted in Burundi and Rwanda. The fact that PBF is mostly associated with positive changes in the use of services that became free suggests an important interaction effect between the two strategies. A possible explanation is that the removal of user fees increases accessibility to health care and acts on the demand side while PBF gives medical staffs incentives for improving the provision of services. More empirical research is needed to understand the sustainability of (the incentive mechanism of) PBF and the interaction between PBF and other health policies.

Abstractobjective Community participation is often described as a key for primary health care in lowincome countries. Recent performance-based financing (PBF) initiatives have renewed the interest in this strategy by questioning the accountability of those in charge at the health centre (HC) level. We analyse the place of two downward accountability mechanisms in a PBF scheme: health committees elected among the communities and community-based organizations (CBOs) contracted as verifiers of health facilities' performance.method We evaluated 100 health committees and 79 CBOs using original data collected in six Burundi provinces (2009)(2010) and a framework based on the literature on community participation in health and New Institutional Economics.

Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in programme documents. However, there are a number of factors which could explain this, including the greater role of external actors and donors, a greater openness to institutional reform, and lower levels of trust within the public system and between government and donors, all of which favour more contractual approaches. These suggest that rather than emerging despite fragility, conditions of fragility may favour the rapid emergence of PBF. We also document few emerging adaptations of PBF to humanitarian settings and limited evidence of health system effects which may be contextually driven, but these require more in-depth analysis. Another area meriting more study is the political economy of PBF and its diffusion across contexts.

This study contributes to the health policy debate on medical systems integration by describing and analysing the interactions between health-care users, indigenous healers, and the biomedical public health system, in the so far rarely documented case of post-conflict Burundi. We adopt a mixed-methods approach combining (1) data from an existing survey on access to health-care, with 6,690 individuals, and (2) original interviews and focus groups conducted in 2014 with 121 respondents, including indigenous healers, biomedical staff, and health-care users. The findings reveal pluralistic patterns of health-care seeking behaviour, which are not primarily based on economic convenience or level of education. Indigenous healers' diagnosis is shown to revolve around the concept of 'enemy' and the need for protection against it. We suggest ways in which this category may intersect with the widespread experience of trauma following the civil conflict. Finally, we find that, while biomedical staff displays ambivalent attitudes towards healers, cross-referrals occasionally take place between healers and health centres. These findings are interpreted in light of the debate on health systems integration in Sub-Saharan Africa. In particular, we discuss policy options regarding healers' accreditation, technical training, management of cross-referrals as well as of herb-drug interactions; and we emphasise healers' psychological support role in helping communities deal with trauma. In this respect, we argue that the experience of conflict, and the experiences and conceptualizations of mental and physical illness, need to be taken into account when devising appropriate public or international health policy responses.

Health Facility Committees (HFCs) made of elected community members are often presented as key for improving the delivery of services in primary health-care facilities. They are expected to help Health Facility (HF) staff make decisions that best serve the interests of the population. More recently, Performance-Based Financing (PBF) advocates have also put the HFC at the core of health reform, expecting it to hold HF staff into account for the HF performances and development. In Burundi, a country where PBF is implemented nationwide, a randomised control trial was implemented in 251 health facilities where the HFC had been largely inactive in recent years. A random sample of 168 HFCs was trained on their roles and rights, with a subset also given information about the performance of their HF (using PBF indicators) and the PBF approach in general. The interventions, taking place in 2011-2013, made the HFCs better organised but largely failed to generate any effect on HF management and service delivery. Nested qualitative analysis reveals important tensions between nurses and HFC members that often prevent further change at the HF. In the HFs that received both the training and information interventions, this tension appeared exacerbated: the turnover of chief nurses was significantly higher as the HFCs exerted pressure to remove them. This situation was more likely to happen if the HFC had already received training before the interventions, thereby suggesting that repeated training empowers committees. Overall, the results provide rare rigorous evidence on HFCs, suggesting that more attention needs to be paid to the socio-economic and cultural contexts in which they operate. They also invite to caution when discussing the role of HFCs as a possible watchdog in PBF schemes.

