Thomas Bossert

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• Ph.D.
• Senior Lecturer Emeritus at Harvard University

The overall goal of this study is to explore the rollout of the community health policy in Guinea in the context of decentralization, and the role of decision space (the decision authority, capacities, and accountability of local officials) in explaining gaps between the policy’s conceptualization and actual implementation. The implementation resea...

Introduction Alive and Thrive (A&T) implemented infant and young child feeding (IYCF) interventions in Bangladesh. We examine the sustained impacts on health workers' IYCF knowledge, service delivery, job satisfaction, and job readiness three years after the program's conclusion. Methods We use data from a cluster-randomized controlled trial desig...

Despite widespread adoption of decentralization reforms, the impact of decentralization on health system attributes, such as access to health services, responsiveness to population health needs, and effectiveness in affecting health outcomes, remains unclear. This study examines how decision space, institutional capacities, and accountability mecha...

A major theoretical issue about health system reform involving decentralization has been whether it promotes equity of health system funding. An article by the principal author and others in 2003 showed that, under certain conditions and policies, decentralization improved the equity of allocation of financial resources to different income levels o...

Background Community health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to e...

Background: Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included n...

Background: Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included...

The protests in Chile in October 2019 raised the issue of health reform to the public agenda again. This article reviews some of the explanations for why there was a widespread protest, including the expectations of continued progress, the emergence of a “fear-based populism” and the decline in legitimacy of most social and political actors. Using...

Background: Systems thinking is a conceptual approach that can assist stakeholders in understanding complexity and making progress on persistent public health challenges. Neglected tropical diseases (NTDs), a complex global health problem, are responsible for a large disease burden among impoverished populations around the world. This aim of this...

Introduction BRAC, an international development organisation based in Bangladesh, uses female volunteer community health workers called Shasthya Shebika (SS), who receive small incentives to implement its home-fortification interventions at the community level. This paper examines the individual, community and BRAC work environment factors that exe...

Objective We assessed the role of home visits by Shasthya Shebika (SS) – female volunteer community health workers (CHWs) – in improving the distribution of micronutrient powder (MNP), and explored the independent effects of caregiver–provider interaction on coverage variables. Design We used data from three cross-sectional surveys undertaken at b...

Objective The aim of this paper is to identify and develop a comprehensive conceptual framework using implementation science that can be applied to assess a nutrition intervention in a real-world setting. Design We conducted a narrative review using electronic databases and a manual search to identify implementation science frameworks, models and...

Objective BRAC, an international development organization based in Bangladesh, engages community health workers called Shasthya Shebikas (SS) to implement home fortification of foods with micronutrient powders (MNP). We identified factors associated with home visits by SS, at different levels of the BRAC programme-delivery hierarchy, to implement h...

Background: Implementation science has been growing as discipline in the past decades, producing an increasing number of models in the area. On the other hand, most frameworks are intended to guide the implementation of programs, focusing on identifying elements and stages that increase their success. This article aims to structure this discussion...

Introduction Cambodia’s health equity fund (HEF) is the country’s most significant social security scheme, covering the poorest one-fifth of the national population. During the last two decades, the HEF system was scaled up from an initial two health districts to national coverage of public health facilities. This is the first national study to exa...

Background: Suboptimal healthcare quality may be a barrier to achieving child health improvements, yet little is known about the relationship between provider compliance with evidence-based practices and client behavior change. We assess provider compliance in the context of infant and young child feeding (IYCF) counseling, its relationship with c...

Background: While measuring, monitoring, and improving supply chain management (SCM) for antiretrovirals (ARVs) is understood at many levels of health systems, a gap remains in the identification and measurement of facility-level practices and behaviors that affect SCM. This study identifies practices and behaviors that are associated with SCM of...

Gaps in postnatal care use represent missed opportunities to prevent maternal and neonatal death in sub-Saharan Africa. As one in every three non-facility deliveries in Nigeria is assisted by a traditional birth attendant (TBA), and the TBA’s advice is often adhered to by their clients, engaging TBAs in advocacy among their clients may increase mat...

Do improvements in health service delivery affect trust in political leaders in Africa? Citizens expect their government to provide social services. Intuitively, improvements in service delivery should lead to higher levels of trust in and support for political leaders. However, in contexts where inadequate services are the norm, and where politica...

