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Despite much lauded change in recent years, Myanmar's national health system still lags behind its regional counterparts. Decades of civil war and military rule have created, at the national level, a 'centralisation by fiat'. This was most recently consolidated prior to the beginning of the country's transition to democracy through the military-drafted 2008 constitution, which centralises power in the military. In part, Myanmar's experience is also one of 'decentralisation by default'. Civil war as well as the country's geographic and demographic circumstances led to greater independence of well over a dozen territories and varying degrees of strength in sub-national structures. In the current period of relative de-confliction and political dialogue, discussions of decentralisation and federalism have never been so important – not the least within political dialogue following the nationwide ceasefire agreement. Moreover, several recent studies have found that public health was a top tier indicator of how Myanmar people of all ethnicities perceive the country's progress. Decentralisation of the health system, as well as some centralisation or convergence of previously separate health systems in terms of information sharing and resource sharing, will be crucial to consolidate the progress made in the peace and democratisation processes. Indeed, the establishment of a decentralised and equitable public health system should be a leading priority for stabilising the country and ensuring its future prosperity. This paper explores decentralisation in Myanmar's health system through current theoretical frameworks. It suggests that Myanmar's experience of 'decentralisation by default' may find similarities in other post-conflict and conflict states. [ABSTRACT FROM AUTHOR]

Decentralisation, which sends power and resources from the Central to local governments, comes with several theoretical promises. One such promise is the improvement in local service provision. However, achieving these theoretical promises of decentralization has been a big challenge in most developing countries. This study aims to address the question "does decentralization improve service delivery levels at the local level, as promised?" This study reviews work on decentralization and service provision in developing countries and bring out some lessons from these works. To do this, the study falls on a set of articles from world-class scholars on decentralisation and service provision and key findings and themes from their works. As has been stressed in the conclusion, decentralisation has made some gains in meeting the real needs of local people in terms of service provision. In some instances, increases in the expenditure of local governments have increased service provision levels. However, the level of quality of these service providers through decentralisation has remained questionable. The author argues that an increase in service provision is good; however, it is the quality of these service provisions at the local level that can reduce poverty at the local level. The study, therefore, recommends for a revisit of the design of decentralisation to embrace the type which seeks to empower the local people to demand transparency and accountability from local government officials. With this, the effectiveness of administrative, fiscal and political decentralisation along with clear channels for local accountability and transparency are necessary for improved and quality service provision. [ABSTRACT FROM AUTHOR]

This paper explores the relationship between micro-economic business models, economic structure, and locally sustainable prosperity. In this respect, the paper takes as a premise the contention that sustainable mobility requires a sustainable industry to create the vehicles and business models to deliver that mobility. The interactions between locality and scale are explored within the context of the anti-globalisation discourse. Thereafter, the paper provides a brief outline of some business models from the automotive industry where alternatives to the monolithic and centralised structure of the mainstream industry have been proposed. [ABSTRACT FROM AUTHOR]

Financial enterprises generate profits based on economic development. More importantly, a healthy market is difficult to achieve due to their susceptibility to the parasitic credit card fraud transactions that accompany economic growth, unless an effective anti-counterfeiting technology is developed to alleviate the issue. To solve the problem, we propose a gradient-boosting decision tree based anti-fraud protection with blockchain Technology, referred to as GBDT-APBT, which treats anti-fraud transaction model as the accumulation of the classfiers' weakness and builds up a classifiers' to judge whether the transaction is fraudulent. Each user's private data is trained offline at the local blockchain node, then the trained model is directly uploaded to the cloud, and the final consensus model is obtained by voting. Due to incorporating blockchain technology, GBDT-APBT demonstrates decentralisation, openness, autonomy, anonymity, and immutability, showing its ability to satisfying the demand for an effective and beneficial anti-counterfeiting system, with high performance and effectiveness in detecting fraud information. Experiments show that compared with other methods, GBDT-APBT offers a promising approach to the security of credit card transactions with reference to the detection accuracy. [ABSTRACT FROM AUTHOR]

Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to illequipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality andaccess within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly. [ABSTRACT FROM AUTHOR]

Two extremes of forest conflict exist: low- and high-intensity conflicts. Theoretical debate on how forest conflict escalates from one extreme to the other has begun to take place; however, empirical research is lacking. Our paper aims to explore the conflict escalation process using a case study approach. We explored whether two theoretical building blocks of conflict escalation (stages and patterns) can be evaluated at the field level. We conducted fieldwork in Baru Pelepat village, Sumatra, to investigate a conflict between a logging company and a local community. We performed interviews and focus group discussions with key stakeholders. The conflict revolved around an unclear boundary between a state forest, within which the logging company operated, and the communal forest, which led to local community opposition to logging activity. The conflict escalated over time as parties failed to find a solution. We describe escalation stages associated with the conflict and also the pattern of conflict escalation. The findings suggest that theoretical frameworks of conflict escalation are applicable at field level. A number of practical options for managing the conflict and the implications for wider forest management are discussed. While understanding the conflict escalation process does not necessarily guarantee effective settlement of a conflict, it nonetheless helps to strategically devise conflict management efforts. [ABSTRACT FROM AUTHOR]

