LMICs are facing many challenges in designing and implementing the “HCRs”. The present study evaluated these challenges in financing, resource generation, and governance (stewardship) which affected the delivery of qualified health services.
Health financing challenges
Based on the results, lack of providing sustainable and adequate funding is considered as one of the most important challenges in HCR financing among LMICs. In fact, HCRs have some challenges in providing adequate budgets such as allocation of a special amount in the budget plan, delay in receiving the budgets, high debts, budget deficit of hospitals, and the problems related to traditional budgeting systems. In addition, some other studies performed in Iran, Peru, Lithuania, Moldavia, and Brazil reported these challenges. Thus, it seems that providing sustainable and continuing fiscal resources can be considered as one of the strategies for succeeding the “HCRS” in these countries (7,13-26,30-32).
Further, inequity in resource allocation among different regions is regarded as another challenge in HCR financing among LMICs, which is increasing due to lack of transparency in guidelines, impact of donor’s interests, and existence of competing priorities. However, some studies conducted in Armenia and Moldavia reported an improvement in equity in financing and directing the budgets received from donors (8,33). Thus, the health system policymakers and managers in LMICs should direct the donor's interests for considering appropriate priorities and setting the clear guidelines and regulations for financial resources management.
Challenges in resource generation
The challenges related to resource generation are divided into human resources, infrastructures, and drug and instrument challenges.
Human resource challenges
Lack of adequate health workforce (HW) which is exaggerated in rural and remote areas is considered as one of the main challenges in human resources. In this regard, the studies conducted in Lithuania and Moldavia reported the shortage of health HW as a challenge in health system reforms (8, 26).
Other challenges are related to lack of motivation, skills, training HW, and structural and legal problems. In addition, some factors such as lack of understanding the skills and abilities by managers, weakness in career management systems, lack of training and high workload, using staffs in positions other than their organizational posts, poor monitoring, and evaluation systems, lack of compensating the weekend and holidays, low salaries, high staff turnover, and ensuring staff safety during night shifts can influence the motivation of HW, which result in increasing frequent absence, leaving the organization by trained staffs, remaining the inexperienced and low skilled staffs, and making concerns about quality of services. Additionally, structural and legal problems like absence or lack of organizational posts, problems in providing budgets for the existing posts and bureaucracy in the recruitment process can create some problems in HW recruitment. In addition, some studies indicated the challenges in providing needed HW in rural and remote areas, high turnover of HW, limited resources for developing the success experiences, and concerns about training (7, 8, 26, 28, 32, 34-37)
Challenges in infrastructures and drugs
Based on the results, physical space, equipment, and drugs are considered as other major challenges in resource generation are. Based on the results, the countries coped with some problems and challenges in providing needed physical space for delivering privacy service, lacking drug, delaying in providing drugs, emptying drug stores, increasing service recipients, increasing demands, centralizing drug providing and distribution system, and lacking access to guidelines in some countries. Further, some conflicts were reported between providers and recipients due to lack of medicines and drugs. Finally, Manyazavil et al. enumerated a shortage of drugs, medical equipment, and instrument as one of the major challenges in hospital reforms (1).
Governance challenges
Based on the results, many governance challenges in HCRs among LMICs based on Siddigi et al.’s(38) framework were divided into the rule of low, strategic direction, responsibilities, collaboration, efficiency, and effectiveness, ethics, equity and comprehensiveness, transparency and information.
In addition, changing the structures based on political motives instead of real needs, lack of enough legal requirement, inappropriate process for decentralization, lack of clarity in roles and tasks, resistance to implementing guidelines with lack of understanding the reform process by managers, as well as lack of clear guidelines and training resulted in confusing executive units and different interpretations by stockholders, blocking the accountability and responsibility due to the creation of levels of double or multiple accountabilities, and accordingly destroying the trust between the provider and recipient, as well as inter-sectorial and multi-sectoral collaborations.
Further, poor monitoring and evaluation systems such as lack of a good mechanism for data monitoring and evaluating human resource performance was regarded as other challenges in HCRs among LMICs.
Furthermore, the disparity between regions in terms of facilities, HR, infrastructure capacity, and budget increased equity and comprehensiveness problems. Additionally, lack of availability of guidelines on time and an increase in informal payments in some countries are considered as ethical challenges.
Other studies highlighted lack of planning and coordination, lack of management capacity for managerial reforms, gaps in technical skills, lack of trusted performance evaluation system and resistance in change (27, 39-40).
In addition, lack of collaboration and rules, transparency and accountability in resource distribution, and social and economic inequality were considered as some of the reform challenges in Lithuania and South Africa (26, 41). In China, equity in outcomes and distribution of public resources in the regions were regarded as some challenges in monitoring and evaluation systems, which influenced the governance of reforming health services (42). Cherry et al. indicated that health care reforms faced many challenges and the main challenge is related to an increase in efficiency and effectiveness of available services (43).
Lawrence outlined three major challenges for “HCRs”. Reforms should be conducted in both public and private system agendas. The second challenges are related to the acceptable and appropriate division of work between actors and key organizations. Finally, a reform model, which is very reliable and politically attractive, should be highlighted (44).
Finally, regarding Brazil's health care reform, the sustainability of reform, monitoring, and evaluation, and problems in quality, and effectiveness of healthcare, which caused largely due to deficiencies in guidelines were regarded as some challenges (7).
Health care delivery challenges
The promotion of the people's health status is the main objective of the health system, which is responsible for delivering health services. However, inadequate resources or poor financing systems can create some weaknesses in this regard (45). Therefore, identifying the related challenges was considered as the main purpose of the present study.
According to WHO, good service delivery should involve comprehensiveness, accessibility, appropriate coverage, continuity, quality, patient-centeredness, coordination, accountability, and efficiency (46). Based on the results, there are challenges in coverage and access, especially in rural and remote areas among LMICs (47, 48). Further, it seems that the continuity of reforms can be influenced by focusing on the unsustainability of financing resources,. Furthermore, there are some concerns about the quality of the delivered services regarding the existing lack of skills, training, and motivation in health HW. Additionally, the donor's interests can affect the financing and kind of reforms and services in some countries since these services are not provided based on the needs. In addition, some studies reported the challenges related to inter-sectorial and multi-sectorial collaborations in these countries, as well as accountability and efficiency may influence service delivery. Finally, the studies conducted in Brazil, Armenia, Lithuania, Greece, China, Turkey, Moldavia, Iran, and Peru emphasized these challenges, which are consistent with the findings in the present study (8, 13-14, 29-29, 33-34).