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Background: Social support services such as day care centres are important in post-diagnostic dementia care to enable people living with dementia stay at home for longer. Little research has addressed potential inequalities in access, with no research on variations before and since COVID-19. The aim of this study was to explore inequalities in social support service usage before and since the pandemic. Methods: Unpaid carers and people living with dementia were interviewed over the phone about their experiences of accessing social support services before and since the COVID-19 pandemic. Transcripts were analysed for key themes using inductive and deductive thematic analysis. Results: Fifty participants (42 unpaid carers; eight people living with dementia) were interviewed, and five themes identified: (1) Service issues; (2) Access issues; (3) Relying on own initiative; (4) New inequalities due to COVID-19; and (5) Missing out on the benefits of support services. Participants reported transport, finances, and location as factors reducing their ability to access support service pre-COVID, with inequalities remaining and at times exacerbated since. Carers and people living with dementia also reported struggling with accessing basic necessities during COVID, including food and medicines. Conclusions: Considering the benefits of accessing support services, resourced procedures and facilities are needed to maintain access to support services with more accessible remote support provision, enabling people from all backgrounds to access the care they need. [ABSTRACT FROM AUTHOR]

Background: This paper discusses the stages of health system resilience (HSR) and the factors underlying differences in HSR during the covid-19 pandemic, especially the vaccination challenge. We studied the relationship between vaccination strategies and macro-context backgrounds in 21 Latin American countries. Our objective was to capture the impact of those aspects in the SR and identify potential improvements for future crises and for vaccination programs in general. Methods: The study uses mixed-methods research to provide insights into how the countries' backgrounds and vaccination strategies impact the HSR. Particularly, we used explanatory sequential mixed methods, which entails a quantitative-qualitative two-phase sequence. The quantitative phase was conducted using cluster and variance analysis, in which the HSR was measured using as a proxy the covid-19 vaccination outcomes in three cut-offs of reaching 25%, 50%, and 75% of population coverage. This approach allows us to discriminate covid-19 vaccination progress by stages and contrast it to the qualitative stage, in which we performed a country-case analysis of the background conditions and the changes in vaccination strategies that occurred during the corresponding dates. Results: The paper provides a rich comparative case analysis of countries, classifying them by early, prompt, and delayed performers. The results show that differences in vaccination performance are due to flexibility in adapting strategies, cooperation, and the ability to design multilevel solutions that consider the needs of various actors in the health ecosystem. These differences vary depending on the vaccination stage, which suggests the importance of acknowledging learning, diffusion, and feedback processes at the regional level. Conclusions: We identified the importance of societal well-being as an ideal country antecedent for high and sustained levels of performance in covid-19 vaccination. Whereas in other countries where the set-up and beginning phases were rough, the value of the operational decisions and the learning on the move regarding their own and their peers' trajectories were crucial and were reflected in performance improvement. A contribution of this study is that the above-mentioned analysis was done using vaccination coverage cut-off points that allow a performance view that takes into consideration the stages of the vaccination progress and the learning process that goes with it. As well as framing this into the HSR shock cycles that allow to differentiate the stages of resilience on which countries must act. [ABSTRACT FROM AUTHOR]