Health care is one of the most financially onerous and contested social policy responsibilities of governments in the early 21st century. We conducted a multi-country study on federalism and decentralization in the governance, financing, administration or delivery of health care based on a decision space approach. Our contributors examined Switzerl...

Sub-Saharan African governments need to make substantial investments to expand access to quality health services, necessitating research that examines the incentives before politicians to make these investments. This paper examined the implications of a national maternal and child health intervention in Nigeria for trust in the President and the ru...

This book is an analysis of the connection between federalism, which involves a degree of political decentralization, and the organization of health care using a decision space analysis to determine the actual degree of health system decentralization. This requires an assessment of whether national or subnational governments have narrow, moderate,...

Background: While 79% of Nigerian mothers who deliver in facilities receive postnatal care within 48 h of delivery, this is only true for 16% of mothers who deliver outside facilities. Most maternal deaths can be prevented with access to timely and competent health care. Thus, the World Health Organization, International Confederation of Midwives,...

Background Institutionalization and sustainability are important issues for any donor funded program as the effectiveness of the initiatives are usually expected to persist after the donor funding period has ended. This report develops a framework for analysis integrating the two concepts and applies it to an important case of donor-funded quality...

Background The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusi...

Background Community health worker (CHW) programs are believed to be poorly coordinated, poorly integrated into national health systems, and lacking long-term support. Duplication of services, fragmentation, and resource limitations may have impeded the potential impact of CHWs for achieving HIV goals. This study assesses mediators of a more harmon...

Additional country context and results. (DOCX)

Conceptual framework for analyzing the harmonization of CHW programs. (DOCX)

COREQ 32-item checklist. (DOCX)

Review and framework. (DOCX)

Priority areas for harmonization. (DOCX)

Country data analysis sheet (sample). (DOCX)

Primary coded data. (XLSX)

Objectives To identify the level of knowledge and competencies related to quality of care during medical education in sub-Saharan African medical schools. Methods A cross-sectional study design was utilized to examine the capacity of medical schools in sub-Saharan African (SSA) countries to teach about the concepts of quality of care and the inclu...

Background Many countries have created community-based health worker (CHW) programs for HIV. In most of these countries, several national and non-governmental initiatives have been implemented raising questions of how well these different approaches address the health problems and use health resources in a compatible way. While these questions have...

Background: Community health workers (CHWs) are increasingly used to increase access to primary healthcare, and considered to be a key health worker cadre to achieve the UNAIDS 90-90-90 target. Despite the recent policy interest in effectively designing, implementing, and evaluating new CHW programs, there is limited evidence on how long-standing C...

Background: Patients are unlikely to share the personal information that is critical for effective healthcare, if they do not trust that this information will remain confidential. Trust in confidentiality may be particularly low in interactions with community health workers (CHW) because CHW deliver healthcare outside the clinic setting. This stud...

Background Health information systems are central to strong health systems. They assist with patient and program management, quality improvement, disease surveillance, and strategic use of information. Many donors have worked to improve health information systems, particularly by supporting the introduction of electronic health information systems...

In 2016, the Flagship Program for improving health systems performance and equity, a partnership for leadership development between the World Bank and the Harvard T.H. Chan School of Public Health and other institutions, celebrates 20 years of achievement. Set up at a time when development assistance for health was growing exponentially, the Flagsh...

Background: Very few of the primary care doctors currently working in China's community health centers have a college degree (issued by 5-year medical schools). How to attract college graduates to community services in the future, therefore, has major policy relevance in the government's ongoing efforts to reform community health care and fill in...

The study of decentralization in Fiji shows that increasing capacities is not necessarily related to increasing decision space of local officials, which is in contrast with earlier studies in Pakistan. Future studies should address the relationship among decision space, capacities, and health system performance.

Launched in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) is the largest disease-focused assistance program in the world. We analyzed PEPFAR budgets for governance and systems for the period 2004-14 to ascertain whether PEPFAR's stated emphasis on strengthening health systems has been manifested financially. The main outcome vari...

Draft report. Please request permission from author(s) before citing. anna.c.heard@gmail.com, tbossert@hsph.harvard.edu

Chile has had a two-tiered health system since the 1980s, though successive governments have worked to strengthen the public tier. Despite improvements in some health indicators, satisfaction with the system has declined, and the need for reform is widely acknowledged.