This paper uses a new approach to the concept of green budgeting within the context of green economy to analyse the different factors influencing the lack of consistency on environmental policies in Spain. It appears that structural issues have prevented Spain from becoming a real green economy, and thus from taking the right measures that could lead it into a sustainable growth path. This case study is presented as example of failure to integrate environmental issues in policy-making, with political factors being one of the main variables under analysis. A quantitative analysis on the approach to public environmental budget management during the period prior to the recent economic crisis is conducted at national and regional levels. Some of the findings are consistent with other European countries but some distinctive structural issues are also identified. [ABSTRACT FROM AUTHOR]

Tuberculosis (TB) is a major public health issue in Papua New Guinea, with incidence rates particularly high in the South Fly District of Western Province. We present three case studies, along with additional vignettes, that were derived from interviews and focus groups carried out between July 2019 and July 2020 of people living in rural areas of the remote South Fly District depicting their challenges accessing timely TB diagnosis and care; most services within the district are only offered offshore on Daru Island. The findings detail that rather than 'patient delay' attributed to poor health seeking behaviours and inadequate knowledge of TB symptoms, many people were actively trying to navigate structural barriers hindering access to and utilisation of limited local TB services. The findings highlight a fragile and fragmented health system, a lack of attention given to primary health services, and undue financial burdens placed on people living in rural and remote areas associated with costly transportation to access functioning health services. We conclude that a person-centred and effective decentralised model of TB care as outlined in health policies is imperative for equitable access to essential health care services in Papua New Guinea. [ABSTRACT FROM AUTHOR]

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This paper analyses the impact of decentralisation on the political organisation, management and provision of sexual and reproductive health services in Ghana. It draws on qualitative research and interviews with key informants from the Ministry of Health, donors, NGOs, regional and district health management teams, local government and community leaders. Within a national reproductive health policy framework, previously disparate family planning, maternal and child health, STI and HIV/AIDS programmes have become more integrated, and donors have pooled or co-ordinated their funding. Some decision-making about resource allocation is meant to happen at district and regional level but in practice, this remains centrally controlled, which may be a necessary safeguard for sexual and reproductive health services. Earmarked donor funds still ensure a regular supply of contraceptives and STI drugs. However, paying for these is problematic at local level. Sexual and reproductive health staff make up a large proportion of primary health care staff, but especially in rural areas they experience poor working conditions, and there is high turnover and vacancies. District and sub-district level links are working well in this new system, but clarity is still needed on how different national sexual and reproductive health bodies relate to each other and to regional and district health authorities. The development of formal mechanisms for priority setting and advocacy at local levels could help to secure benefits for sexual and reproductive health care. Cet article analyse l'impact de la décentralisation sur l'organisation politique, la gestion et la prestation de services de santé génésique au Ghana. Il s'appuie sur des recherches qualitatives et des entretiens avec des informateurs du Ministère de la santé, des donateurs, des ONG, des équipes de gestion au niveau régional et de district, des responsables locaux et communautaires. Des programmes disparates de planification familiale, de santé maternelle et infantile, d'IST et de VIH/SIDA ont été intégrés dans un cadre national de santé génésique et les donateurs ont coordonné leur financement. Certaines décisions sur l'allocation des ressources qui devraient être prises au niveau régional et du district demeurent contrôlées centralement, ce qui peut être une précaution nécessaire pour les services de santé génésique. Les fonds réservés par les donateurs garantissent un approvisionnement régulier de contraceptifs et de médicaments pour les IST. Le personnel de santé génésique représente une forte proportion du personnel de soins de santé primaires, mais, surtout en zone rurale, les conditions de travail sont mauvaises, avec un fort taux de rotation. Les liens entre le district et le sous-district fonctionnent bien dans ce nouveau système, mais il faut clarifier les relations entre les organes nationaux de santé génésique et les autorités sanitaires régionales et de district. La création de mécanismes locaux de définition des priorités et de plaidoyer pourrait être bénéfique pour les soins de santé génésique. Este artı́culo analiza el impacto de la descentralización sobre la organización polı́tica, gestión y provisión de servicios de salud reproductiva en Ghana. Se basa en la investigación cualitativa y en entrevistas con informantes claves del Ministerio de Salud, organismos donantes, ONG, equipos de gestión en salud regionales y de distrito, y dirigentes comunitarios y de gobierno local. Una polı́tica nacional de salud reproductiva ha integrado programas de planificación familiar, salud materno-infantil, ITS y VIH/SIDA, y los organismos donantes han cooperado para coordinar el financiamiento. Algunas decisiones tocante a la distribución de recursos deben tomarse a nivel regional o de distrito, pero en la práctica siguen siendo controladas a nivel central, lo cual puede ser necesario para salvaguardar los servicios de salud sexual y reproductiva. Los fondos restringidos todavı́a aseguran un abastecimiento regular de anticonceptivos y medicamentos. Una proporción significativa del personal de salud primaria presta servicios de salud sexual y reproductiva, pero las condiciones de trabajo son deficientes, especialmente en las áreas rurales, y hay mucho recambio. Los vı́nculos de distrito y sub-distrito funcionan bien en el sistema nuevo, pero falta claridad acerca de la relación entre las distintas entidades nacionales de salud salud y entre ellas y las autoridades regionales y de distrito. El desarrollo de mecanismos formales para fijar prioridades y para la promoción a nivel local podrı́an ayudar a obtener beneficios para la atención en salud sexual y reproductiva. [ABSTRACT FROM AUTHOR]