Background: Healthcare workers (HCWs) in the United Kingdom (UK) have faced many challenges during the COVID-19 pandemic, some of these arising out of their social positions. Existing literature explicating these challenges (e.g., lack of appropriate PPE, redeployment, understaffing) have highlighted inequities in how these have been experienced by HCWs based on ethnicity, gender or, job role. In this paper, we move a step ahead and examine how the intersection of these social positions have impacted HCWs' experiences of challenges during the pandemic. Methods: We collected qualitative data, using interviews and focus groups, from 164 HCWs from different ethnicities, gender, job roles, migration statuses, and regions in the United Kingdom (UK) between December 2020 and July 2021. Interviews and focus groups were conducted online or by telephone, and recorded with participants' permission. Recordings were transcribed and a hybrid thematic analytical approach integrating inductive data-driven codes with deductive ones informed by an intersectional framework was adopted to analyse the transcripts. Results: Thematic analysis of transcripts identified disempowerment, disadvantage and, discrimination as the three main themes around which HCWs' experiences of challenges were centred, based on their intersecting identities (e.g., ethnicity gender, and/or migration status). Our analysis also acknowledges that disadvantages faced by HCWs were linked to systemic and structural factors at the micro, meso and macro ecosystemic levels. This merging of analysis which is grounded in intersectionality and considers the ecosystemic levels has been termed as 'intrasectionalism'. Discussion: Our research demonstrates how an intrasectional lens can help better understand how different forms of mutually reinforcing inequities exist at all levels within the healthcare workforce and how these impact HCWs from certain backgrounds who face greater disadvantage, discrimination and disempowerment, particularly during times of crisis like the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Partnerships between Higher Education Institutions (HEIs) in the global north and south have commonly been used as a vehicle to drive global health research and initiatives. Among these initiatives, include health system strengthening, research capacity building, and human resource training in developing countries. However, the partnership functioning of many global north-south partnerships still carry legacies of colonialism through unrecognized behavior patterns, attitudes, and belief systems in how they function. Even with research literature calling for a shift from equality to equity in the functioning of these partnerships, many still struggle with issues of complex and unspoken power dynamics. To understand the successes and challenges of north-south partnerships, this paper explored partnership development and functioning of a northern and multi-southern HEIs partnership focused on nutrition education and research. Methods: A qualitative research approach was used; data were collected through in-depth interviews (IDIs) with questions developed from the Bergen Model of Collective Functioning (BMCF). Thirteen IDIs were conducted with partners from all institutions including stakeholders. Findings: The partnership was built on the foundation of experiences and lessons of a previous partnership. Partners used these experiences and lessons to devise strategies to improve partnership inputs, communication, leadership, roles and structures, and maintenance and communication tasks. However, these strategies had an impact on partnership functioning giving rise to issues of inequitable power dynamics. The northern partner had two roles: one as an equal partner and another as distributor of project funds; this caused a conflict in roles for this partner. The partners distinguished themselves according to partner resources – two partners were named implementing partners and two named supportive partners. Roles and partner resources were the greatest contributors to power imbalances and caused delays in project activities. Conclusion: Using the BMCF to examine partnership dynamics illuminated that power imbalances caused a hierarchical stance in the partnership with northern partners having overall control and power of decision-making in the partnership. This could impact the effectiveness and sustainability of project in the southern institutions going forward. [ABSTRACT FROM AUTHOR]

Background and aims: Sepsis is a serious and life-threatening condition caused by a dysregulated immune response to an infection. Recent guidance issued in the UK gave recommendations around recognition and antibiotic treatment of sepsis, but did not consider factors relating to health inequalities. The aim of this study was to summarise the literature investigating associations between health inequalities and sepsis. Methods: Searches were conducted in Embase for peer-reviewed articles published since 2010 that included sepsis in combination with one of the following five areas: socioeconomic status, race/ethnicity, community factors, medical needs and pregnancy/maternity. Results: Five searches identified 1,402 studies, with 50 unique studies included in the review after screening (13 sociodemographic, 14 race/ethnicity, 3 community, 3 care/medical needs and 20 pregnancy/maternity; 3 papers examined multiple health inequalities). Most of the studies were conducted in the USA (31/50), with only four studies using UK data (all pregnancy related). Socioeconomic factors associated with increased sepsis incidence included lower socioeconomic status, unemployment and lower education level, although findings were not consistent across studies. For ethnicity, mixed results were reported. Living in a medically underserved area or being resident in a nursing home increased risk of sepsis. Mortality rates after sepsis were found to be higher in people living in rural areas or in those discharged to skilled nursing facilities while associations with ethnicity were mixed. Complications during delivery, caesarean-section delivery, increased deprivation and black and other ethnic minority race were associated with post-partum sepsis. Conclusion: There are clear correlations between sepsis morbidity and mortality and the presence of factors associated with health inequalities. To inform local guidance and drive public health measures, there is a need for studies conducted across more diverse setting and countries. [ABSTRACT FROM AUTHOR]

