Classication and Review of Health Financing Frameworks: What do they Focus on to Assess and Improve the Situation?

Health financing assessment is of growing interest to policy makers to develop reform strategies towards achieving universal health coverage. Different frameworks for assessing of health financing systems have been developed. The purpose of this study is to review the current frameworks for understanding and assessing health financing and draw out the dimensions of conceptual frameworks and how different concepts are used in relation to the concept of health financing assessment. Lessons learned from different frameworks would guide the future use and formulation of such frameworks.

Health policy makers around the world are faced with increasingly difficulties to sustain 66 sufficient financing for health care (5). Tens of millions of people the world over either do not 67 have access to health care services they need or they have to pay for it, which are catastrophic 68 or impoverishing (3). 69 Many countries, particularly low and middle-income ones, are developing health financing 70 systems that enable them to sustain or to move towards universal health coverage. However, 71 there is still a gap in evidence and knowledge about national and country-level health 72 financing systems that perform well in terms of improving health outcomes and financial 73 protection (3, 6, 7). 74 To date, multiple frameworks to assess or review health financing have been developed. The 75 ultimate goal of a conceptual framework is to provide a "starting point" for a national health formulation of proper reforms to improve health financing system performance. We described 95 and compared health financing frameworks to guide policymakers when selecting a 96 framework to use for assessing health financing and help them use evidence for health finance 97 policy making. This is accomplished by giving a brief overview of frameworks focusing on 98 the dimensions and metrics for each one and summarizing qualitatively the key dimensions, 99 which the majority of the included frameworks highlighted for health financing review. Method 102 We carried out a systematic search strategy, using the PubMed database to find peer reviewed 103 published literature up to April 2020. The search was guided by the following search terms: 104 health, finance*, framework*, assess*. A search using generic search engines (Google 105 Scholar and the Google) was also performed through a less structured search using general 106 terms representing "health financing framework" and "health financing" to find additional  Our initial intention was to focus on reviews, and meanwhile on the usages of framework(s) 113 in assessing health financing systems. Therefore, the final selection of papers included a 114 combination of both papers, which either have proposed a framework or used a conceptual 115 framework to frame the design of their research project or to explain the outcomes of policy 116 assessment of how a country"s health financing are organized. 117 We included any type of report or peer reviewed journal article that reported frameworks to 118 assess, review and map financing functions and sub-functions and highlight different factors 119 that affect it, in order to identify all functional and non-functional dimensions needed to be 120 considered in assessing or reviewing of health financing system. Towards this end, analytical, 121 descriptive and even prescriptive frameworks were selected. The frameworks that analyze the 122 performance of the entire health system are also considered since health financing is a main 123 component of health system.

Results
Fifteen frameworks/tools developed during 2001 until 2020 were found. The identified 127 frameworks or tools goals were "assessing" or ""reviewing" health financing. We classified 128 frameworks by grouping them into systems approachanalytical frameworks ,indicator-129 based, and descriptive/ narrative categories. These frameworks vary in the concepts, 130 functions and processes, dimensions, strategies and meet various international or country-131 specific challenges.  Kutzin suggested an analytical tool for critical assessing of the functions of health financing.

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The framework identifies three pillars (1) "explicit health financing policy objectives as 139 assessment criteria"; (2) "a function-based framework as a basis for describing health   shape the performance of health systems. It built upon the idea of the institutional design and 152 organizational practice for health financing performance proposed by Mathauer and Carrin. 153 This framework consists of seven dimensions: "institutional arrangements", "enforcement 154 mechanisms", "property rights", "incentives", "intrinsic and extrinsic motivation", "behavioral changes" 155 and "organization"s performance". Meessen highlighted the relations between these dimensions and 156 stated that power and motivations of the key actors, enforcement mechanisms and the content of rules 157 shaped the "property rights". These decision rights analyses include the decision and earning rights of 158 the main actors, which in return defines the alignment of actor"s incentives with principals" 159 objectives. Incentives usually take advantage of intrinsic and extrinsic motivation and determine 160 behavioral changes. Assessing the contribution of behaviors to the goals of health system is the last         independently. It is a tool aims to assess a country"s health financing system relative to the 254 goal of universal health coverage (UHC) and the challenges faced in moving towards UHC.

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The approach is predominantly qualitative with some supporting quantitative data. It is a 256 comprehensive guidance for situation analysis, and unlike other frameworks; this model goes  The "aligning public financial management and health financing guide " is jointly prepared by   The FinHealth PFM-in-health toolkit aims to provide a "whole-of-system" view, from the 346 upstream planning and budgeting to the downstream budget execution process grouped 347 across 24 health functions, derived from a framework that brings together supply-side service 348 delivery issues, key PFM systems and health financing best practice.
Using this framework, the tool aims to make clear the linkages between identified PFM 350 problems, health financing in general, and service delivery. In this way, it is different tofor 351 examplea PEFA for health approach, which focuses on the operation of PFM systems but 352 with no specific focus as to how these affect service delivery.   Ovretviet and Marmor believed that comparative health policy helped to "expand 397 relationships among different countries by understanding their similarities and differences" 398 and by "adapting ideas that have worked elsewhere" (28). Quoting Rose andMarmor (1993, 1997), it has been argued that "shaping of a common global framework for health financing is 400 a fallacy in international health comparisons discussions as it overlooks the importance of 401 context" (38).

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Health systems research focuses more on the "science of delivery" today, which means how financing functions has a practical value. We hope that in seeking to build a practical 465 framework, we at least help to give a comprehensive picture of health financing frameworks to 466 initiate and facilitate more works as at present UHC &SDG are in the global agenda.