The author's 1998 article on decentralization focused on the element of choice as the major issue of decentralization – granting authority and responsibility for choice to administrative and elected officials at peripheral levels of organizations and governments – and introduced the concept of " decision space " to describe the range of choice allo...

Central policy questions on decentralization in health relate to whether and in which ways health sector decentralization can improve health outcomes. Focusing on a maternal, neonatal and child health program in Pakistan, this study examines relationships between three dimensions of decentralization: the degree of local decision-making choice (“dec...

The shortage of health personnel and nurses is an important issue in many developed and developing countries. Understanding preferred choice of work setting is an important strategy for retaining nurses in their work. The purpose of this study was to determine choices made by nurses in Thailand relative to their preferences for a work setting. A di...

In this article we present a study design to evaluate the causal impact of providing supply-side performance-based financing incentives in combination with a demand-side cash transfer component on equitable access to and quality of maternal and neonatal healthcare services. This intervention is introduced to selected emergency obstetric care facili...

Decentralization of health systems is a growing trend in most nations. However, there are a series of new challenges that face these processes of decentralization. To assess these challenges, this chapter first starts with a definition of decentralization that defines who gets more choice (deconcentration or devolution) and how much choice they get...

Background: Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), yet few studies have examined their effects on health systems. Objective: To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the largest investor...

Governance is increasingly recognized as an important factor in health system performance, yet conceptually and practically it remains poorly understood and subject to often vague and competing notions of both what its role is and how to address its weaknesses. This overview article for the symposium on health governance presents a model of health...

Background: Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Ira...

Health sector decentralization has been widely adopted to improve delivery of health services. While many argue that institutional capacities and mechanisms of accountability required to transform decentralized decision-making into improvements in local health systems are lacking, few empirical studies exist which measure or relate together these c...

The Government of Andhra Pradesh has invested in the Rajiv Aarogyasri Community Health Insurance Scheme as a means to reduce burdensome health expenses incurred by the state's below-the-poverty-line population. However, recent household data collected in two districts of ap suggest that poor patients continue to spend significantly on conditions th...

Advocates of local government often argue that when decentralisation is accompanied by adequate mechanisms of accountability, particularly those responsive to local preferences, improved service delivery will result. From the perspective of the health sector, the appropriate degree of decentralisation and the necessary mechanisms of accountability...

To raise the awareness of a global crisis in human resources for health care, the World Health Organization has suggested a minimum target for all countries: 2.3 health professionals per 1,000 people. Many countries cannot afford to meet the target; in fact, funding the proposed number of health workers would require some countries to devote 50 per...

Attempts to establish a health plan for the occupied Palestinian territory were made before the 1993 Oslo Accords. However, the first official national health plan was published in 1994 and aimed to regulate the health sector and integrate the activities of the four main health-care providers: the Palestinian Ministry of Health, Palestinian non-gov...

The capacity of recipient governments to absorb increased aid is a serious concern. This article explains a'Capacity Assessment Tool'that has been developed for the health sector, but - with suitable adaptations - similar assessments can be conducted in other sectors. The tool makes it possible to identify and to provide rapid assessments of incapa...

Studies of social capital have focused on the static relationship between social capital and health, governance and economic conditions. This study is a first attempt to evaluate interventions designed to improve the levels of social capital in post-conflict communities in Nicaragua and to relate those increases to health and governance issues. The...

Increased immunization coverage is an important step towards fulfilling the Millennium Development Goal of reducing childhood mortality. Recent cross-sectional and cross-national research has indicated that physician, nurse and midwife densities may positively influence immunization coverage. However, little is known about relationships between den...

Many studies suggest that social capital, defined as those intangible resources of a society or community (trust, participation and reciprocity), that might facilitate collective action, can be associated with positive health effects. To explore the relationship between social capital an the level of mental health, in urban communities of Santiago,...

Many studies suggest that social capital, defined as those intangible resources of a society or community (trust, participation and reciprocity), that might facilitate collective action, can be associated with positive health effects. Aim: To explore the relationship between social capital an the level of mental health, in urban communities of Sant...

Efficient logistics systems move essential medicines down the supply chain to the service delivery point, and then to the end user. Experts on logistics systems tend to see the supply chain as requiring centralized control to be most effective. However, many health reforms have involved decentralization, which experts fear has disrupted the supply...