Background: The Russia-Ukraine war has undeniably impacted global science and healthcare in Ukraine. Many Ukrainian researchers have had their projects disrupted by this war, either due to loss of life, displacement, or destruction of resources. Despite these challenges, these researchers have sought to make their voices heard. This scoping review highlights the trend of healthcare-related publications on the current Russia-Ukraine war and characterizes the contribution of Ukrainian authors to these publications. Method: A comprehensive literature search was performed using two databases (Scopus and Pubmed) for publications related to the ongoing Russia-Ukraine war. We included articles only related to healthcare. We then extracted and analyzed bibliometric data. Result: One hundred and eighty-three articles were identified, including 12 (6.6%) original articles, 26 (14.2%) cross-sectional studies, 19 (10.4%) letters to the editor, 10 (5.5%) commentaries, 5 (2.7%) perspectives, 35 (19.1%) editorials, 2 (1.1%) randomized controlled trials, 11(6.0%) correspondences, 13 (7.1%) opinions, 8 (4.4%) reviews and 42 (23.0%) are identified as others. 180 (98.4%) studies were in English, and 3 (1.7%) were in German. 54 (29.5%) papers on the war had at least one author affiliated with a Ukrainian institution, and 29 (15.9%) studies had authors with Ukrainian affiliation as first authors. Conclusion: our study shows that there has been a significant number of publications on the Russia-Ukraine war and only a small portion of first authors, co-authors, and last authors of these publications are affiliated to an institution in Ukraine. Therefore, despite the relatively high number of publications, most publications do not arise from the perspective of Ukrainian authors. [ABSTRACT FROM AUTHOR]

Background: China has made intensive efforts to eliminate extreme poverty by 2020. This paper aims to evaluate the changes in health service needs, utilization, and medical expenses for poor people during the poverty alleviation period. Methods: The study used data from national health services surveys in 2013 and 2018. The poor people were identified and certified by the local government. Health service needs, utilization, medical expenses, and reimbursement rates were analyzed and compared between 2013 and 2018, between the poor and the non-poor groups. Results: People living in poverty were usually elderly, illiterate, and unemployed. The poor people had a significantly higher two-week morbidity rate and a higher prevalence of chorionic non-communicable diseases than the non-poor group. For both the poor and non-poor, health service needs increased between 2013 and 2018. Accordingly, the poor people had more use of outpatient and inpatient services. The annual inpatient admission rates were 20.8% and 13.1% for the poor and non-poor, respectively, in 2018. The average medical expenses per inpatient admission were much lower for the poor than for the non-poor. Out-of-pocket (OOP) payment share decreased from 41.9% to 2013 to 31.9% in 2018 for the poor, while for the non-poor, the OOP rate was much higher (45.4%) and had no significant changes between the two surveys. The reduction in the OOP share occurred mostly in rural areas. Conclusions: Poverty alleviation in China may have positive effect in improving poor people's access to health services, and reducing their financial burden due to illness and health service utilization. [ABSTRACT FROM AUTHOR]

Background: Indigenous Maya women in the rural highlands of Guatemala have traditionally faced constraints to decision-making and participation in community affairs. Anecdotal experiences from previous Curamericas Global projects in Guatemala and Liberia have suggested that interventions using the CBIO+ Approach (which consists of implementing together the Census-Based, Impact-Oriented Approach, the Care Group Approach, and Community Birthing Centers), can be empowering and can facilitate improvements in maternal and child health. This paper, the eighth in a series of 10 papers examining the effectiveness of CBIO+ in improving the health and well-being of mothers and children in an isolated mountainous rural area of the Department of Huehuetenango, explores changes in women's empowerment among mothers of young children associated with the Curamericas/Guatemala Maternal and Child Health Project, 2011–2015. Methods: Knowledge, practice, and coverage (KPC) surveys and focus group discussions (FGDs) were used to explore six indicators of women's empowerment focusing on participation in health-related decision-making and participation in community meetings. KPC surveys were conducted at baseline (January 2012) and endline (June 2015) using standard stratified cluster sampling. Seventeen FGDs (9 with women, 3 with men, 2 with mothers-in-law, and 3 with health committees), approximately 120 people in all, were conducted to obtain opinions about changes in empowerment and to identify and assess qualitative factors that facilitate and/or impede women's empowerment. Results: The KPC surveys revealed statistically significant increases in women's active participation in community meetings. Women also reported statistically significant increases in rates of participation in health-related decision-making. Further, the findings show a dose-response effect for two of the six empowerment indicators. The qualitative findings from FGDs show that the Project accelerated progress in increasing women's empowerment though women still face major barriers in accessing needed health care services for themselves and their children. Conclusion: The Project achieved some notable improvements in women's decision-making autonomy and participation in community activities. These improvements often translated into making decisions to practice recommended health behaviors. Traditional cultural norms and the barriers to accessing needed health services are not easily overcome, even when empowerment strategies are effective. [ABSTRACT FROM AUTHOR]