Background: A corruption event in 2009 led to changes in how donors supported the Zambian health system. Donor funding was withdrawn from the district basket mechanism, originally designed to pool donor and government financing for primary care. The withdrawal of these funds from the pooled financing mechanism raised questions from Government and donors regarding the impact on primary care financing during this period of aid volatility. Objectives: To examine the budgets and actual expenditure allocated from central Government to the district level, for health, in Zambia from 2006 to 2017 and determine trends in funding for primary care. Methods: Financial data were extracted from Government documents and adjusted for inflation. Budget and expenditure for the district level over the period 2006 to 2017 were disaggregated by programmatic area for analysis. Results: Despite the withdrawal of donor funding from the district basket after 2009, funding for primary care allocated to the district level more than doubled from 2006 to 2017. However, human resources accounted for this increase. The operational grant, on the other hand, declined. Conclusion: The increase in the budget allocated to primary care could be an example of ‘reverse fungibility’, whereby Government accounted for the gap left by donors. However, the decline in the operational grant demonstrates that this period of aid volatility continued to have an impact on how primary care was planned and financed, with less flexible budget lines most affected during this period. Going forward, Government and donors must consider how funding is allocated to ensure that primary care is resilient to aid volatility; and that the principles of aid effectiveness are prioritised to continue to provide primary health care and progress towards achieving health for all. [ABSTRACT FROM AUTHOR]

Background: Decentralisation of antiretroviral therapy has been implemented to scale up HIV care provision for patients in resource-limited countries. Youth living with HIV demonstrate the poorest care outcomes, compared to other age groups. Objectives: To systematically evaluate evidence on the effects of decentralising facility-based HIV care on care outcomes for youth living with HIV in low- and middle-income countries. Methods: A systematic review was conducted through 12 electronic databases of peer-reviewed articles, conference abstracts, and grey literature; contacting relevant experts; and hand-searching references. Records were included if they were published after 1 January 1996 (advent of triple-drug ART) and reported health outcomes for decentralised and centralised care, separately, or evaluated the effect of decentralised care on care outcomes. Two authors independently screened search results. When age-disaggregated data (10–24 years old) were required for inclusion, we contacted study authors for data abstraction. Implementation fidelity of decentralisation, study quality, and risk of bias was assessed using the TIDieR checklist, CASP checklists, and ROBINS-I tool, respectively. Results: Of 11 potentially eligible studies, two studies from sub-Saharan Africa met inclusion criteria after data disaggregation by age. The studies and abstracted data were insufficiently homogenous in implementation and study design to justify meta-analysis. However, evidence suggests the potential for decentralised care to result in at least equivalent attrition-related outcomes (retention in care and mortality) for youth within decentralised HIV care. Limited sample size and significant selection and allocation bias confound clear, generalisable conclusions for youth living with HIV in resource-limited settings. Conclusions: There is a paucity of evidence for the effects of decentralising HIV care for youth living in resource-limited settings, particularly recent evidence reflective of the current HIV care landscape. Further work is required to rigorously analyse the effects of decentralising HIV care to inform policymakers and care providers, particularly as demand for HIV care in this population grows. [ABSTRACT FROM AUTHOR]

