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      The governance of local health systems in the era of Sustainable Development Goals: reflections on collaborative action to address complex health needs in four country contexts

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          Abstract

          This analysis reflects on experiences and lessons from four country settings—Zambia, India, Sweden and South Africa—on building collaborations in local health systems in order to respond to complex health needs. These collaborations ranged in scope and formality, from coordinating action in the community health system (Zambia), to a partnership between governmental, non-governmental and academic actors (India), to joint planning and delivery across political and sectoral boundaries (Sweden and South Africa). The four cases are presented and analysed using a common framework of collaborative governance, focusing on the dynamics of the collaboration itself, with respect to principled engagement, shared motivation and joint capacity. The four cases, despite their differences, illustrate the considerable challenges and the specific dynamics involved in developing collaborative action in local health systems. These include the coconstruction of solutions (and in some instances the problem itself) through engagement, the importance of trust, both interpersonal and institutional, as a condition for collaborative arrangements, and the role of openly accessible information in building shared understanding. Ultimately, collaborative action takes time and difficulty needs to be anticipated. If discovery, joint learning and developing shared perspectives are presented as goals in themselves, this may offset internal and external expectations that collaborations deliver results in the short term.

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          An Integrative Framework for Collaborative Governance

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            Trust and the development of health care as a social institution

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              Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania

              The World Health Assembly of 2005 called for all health systems to move towards universal coverage, defined as " access to adequate health care for all at an affordable price" . A crucial aspect in achieving universal coverage is the extent to which there are income and risk cross-subsidies in health systems. Yet this aspect appears to be ignored in many of the policy prescriptions directed at low- and middle-income countries, often resulting in high degrees of health system fragmentation. The aim of this paper is to explore the extent of fragmentation within the health systems of three African countries (Ghana, South Africa and the United Republic of Tanzania). Using a framework for analysing health-care financing in terms of its key functions, we describe how fragmentation has developed, how each country has attempted to address the arising equity challenges and what remains to be done to promote universal coverage. The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way. To achieve universal coverage, health systems must reduce their reliance on out-of-pocket payments, maximize the size of risk pools, and resource allocation mechanisms must be put in place to either equalize risks between individual insurance schemes or equitably allocate general tax (and donor) funds. Ultimately, there needs to be greater integration of financing mechanisms to promote universal cover with strong income and risk cross-subsidies in the overall health system.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2019
                6 June 2019
                : 4
                : 3
                : e001645
                Affiliations
                [1 ] departmentSchool of Public Health and SAMRC Health Services to Systems Research Unit , University of the Western Cape , Cape Town, South Africa
                [2 ] departmentSchool of Public Health , University of Zambia , Lusaka, Zambia
                [3 ] Emmanuel Hospital Association , New Delhi, Delhi, India
                [4 ] departmentDepartment of Epidemiology and Global Health , Umeå University , Umeå, Sweden
                [5 ] Western Cape Government:Health , Cape Town, South Africa
                Author notes
                [Correspondence to ] Professor Helen Schneider; hschneider@ 123456uwc.ac.za
                Author information
                http://orcid.org/0000-0002-0418-1828
                Article
                bmjgh-2019-001645
                10.1136/bmjgh-2019-001645
                6570980
                31263592
                68425e26-b100-4190-97c3-0b4e8ce54f3f
                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 15 April 2019
                : 08 May 2019
                : 11 May 2019
                Funding
                Funded by: South African National Research Foundation (NRF)/Swedish Foundation for International Cooperation in Research and Higher Education (STINT), Science and Technology Research Collaboration;
                Award ID: Grant UID:106770
                Categories
                Analysis
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                governance,collaborative governance,local health systems,coordination,collaboration,shared motivation

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