Background: In Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+. Methods: We undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff. Results: During the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere. Conclusion: The Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right. [ABSTRACT FROM AUTHOR]

Background: The Curamericas/Guatemala Maternal and Child Health Project, 2011–2015, implemented the Census-Based, Impact-Oriented Approach, the Care Group Approach, and the Community Birthing Center Approach. Together, this expanded set of approaches is known as CBIO+. This is the fifth of 10 papers in our supplement describing the Project and the effectiveness of the CBIO+ Approach. This paper assesses causes, levels, and risk factors for mortality along with changes in mortality. Methods: The Project maintained Vital Events Registers and conducted verbal autopsies for all deaths of women of reproductive age and under-5 children. Mortality rates and causes of death were derived from these data. To increase the robustness of our findings, we also indirectly estimated mortality decline using the Lives Saved Tool (LiST). Findings: The leading causes of maternal and under-5 mortality were postpartum hemorrhage and pneumonia, respectively. Home births were associated with an eight-fold increased risk of both maternal (p = 0.01) and neonatal (p = 0.00) mortality. The analysis of vital events data indicated that maternal mortality declined from 632 deaths per 100,000 live births in Years 1 and 2 to 257 deaths per 100,000 live birth in Years 3 and 4, a decline of 59.1%. The vital events data revealed no observable decline in neonatal or under-5 mortality. However, the 12–59-month mortality rate declined from 9 deaths per 1000 live births in the first three years of the Project to 2 deaths per 1000 live births in the final year. The LiST model estimated a net decline of 12, 5, and 22% for maternal, neonatal and under-5 mortality, respectively. Conclusion: The baseline maternal mortality ratio is one of the highest in the Western hemisphere. There is strong evidence of a decline in maternal mortality in the Project Area. The evidence of a decline in neonatal and under-5 mortality is less robust. Childhood pneumonia and neonatal conditions were the leading causes of under-5 mortality. Expanding access to evidence-based community-based interventions for (1) prevention of postpartum hemorrhage, (2) home-based neonatal care, and (3) management of childhood pneumonia could help further reduce mortality in the Project Area and in similar areas of Guatemala and beyond. [ABSTRACT FROM AUTHOR]

Background: An increasing number of evaluations of social accountability (SA) interventions have been published in the past decade, however, reporting gaps make it difficult to summarize findings. We developed the Social Accountability Reporting for Research (SAR4Research) checklist to support researchers to improve the documentation of SA processes, context, study designs, and outcomes in the peer reviewed literature and to enhance application of findings. Methods: We used a multi-step process, starting with an umbrella review of reviews on SA to identify reporting gaps. Next, we reviewed existing guidelines for reporting on behavioral interventions to determine whether one could be used in its current or adapted form. We received feedback from practitioners and researchers and tested the checklist through three worked examples using outcome papers from three SA projects. Results: Our umbrella review of SA studies identified reporting gaps in all areas, including gaps in reporting on the context, intervention components, and study methods. Because no existing guidelines called for details on context and the complex processes in SA interventions, we used CONSORT-SPI as the basis for the SAR4Research checklist, and adapted it using other existing checklists to fill gaps. Feedback from practitioners, researchers and the worked examples suggested the need to eliminate redundancies, add explanations for items, and clarify reporting for quantitative and qualitative study components. Conclusions: Results of SA evaluations in the peer-reviewed literature will be more useful, facilitating learning and application of findings, when study designs, interventions and their context are described fully in one or a set of papers. This checklist will help authors report better in peer-reviewed journal articles. With sufficient information, readers will better understand whether the results can inform accountability strategies in their own contexts. As a field, we will be better able to identify emerging findings and gaps in our understanding of SA. [ABSTRACT FROM AUTHOR]