BackgroundHuman resources for health are self-evidently critical to running a health service and system. There is, however, a wider set of social issues which is more rarely considered. One area which is hinted at in literature, particularly on fragile and conflict-affected states, but rarely examined in detail, is the contribution which health staff may or do play in relation to the wider state-building processes. This article aims to explore that relationship, developing a conceptual framework to understand what linkages might exist and looking for empirical evidence in the literature to support, refute or adapt those linkages.MethodsAn open call for contributions to the article was launched through an online community. The group then developed a conceptual framework and explored a variety of literatures (political, economic, historical, public administration, conflict and health-related) to find theoretical and empirical evidence related to the linkages outlined in the framework. Three country case reports were also developed for Afghanistan, Burundi and Timor-Leste, using secondary sources and the knowledge of the group.FindingsWe find that the empirical evidence for most of the linkages is not strong, which is not surprising, given the complexity of the relationships. Nevertheless, some of the posited relationships are plausible, especially between development of health cadres and a strengthened public administration, which in the long run underlies a number of state-building features. The reintegration of factional health staff post-conflict is also plausibly linked to reconciliation and peace-building. The role of medical staff as part of national elites may also be important.ConclusionsThe concept of state-building itself is highly contested, with a rich vein of scepticism about the wisdom or feasibility of this as an external project. While recognizing the inherently political nature of these processes, systems and sub-systems, it remains the case that state-building does occur over time, driven by a combination of internal and external forces and that understanding the role played in it by the health system and health staff, particularly after conflicts and in fragile settings, is an area worth further investigation. This review and framework contribute to that debate.

Motivation Higher education is regarded as a key instrument to enhance socioeconomic mobility and reduce inequalities. Recent literature reviews have examined inequalities in the higher education systems of high‐income countries, but less is known about the situation in low‐ and middle‐income countries, where higher education is expanding fast. Purpose The article reviews the academic literature on higher education in low‐ and middle‐income countries using a research framework inspired by social justice and capability approaches. It considers the financial, sociocultural, human and political resource domains on which people draw, and how they relate to access, participation and outcomes in higher education. Methods A literature search for studies explicitly discussing in‐country inequalities in higher education revealed 22 publications. Substantial knowledge gaps remain, especially regarding the political (and decision‐making) side of inequalities; the ideologies and philosophies underpinning higher education systems; and the linkages between resource domains, both micro and macro. Findings The review highlights key elements for policy‐makers and researchers: (1) the financial lens alone is insufficient to understand and tackle inequalities, since these are also shaped by human and other non‐financial factors; (2) sociocultural constructs are central in explaining unequal outcomes; and (3) inequalities develop throughout one’s life and need to be considered during higher education, but also before and after. The scope of inequalities is wide, and the literature offers a few ideas for short‐term fixes, such as part‐time and online education. Policy implications Inclusive policy frameworks for higher education should include explicit goals related to (in)equality, which are best measured in terms of the extent to which certain actions or choices are feasible for all. Policies in these frameworks, we argue, should go beyond providing financial support, and also address sociocultural and human resource constraints and challenges in retention, performance and labour market outcomes. Finally, they should consider relevant contextual determinants of inequalities.

This paper provides evidence that the COVID-19-related mortality rate of national government ministers and heads of state has been substantially higher than that of people with a similar sex and age profile in the general population, a trend that is driven by African cases (17 out of 24 reported deaths worldwide, as of 6 February 2021). Ministers’ work frequently puts them in close contact with diverse groups, and therefore at higher risk of contracting SARS-CoV-2, but this is not specific to Africa. This paper discusses five non-mutually exclusive hypotheses for the Africa-specific trend, involving comorbidity, poorly resourced healthcare and possible restrictions in accessing out-of-country health facilities, the underreporting of cases, and, later, the disproportionate impact of the so-called ‘South African’ variant (501Y.V2). The paper then turns its attention to the public health and political implications of the trend. While governments have measures in place to cope with the sudden loss of top officials, the COVID-19-related deaths have been associated with substantial changes in public health policy in cases where the response to the pandemic had initially been contested or minimal. Ministerial deaths may also result in a reconfiguration of political leadership, but we do not expect a wave of younger and more gender representative replacements. Rather, we speculate that a disconnect may emerge between the top leadership and the public, with junior ministers filling the void and in so doing putting themselves more at risk of infection. Opposition politicians may also be at significant risk of contracting SARS-CoV-2.