City governments are well-positioned to effectively address urban health challenges in the context of rapid urbanization in Asia. They require good quality and timely evidence to inform their planning decisions. In this article, we report our analyses of degree of data-informed urban health planning from three Asian cities: Dhaka, Hanoi and Pokhara. Our theoretical framework stems from conceptualizations of evidence-informed policymaking, health planning and policy analysis, and includes: (1) key actors, (2) approaches to developing and implementing urban health plans, (3) characteristics of the data itself. We collected qualitative data between August 2017 and October 2018 using: in-depth interviews with key actors, document review and observations of planning events. Framework approach guided the data analysis. Health is one of competing priorities with multiple plans being produced within each city, using combinations of top-down, bottom-up and fragmented planning approaches. Mostly data from government information systems are used, which were perceived as good quality though often omits the urban poor and migrants. Key common influences on data use include constrained resources and limitations of current planning approaches, alongside data duplication and limited co-ordination within Dhaka’s pluralistic system, limited opportunities for data use in Hanoi and inadequate and incomplete data in Pokhara. City governments have the potential to act as a hub for multi-sectoral planning. Our results highlight the tensions this brings, with health receiving less attention than other sector priorities. A key emerging issue is that data on the most marginalized urban poor and migrants are largely unavailable. Feasible improvements to evidence-informed urban health planning include increasing availability and quality of data particularly on the urban poor, aligning different planning processes, introducing clearer mechanisms for data use, working within the current systemic opportunities and enhancing participation of local communities in urban health planning.

Fragile and shock-prone settings (FASP) present a critical development challenge, eroding efforts to build healthy, sustainable and equitable societies. Power relations and inequities experienced by people because of social markers, e.g., gender, age, education, ethnicity, and race, intersect leading to poverty and associated health challenges. Concurrent to the growing body of literature exploring the impact of these intersecting axes of inequity in FASP settings, there is a need to identify actions promoting gender, equity, and justice (GEJ). Gender norms that emphasise toxic masculinity, patriarchy, societal control over women and lack of justice are unfortunately common throughout the world and are exacerbated in FASP settings. It is critical that health policies in FASP settings consider GEJ and include strategies that promote progressive changes in power relationships. ReBUILD for Resilience (ReBUILD) focuses on health systems resilience in FASP settings and is underpinned by a conceptual framework that is grounded in a broader view of health systems as complex adaptive systems. The framework identifies links between different capacities and enables identification of feedback loops which can drive or inhibit the emergence and implementation of resilient approaches. We applied the framework to four different country case studies (Lebanon, Myanmar, Nepal and Sierra Leone) to illustrate how it can be inclusive of GEJ concerns, to inform future research and support context responsive recommendations to build equitable and inclusive health systems in FASP settings.

BackgroundNepal has been receiving foreign aid since the early 1950s. Currently, the country’s health care system is heavily dependent on aid, even for the provision of basic health services to its people. Globally, the mechanism for the dispersal of foreign aid is becoming increasingly complex. Numerous stakeholders are involved at various levels: donors, intermediary organisations, project-implementing partners and the beneficiaries, engaging not only in Nepal but also globally. To illustrate how branding and bidding occurs, and to discuss how this process has become increasingly vital in securing foreign aid to run MCH activities in Nepal.MethodThis paper is based on a qualitative study. The data collection method includes Key Informant Interviews, the review of relevant policy documents and secondary data, and finally field observation visits to four maternal and child health (MCH) projects, currently funded by foreign aid. Through these methods we planned to gain a comprehensive understanding of the aid dispersing mechanism, and the aid-securing strategies, used by organisations seeking funds to provide MCH services in Nepal.ResultsStudy findings suggest that foreign aid for the provision of MCH services in Nepal is channeled increasingly to its beneficiaries, not through the Government system, but rather via various intermediary organisations, employing branding and bidding processes. These organisations adapt commercial models, seeking to justify their ‘cost-effectiveness’. They argue that they are ‘yielding good value for money’, with short-term target oriented projects. This ethos is evident throughout the aid dispersing chain. Organisations use innovative ideas and intervention packages, branded internationally and nationally, and employ the appropriate language of commerce in their bid to secure funds. The paper raises an important question as to whether the current mechanisms of channeling foreign aid in the MCH sector, via intermediary organisations, can actually be cost-effective, given the complex bureaucratic processes involved.ConclusionsThe study findings are very important, for Nepal’s development in particular, and for international development in general. The paper concludes by recommending strongly that foreign aid should concentrate on supporting and strengthening the national government system. Complex bureaucratic process must be minimised and streamlined in order to provide quality care to the beneficiaries.

Introduction to comments on 'Outsourcing: how to reform WHO for the 21st century'.

Many countries, and particularly those including fragile contexts, have a shortage of formal health workers and are increasingly looking to close-to-community (CTC) providers to fill the gap. The experiences of CTC providers are shaped by context-embedded gender roles and relations. This qualitative research study in Lebanon, Nepal, Myanmar and Sierra Leone explored the gendered experiences of CTC providers during the COVID-19 pandemic in fragile settings. We used document review, in-depth interviews or focus group discussions with CTC providers, and key informant interviews with local stakeholders to generate in-depth and contextual information. The COVID-19-associated lockdowns and school closures brought additional stresses, with a gendered division of labour acutely felt by women CTC providers. Their work is poorly or not remunerated and is seen as risky. CTC providers are embedded within their communities with a strong willingness to serve. However, they experienced fractures in community trust and were sometimes viewed as a COVID-19 risk. During COVID-19, CTC providers experienced additional responsibilities on top of their routine work and family commitments, shaped by gender, and were not always receiving the support required. Understanding their experience through a gender lens is critical to developing equitable and inclusive approaches to support the COVID-19 response and future crises.