Objectives: Teenage pregnancy and motherhood is a crucial problem in countries of the World Health Organisation Eastern Mediterranean Region (WHO–EMR). The aim of this paper is to describe and analyse the phenomenon of adolescent childbearing in ten countries according to social determinants like milieu (rural–urban), education level, wealth quintiles, territoriality (countries, regions) and nationality. Methods: Inequity in terms of adolescent childbearing was analysed using disaggregated data given by Demographic Health Surveys (DHS), UNICEF Multiple Indicator Cluster Surveys (MICS) and the Pan Arab Project for Family Health (PAPFAM) surveys. Beside the absolute differences (gaps) and relative differences (ratios), the index of dissimilarity (ID) was used to compare the distributions of adolescent pregnancy and motherhood by social determinants in each country. Results: Data analysis indicates that the average percentage of adolescent women aged 15–19 years who have begun childbearing shows a large difference between countries, varying from 0.4% in Tunisia to 15.1% in Sudan, combined with huge gaps within each country as indicated by the values of the index of dissimilarity. Poor, rural and non-educated adolescent girls are more exposed to teenage childbearing than their counterparts—rich, urban and educated girls. Conclusion: According to different social determinants, sensible variations are seen in terms of adolescent pregnancy and motherhood within the ten countries considered in this study. This is a clear appeal to decision makers to reduce child marriage and pregnancy by acting on social determinants of health, targeting disadvantaged girls coming mainly from marginalised groups and poor families living in remote rural zones. [ABSTRACT FROM AUTHOR]

Background: There is increasing acceptance of the importance of social values such as equity and fairness in health care priority setting (PS). However, equity is difficult to define: the term means different things to different people, and the ways it is understood in theory often may not align with how it is operationalized. There is limited literature on how development assistance partner organizations (DAP) conceptualize and operationalize equity in their health care prioritization decisions that affect low-income countries (LIC). This paper explores whether and how equity is a consideration in DAP priority setting processes. Methods: This was a qualitative study involving 38 in-depth interviews with DAPs involved in health-system PS for LICs and a review of their respective webpages. Results: While several PS criteria were identified, direct articulation of equity as an explicit criterion was lacking. However, the criterion was implied in some of the responses in terms of prioritizing vulnerable populations. Where mentioned, respondents discussed the difficulties of operationalizing equity as a PS criterion since vulnerability is associated with several varying and competing factors including gender, age, geography, and income. Some respondents also suggested that equity could be operationalized in terms of an organization not supporting the pre-existing inequities. Although several organizations' webpages identify addressing inequities as a guiding principle, there were variations in how they spoke about its operationalization. While intersectionalities in vulnerabilities complicate its operationalization, if organizations explicitly articulate their equity focus the other organizations who also have equity as a guiding principle may, instead of focusing on the same aspect, concentrate on other dimensions of vulnerability. That way, all organizations will contribute to achieving equity in all the relevant dimensions. Conclusions: Since most development organizations support some form of equity, this paper highlights a need for an internationally recognized framework that recognizes the intersectionalities of vulnerability, for mainstreaming and operationalizing equity in DAP priority setting and resource allocation. Such a framework will support consistency in the conceptualization of and operationalization of equity in global health programs. There is a need for studies which to assess the degree to which equity is actually integrated in these programs. Research highlights: Equity has become an increasingly important focus in the health and social science literature, however, equity is a contested concept. While development assistance partners supporting health development subscribe to equity as a guiding principle, they struggle with its operationalization. There is need for a general framework that explicitly conceptualizes the operationalization of equity in health development. [ABSTRACT FROM AUTHOR]