A dominant perspective in social capital research emphasizes a “structural” dimension of social capital, consisting of network connections, and a “cognitive” dimension, consisting of attitudes toward trust. Correspondingly, membership in organizations (i.e., membership density) and general trust in people (i.e., social trust) are two indicators com...

Compared to neighboring countries, the Philippines has high fertility rates and a low prevalence of modern-method contraception use. The Philippine government faces political and cultural barriers to addressing family planning needs, but also legal barriers erected by its own policies. We conducted a review of laws and policies relating to family p...

To investigate the relation between decentralization and equity of resource allocation in Colombia and Chile. The "decision space" approach and analysis of expenditures and utilization rates were used to provide a comparative analysis of decentralization of the health systems of Colombia and Chile. Evidence from Colombia and Chile suggests that dec...

This study reviews the experience of decentralization in four developing countries: Ghana, Uganda, Zambia and the Philippines. It uses two analytical frameworks to describe and compare the types and degrees of decentralization in each country. The first framework specifies three types of decentralization: deconcentration, delegation and devolution....

Decentralization is often a major part of health reform policies. However, there have been few attempts to comparatively study the degree of decentralization and the effects of decentralization on equity of allocations to health, so we do not know how best to implement this reform. This article uses an innovative comparative analysis of the "decisi...

Decentralization has long been advocated as a desirable process for improving health systems. Nevertheless, we still lack a sufficient analytical framework for systematically studying how decentralization can achieve this objective. We do not have adequate means of analyzing the three key elements of decentralization: (1) the amount of choice that...

Ministries of health are being called upon to lead major health reforms; at the same time they must reform themselves to become more modern institutions and assume new and different functions and roles in the more dynamic reformed system. The literature on public administration and on health reform has recommended many processes of institutional re...

This paper applies an interdisciplinary approach to analyze the process of health reform in four significant periods in Chilean history: (1) the consolidation of state responsibility for public health in the 1920s, (2) the creation of the state-run National Health Service in the 1950s, (3) the decentralization of primary care and privatization of h...

Decentralization and ‘bottom-up’ planning have been objectives of many projects in recent years. This article examines the implementation of one project - the Comprehensive Health Improvement Program-Province Specific (CHIPPS) - which was partially effective in promoting decentralization to the provincial and local levels in the Indonesian Ministry...

This article presents a synthesis of five country studies of the sustainability of U.S. government-funded health projects in Central America and Africa. The studies reviewed health projects with a comparative framework to determine which project activities had continued after the donor funding ceased. This review found that health projects in Afric...

Introduction * Lost Promise: Explaining Latin American Underdevelopment Peter F. Klarn. Modernization * Values, Education and Entrepreneurship Seymour Martin Lipset. * The Politics of Social and Economic Change in Latin America Kalman H. Silvert. * Political Change in Latin America: The Emergence of the Middle Sectors John J. Johnson. * Responsibil...

Despite increasing knowledge about technical aspects of Primary Health Care (PHC), there has been as yet only limited research into political and administrative influences on the effectiveness of PHC programs. A three-stage model of the policy process is developed as a framework for organizing the relationships between elements of (1) the national...

The revolutionary regime in Nicaragua has made great strides toward the achievement of the central goals of equity of access to health services, emphasis on preventive rather than curative services. and encouragement of community participation. Nevertheless, during the first year of the regime choices were made which were inconsistent with the full...

The central problem of this special issue of Social Science and Medicine is: why and how governments adopt (or fail to adopt) the primary care approach to health care delivery. The papers approach this problem from different perspectives, including the international arena, economic and social constraints, regime and institutional characteristics, a...

The reprint of this special journal issue contains nine papers on health policies. Three of the the papers have a general continental range; the others are more specific on individual countries, i.e. Cuba, Chile, Tanzania, Colombia, Kenya, Ghana, and Cameroun. All papers are abstracted separately with the journal reference. -M.A.Bass

Thomas Bossert, profesor de la Escuela de Salud Pública de la Universidad de Harvard, explica el carácter no universal del sistema de salud en Estados Unidos, la forma como funciona, y los problemas del sistema. Adicionalmente, hace un análisis retrospectivo de los intentos de reforma al sistema desde 1930, y plantea los compromisos y logros de la...