In this study an attempt has been made to solve a problematic phenomenon regarding how a decentralised environment mediates the effect on supply chain performance (SCP) - by taking various dimensions of knowledge management (KM) - specifically in the dairy sector of Lahore, Pakistan. This study also explores the relationship between KM practices and SCP in the presence of a general system theory; the theory claims that every system is has sub-parts, and every sub-part is surrounded by other sub-parts. Decentralisation has a mediating role which influences the relationship between KM practices and SCP in the dairy sector of Pakistan. A self-administered questionnaire was developed, and data were collected through a random sampling of 355 supply chain members of different dairy organisations in central Punjab. The data was analysed by AMOS software and through structure equation modelling (SEM). The underlying study reveals that the hypothesis is accepted, that decentralisation mediates the relationship between KM practices and SCP at a 1% level of significance; it also reveals that KM practices (with the exceptions of knowledge creation and knowledge sharing) have a direct relationship with SCP. Meanwhile, statistical analysis also indicates that KM practices (with the exception of knowledge creation) have a significant positive relationship with decentralisation at the 1% significance level. [ABSTRACT FROM AUTHOR]

Health care systems are faced with the challenge of resource scarcity and have insufficient resources to respond to all health problems and target groups simultaneously. Hence, priority setting is an inevitable aspect of every health system. However, priority setting is complex and difficult because the process is frequently influenced by political, institutional and managerial factors that are not considered by conventional priority-setting tools. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority setting in district health management were studied. This review is based on a PhD thesis that aimed to analyse health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness (A4R) approach to priority setting in Tanzania. A qualitative case study in Mbarali district formed the basis of exploring the sociopolitical and institutional contexts within which health care decision making takes place. The study also explores how the A4R intervention was shaped, enabled and constrained by the contexts. Key informant interviews were conducted. Relevant documents were also gathered and group priority-setting processes in the district were observed. The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. The study also found that while the A4R approach was perceived to be helpful in strengthening transparency, accountability and stakeholder engagement, integrating the innovation into the district health system was challenging. This study underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context is imperative in fostering sustainability. Additionally, the study stresses the need to deal with power asymmetries among various actors in priority-setting contexts. [ABSTRACT FROM AUTHOR]

Background: Sub-Saharan Africa (SSA) has had more major armed conflicts (wars) in the past two decades - including 13 wars during 1990-2015 - than any other part of the world, and this has had an adverse effect on health systems in the region. Objective: To understand the best health system practices in five SSA countries that experienced wars during 1990-2015, and yet managed to achieve a maternal mortality reduction - equal to or greater than 50% during the same period - according to the Maternal Mortality Estimation Inter-Agency Group (MMEIG). Maternal mortality is a death of a woman during pregnancy, or within 42 days after childbirth - measured as maternal mortality ratio (MMR) per 100,000 live births. Design: We conducted a selective literature review based on a framework that drew upon the World Health Organisation's (WHO) six health system building blocks. We searched seven databases, Google Scholar as well as conducting a manual search of sources in articles' reference lists - restricting our search to articles published in English. We searched for terms related to maternal healthcare, the WHO six health system building blocks, and names of the five countries. Results: Our study showed three general health system reforms across all five countries that could explain MMR reduction: health systems decentralisation, the innovation related to the WHO workforce health system building block such as training of community healthcare workers, and governments-financing reforms. Conclusion: Restoring health systems after disasters is an urgent concern, especially in countries that have experienced wars. Our findings provide insight from five war-affected SSA countries which could inform policy. However, since few studies have been conducted concerning this topic, our findings require further research to inform policy, and to help countries rebuild and maintain their health systems resilience. [ABSTRACT FROM AUTHOR]

In Nigeria, the shortage of health workers is worst at the primary health care (PHC) level, especially in rural communities. And the responsibility for PHC – usually the only form of formal health service available in rural communities – is shared among the three tiers of government (federal, state, and local governments). In addition, the responsibility for community engagement in PHC is delegated to community health committees. This study examines how the decentralisation of health system governance influences retention of health workers in rural communities in Nigeria from the perspective of health managers, health workers, and people living in rural communities. The study adopted a qualitative approach, and data were collected using semi-structured in-depth interviews and focus group discussions. The multi-stakeholder data were analysed for themes related to health system decentralisation. The results showed that decentralisation influences the retention of rural health workers in two ways: 1) The salary of PHC workers is often delayed and irregular as a result of delays in transfer of funds from the national to sub-national governments and because one tier of government can blame failure on another tier of government. Further, the primary responsibility for PHC is often left to the weakest tier of government (local governments). And the result is that rural PHC workers are attracted to working at levels of care where salaries are higher and more regular – in secondary care (run by state governments) and tertiary care (run by the federal government), which are also usually in urban areas. 2) Through community health committees, rural communities influence the retention of health workers by working to increase the uptake of PHC services. Community efforts to retain health workers also include providing social, financial, and accommodation support to health workers. To encourage health workers to stay, communities also take the initiative to co-finance and co-manage PHC services in order to ensure that PHC facilities are functional. In Nigeria and other low- and middle-income countries with decentralised health systems, intervention to increase the retention of health workers in rural communities should seek to reform and strengthen governance mechanisms, using both top-down and bottom-up strategies to improve the remuneration and support for health workers in rural communities. [ABSTRACT FROM AUTHOR]