Background: The accessibility and fairness of the floating population's access to basic public health services have an important impact on improving the health level of the whole population. Existing studies have shown that medical insurance and social integration have an impact on basic public health services, but there are few studies on the specific influence path between the three. Therefore, the research purpose of this paper is to explore the effects of medical insurance for urban and rural residents and basic medical insurance for urban employees on the utilization of basic public health services, and to analyze the mediating effect of social integration. Methods: The data in this paper are derived from the 2017 China Mobile Population Dynamic Monitoring Survey data, which collects information on 31 provinces (regions, cities) and Xinjiang Production and Construction Corps mobile population 169,989 people, all of whom come from China's relatively concentrated mobile population inflow areas (NHC FPSCo. 2021. Floating Population Service Center of NHC). After deleting part of the missing data and replacing the mean value, 154,586 people were finally included in the analysis. The proportion is 90.9%. Based on the data of China's floating population dynamic survey in 2017,we used Logistic regression method to analyze the effects of basic medical insurance for urban and rural residents, basic medical insurance for urban employees and social integration on the utilization of basic public health services. Then we used the Bootstrap method of structural equation model to analyze the mediating effect of social integration. Results: Medical insurance for urban and rural residents (β = 0.236;95%CI:1.195 ~ 1.342) has positive impact on health education, it (β = 0,190;95%CI:1.150 ~ 1.272) also has positive impact on the establishment of residents' health records. Social integration (including political participation (β = 0.312;95%CI:1.324 ~ 1.410),activity participation (β = 0.724;95%CI:2.009 ~ 2.119), identity (β = 0.421; 95%CI:1.387 ~ 1.675))has positive impact on health education, it ((β = 0.312;95%CI:1.324 ~ 1.410), (β = 0.404;95%CI:1.463 ~ 1.534), (β = 0.282;95%CI:1.191 ~ 1.477)) also has positive impact on the establishment of residents' health records. In addition, BMIUE (β = 0.169;95%CI:1.150 ~ 1.219) has an impact on the establishment of residents' health records. The direct effect of medical insurance on the utilization of public health services was 0.092 (95%CI: 0.093 ~ 0.103), social integration was a partial mediator, the mediating effect was 0.127 (95%CI: 0.108 ~ 0.127), and the mediating effect size was 57.73%. Conclusions: Medical insurance can directly promote the floating population to use basic public health services, and can indirectly promote the improvement of public health service utilization level through social integration. [ABSTRACT FROM AUTHOR]

Background: Health inequalities are persistent and widening with transformative policy change needed. Radically shifting policy to tackle upstream causes of inequalities is likely to require public participation to provide a mandate, evidence and to address questions of co-design, implementation and acceptability. The aim of this paper is to explore perceptions among policy actors on why and how the public should be involved in policymaking for health inequalities. Methods: In 2019–2020, we conducted exploratory, in-depth, semi-structured interviews with 21 Scottish policy actors from a range of public sector bodies and agencies and third sector organisations that work in, or across, health and non-health sectors. Data were analysed thematically and used to examine implications for the development of participatory policymaking. Results: Policy actors viewed public participation in policymaking as intrinsically valuable for democratic reasons, but the main, and more challenging, concern was with how it could affect positive policy change. Participation was seen as instrumental in two overlapping ways: as evidence to improve policies to tackle health inequalities and to achieve public acceptance for implementing more transformative policies. However, our analysis suggests a paradox: whilst policy actors place importance on the instrumental value of public participation, they simultaneously believe the public hold views about health inequalities that would prevent transformative change. Finally, despite broad agreement on the need to improve public participation in policy development, policy actors were uncertain about how to make the necessary changes due to conceptual, methodological and practical challenges. Conclusions: Policy actors believe in the importance of public participation in policy to address health inequalities for intrinsic and instrumental reasons. Yet, there is an evident tension between seeing public participation as a route to upstream policies and a belief that public views might be misinformed, individualistic, short-term or self-interested and doubts about how to make public participation meaningful. We lack good insight into what the public think about policy solutions to health inequalities. We propose that research needs to shift from describing the problem to focusing more on potential solutions and outline a potential way forward to undertake effective public participation to tackle health inequalities. [ABSTRACT FROM AUTHOR]

