Rising numbers of refugees, prolonged displacement and reduced funding have led to challenges in terms of how to address their healthcare needs, with different approaches taken, ranging from parallel mechanisms to arrangements that are integrated (to different extents) within the national health system. Increasingly, global frameworks call for focus on the inclusion of refugees in national health systems. Based on six case studies, this paper analyses the trajectory towards health system integration in the healthcare responses for refugees to understand how contextual features play a role, and explore enablers and barriers of greater health system integration. Methods included documentary reviews, key informant interviews and focus group discussions (FGDs). Analysis was carried out separately for each setting and findings were later mapped, compared and contrasted for synthesis. All settings follow a normative pathway from an initial parallel response to hybrid, transitional arrangements to health system integration – though the latter is at different stages across settings. Some elements influence the timeframe of the shift, its completeness and effectiveness. These include: the scale and pace of refugee flow; the salience of political discourses on refugees and public perceptions, in some instances mediated by ethnic and cultural affinity; the country’s level of income and social protection systems; existing legal and policy frameworks, refugee rights and societal integration processes; availability of funds; capacity of the national health system, and its universalist approach. While it is difficult to alter some of these elements, each has to be carefully considered for health system integration processes. Priorities will generally include promptly strengthening local health systems to address the difference in healthcare provision for refugees and hosts, and effectively leveraging available funding (including from development and private sector sources) as well as existing, inclusive health system arrangements, such as free healthcare or social health insurance.

The global refugee population has nearly doubled in the last decade, and many of these populations face chronic displacement, often in neighbouring countries with limited resources. Emergency, short-term responses are being transitioned to longer term approaches, including a focus on inclusion through coverage in national health systems. However, analysis of empirical and comparative evidence on how to enact these approaches has been limited. In this article, we analyse the inclusion of refugees in six low and middle-income country (LMIC) health systems (Kenya, Kurdistan Region of Iraq (KRI), Mauritania, Pakistan, Peru and Zambia). Using a shared framework and tools, we collected data over 2023 to 2025, using document reviews, key informant interviews, focus group discussions and participatory workshops. Analysis was carried out separately for each setting, validated locally, and later compared and contrasted for synthesis. We focus on key health system domains – governance, health financing, service delivery (including health workforce) and health information systems - outlining the attributes of refugee inclusion and system integration in each, identifying patterns across the case studies and barriers and enablers. We identify leverage points for improving integration but highlight that inclusion of refugees into national health systems is complex and does not guarantee improved outcomes, especially when refugees previously benefited from a higher level of resources and are being included in strained host health systems. However, committed government leadership, coordinated international support, and multi-year investments in strengthening key components of the local health system, including enabling refugee health staff to engage effectively in it, can make the transition one which benefits both refugee and host communities.

Abstract Despite its widespread application in public financial management reforms across low- and middle-income countries, programme-based budgeting (PBB) implementation often remains relative superficial. The technical weaknesses of the reform have been widely documented; however, the political economy dynamics around the introduction and implementation of PBB in the health sector have not been studied. This comparative case study analysis of seven low and middle-income countries (Burkina Faso, Cameroon, Ghana, Kenya, Peru, Philippines, and South Africa) aims to unpack the political economy drivers of PBB reform in the health sector. The study draws from a global literature review, as well as documentary reviews and expert interviews in each of the seven study settings. Findings describe the policy processes relating to PBB introduction and implementation in the health sector, and provide a detailed, comparative stakeholder mapping and political economy analysis. This describes the position of the key actors in relation to PBB reform in health, which is explained by their interests and how PBB reform would impact them, and how they used their power to affect the PBB reform processes in health. Our analysis identifies political dynamics, processes and narratives that can be strategically leveraged to better inform PBB implementation in the health sector. It also underscores how the insights from PEA can help to advance budgeting reforms in the health sector as part of overall health financing reforms in support of UHC agenda in low and middle-income settings, which experience has shown do not lend themselves to technical solutions alone.

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.