Financial autonomy of facilities providing primary health care services
in low and middle income countries: assessing the evidence to inform the
development of a typology and conceptual framework
Abstract
Provider autonomy is increasingly asserted as an important attribute in
health systems, but is rarely interrogated in-depth, particularly at
primary care level. This article examines the current state of evidence
on the role of financial autonomy in primary care, focusing on the
public sector in low and middle income settings (LMICs). It draws from a
scoping review of the literature (91 documents), 12 expert interviews
and the knowledge of the research team. Findings were also discussed
with health financing and public financial management experts at a
meeting in 2023 to deepen the reflections. In the article, we discuss
definitions of financial autonomy and the reforms which have been
associated with triggering or at least raising the profile of financial
autonomy as an important attribute. We highlight the picture on current
patterns of autonomy at primary level across countries. While financial
autonomy is prima facie a positive attribute, the understanding of
autonomy over what, for which purposes and by whom is still not clearly
addressed in the literature, along with the implications for purchasing
and public financial management (which is key to enable financial
autonomy, as well as being affected by it). This paper moves the field
forward by developing a typology of levels and features of financial
autonomy, structured by the budget cycle and a conceptual framework. The
framework highlights key considerations in terms of contextual
influencers of financial autonomy, prerequisites for it to be deployed,
and the potential positive and negative effects of financial autonomy at
primary care level.