Background: This is the fourth paper in our supplement on improving the health and well-being of rural indigenous Maya mothers and children in the Western Highlands of Guatemala, where the prevalence of stunting is the highest in Latin America and among the highest in the world. Reducing childhood undernutrition was one of the objectives of the Maternal and Child Health Project, 2011–2015, implemented by Curamericas/Guatemala. The implementation research portion of the Project attempted to determine if there were greater improvements in childhood nutritional status in the Project Area than in comparison areas and whether or not a dose–response effect was present in terms of a greater improvement in the Project Area with a longer duration of interventions. Methods: The Project provided nutrition-related messages to mothers of young children, cooking sessions using locally available nutritious foods, a lipid-based nutrient supplement (Nutributter®) for a short period of time (4 months), anti-helminthic medication, and repeated growth monitoring and nutrition counseling. Measures of height and weight for calculating the prevalence of underweight, stunting, and wasting in under-2 children were analyzed and compared with the anthropometric data for children in the rural areas of the Northwestern Region and in the Western Highlands of Guatemala. Results: The prevalence of stunting declined in Area A from 74.5% in September 2012 to 39.5% in June 2015. Area A comprised approximately one-half of the Project Area and was the geographic area with the greatest intensity and duration of nutrition-related Project interventions. Minimal improvements in stunting were observed in the Northwestern Region, which served as a comparison area. Improvements in multiple output and outcome indicators associated with nutritional status were also observed in Areas A and B: infant and young child feeding practices, routine growth monitoring and counseling, and household practices for the prevention and treatment of diarrhea. Conclusion: The Project Area in which Curamericas/Guatemala implemented the CBIO+ Approach experienced a reduction in the prevalence of stunting and other measures of undernutrition in under-2 children. Given the burden of undernutrition in Guatemala and other parts of the world, this approach merits broader application and further evaluation. [ABSTRACT FROM AUTHOR]

Background: Language has been well documented to be a key determinant of accessing healthcare. Most of the literature about language barrier in accessing healthcare is in the context of miscommunication. However, it is critical to consider the historical and political contexts and power dynamics underlying actions. The literature in this matter is short. In this paper we aimed to find out how first-language affects access to healthcare for people who do not speak the official language, with a particular focus on language oppression. Methods: We conducted this qualitative study based on patient-reported experiences of the Kurds in Turkey, which is a century-long oppressed population. We conducted 12 in-depth interviews (all ethnically Kurdish, non-Turkish speaking) in Şırnak, Turkey, in 2018–2019 using maximum variation strategy. We used Levesque's 'Patient-Centred Access to Healthcare' framework which addresses individual and structural dimensions to access. Results: We found that Kurds who do not speak the official language face multiple first-language related barriers in accessing healthcare. Poor access to health information, poor patient-provider relationship, delay in seeking health care, dependence on others in accessing healthcare, low adherence to treatments, dissatisfaction with services, and inability to follow health rights were main issues. As an unusual outcome, we discovered that the barrier processes in accessing healthcare are particularly complicated in the context of oppression and its internalization. Internalized oppression, as we found in our study, impairs access to healthcare with creating a sense of reluctance to seek healthcare, and impairs their individual and collective agency to struggle for change. Conclusions: A human-rights-based top-down policy shift, and a bottom-up community empowerment approach is needed. At the system level, official recognition of oppressed populations, acknowledgement of the determinants of their health; and incorporating their language in official capacities (particularly education and healthcare) is crucial. Interventions should include raising awareness among relevant professions and stakeholders that internalized oppression is an issue in accessing healthcare to be considered. Given that internalized oppression can be in other forms than language or ethnicity, future research aimed at examining other aspects of access to healthcare should pay a special attention to internalized oppression. [ABSTRACT FROM AUTHOR]

