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Background: How do governance interventions that engage citizens in public service delivery planning, management and oversight impact the quality of and access to services and citizens' quality of life? This systematic review examined high quality evidence from 35 citizen engagement programmes in low- and middle-income countries that promote the engagement of citizens in service delivery through four routes: participation (participatory priority setting); inclusion of marginalised groups; transparency (information on rights and public service performance), and/or citizen efforts to ensure public service accountability (citizen feedback and monitoring); collectively, PITA mechanisms. We collected quantitative and qualitative data from the included studies and used statistical meta-analysis and realist-informed framework synthesis to analyse the findings. Results: The findings suggest that interventions promoting citizen engagement by improving direct engagement between service users and service providers, are often effective in stimulating active citizen engagement in service delivery and realising improvements in access to services and quality of service provision, particularly for services that involve direct interaction between citizens and providers. However, in the absence of complementary interventions to address bottlenecks around service provider supply chains and service use, citizen engagement interventions alone may not improve key wellbeing outcomes for target communities or state-society relations. In addition, interventions promoting citizen engagement by increasing citizen pressures on politicians to hold providers to account, are not usually able to influence service delivery. Conclusions: The citizen engagement interventions studied were more likely to be successful: (1) where the programme targeted a service that citizens access directly from front-line staff, such as healthcare, as opposed to services accessed independently of service provider staff, such as roads; (2) where implementers were able to generate active support and buy-in for the intervention from both citizens and front-line public service staff and officials; and (3) where the implementation approach drew on and/or stimulated local capacity for collective action. From a research perspective, the review found few studies that investigated the impact of these interventions on women or other vulnerable groups within communities, and that rigorous impact evaluations often lack adequately transparent reporting, particularly of information on what interventions actually did and how conditions compared to those in comparison communities.

Background The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. Methods We extracted GDP, government spending in 184 countries from 1980-2015, and health spend data from 1995-2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. Findings We estimated that global spending on health will increase from US$9.21 trillion in 2014 to $24.24 trillion (uncertainty interval [UI] 20.47-29.72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5.3% (UI 4.1-6.8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4.2% (3.8-4.9). High-income countries are expected to grow at 2.1% (UI 1.8-2.4) and low-income countries are expected to grow at 1.8% (1.0-2.8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133-181) per capita in 2030 and $195 (157-258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157-258) per capita was available for health in 2040 in low-income countries. Interpretation Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential. ; Peer reviewed

Achieving universal health coverage (UHC) requires health financing systems that provide prepaid pooled resources for key health services without placing undue financial stress on households. Understanding current and future trajectories of health financing is vital for progress towards UHC. We used historical health financing data for 188 countries from 1995 to 2015 to estimate future scenarios of health spending and pooled health spending through to 2040.We extracted historical data on gross domestic product (GDP) and health spending for 188 countries from 1995 to 2015, and projected annual GDP, development assistance for health, and government, out-of-pocket, and prepaid private health spending from 2015 through to 2040 as a reference scenario. These estimates were generated using an ensemble of models that varied key demographic and socioeconomic determinants. We generated better and worse alternative future scenarios based on the global distribution of historic health spending growth rates. Last, we used stochastic frontier analysis to investigate the association between pooled health resources and UHC index, a measure of a country's UHC service coverage. Finally, we estimated future UHC performance and the number of people covered under the three future scenarios.