Background: Health and care workers (HCWs) are at the forefront of COVID-19 response, at high risk of infection, and as a result they are a priority group for COVID-19 vaccination. This paper presents the global patterns in COVID-19 vaccination coverage among HCWs in 2021, how HCWs were prioritized, and identifies factors associated with the early vaccination coverage. Methods: Using monthly data reported to the World Health Organization, the percentages of partially and fully vaccinated HCWs were computed. The rates of vaccination of HCWs for the first and second half of 2021 were compared in a stratified analysis using several factors. A multivariate analysis was used to investigate the independent associations of these factors with the percentage of HCWs fully vaccinated. Results: Based on data from 139 Member States, as of end of 2021, 82% HCWs were reported as fully vaccinated with important variations by income groups: 33% for low income countries, 83% for lower-middle income countries, 79% for upper-middle income countries and 88% for high income countries. Overall 76% of countries did not achieve 70% vaccination coverage of their HCWs in the first half of 2021, and 38% of countries by end of 2021. Compared with the general population, the rate of HCWs full vaccination was 3.5 times higher, in particular for low income countries (RR = 5.9). Stratified analysis showed that beyond income group, the availability of vaccine doses was a critical factor of HCWs vaccination coverage with medians of 59.1% and 88.6% coverage in the first and second half of 2021, respectively for countries with enough doses to cover 70% of their population, compared with 0.8% and 47.5% coverage, respectively for countries with doses to cover 40% of their population. The multivariate analysis confirmed this observation with a 35.9% overall difference (95%CI 15.1%; 56.9%) between these two groups. Conclusion: Despite being considered a priority group, more than a third of countries did not achieve 70% vaccination coverage of their HCWs at the end of 2021. Large inequities were observed with low income countries lagging behind. Additional efforts should be dedicated to ensure full protection of HCWs through vaccination. [ABSTRACT FROM AUTHOR]

Background: To better meet people's growing demand for medical and health services, 21 cities in Guangdong Province were involved in the reform of public hospitals in 2017. This paper evaluates the equity and efficiency of public hospitals' health resource allocation in Guangdong Province and explores ways to change the current situation. Methods: Data were collected from the Guangdong Health Statistical Yearbook 2016–2020 and Guangdong Statistical Yearbook 2017–2021. The Gini coefficient (G), Theil index (T), and health resource density index (HRDI) were used to measure the equity of health resource allocation. An improved three-stage DEA method was applied in efficiency evaluation. The entropy weight method was employed to calculate the weight of different indicators to obtain a comprehensive indicator representing the overall volume of health resources in each city. A two-dimensional matrix was drawn between the HRDI of the comprehensive indicator and efficiency and the per capita government financial subsidies and efficiency to observe the coordination of equity and efficiency across regions. Results: From 2016 to 2020, the G of public hospital, bed, and health technician allocation by population remained below 0.2, while that by geographical area ranged from 0.4 to 0.6; the G of government financial subsidies by population was above 0.4, while that by geographical area was greater than 0.7. The results for T showed that inequality mainly comes from intraregional differences, and the Pearl River Delta contributes most to the overall differences. Although the HRDI of the Pearl River Delta is far greater than that of other regions, obvious differences exist across cities in the region. Only 38.1% of cities were found to be efficient in 2020. The Pearl River Delta was in the first quadrant, and the other three regions were in the third quadrant, accounting for a large proportion. Conclusion: The equity of government financial subsidies allocation was the worst, and there were distinct regional differences in the geographical distribution of health resources. The development of healthcare within the Pearl River Delta was highly unbalanced. The development of healthcare was uneven between the Pearl River Delta, eastern, western, and mountainous regions. In addition, most cities in the eastern, western, and mountainous regions bore the dual pressures of relatively insufficient health resources and inefficiency. [ABSTRACT FROM AUTHOR]

Background: Research has generally found a significant inverse relationship in mortality risk across socioeconomic (SE) groups. This paper focuses on Spain, a country for which there continues to be very little evidence available concerning retirement pensioners. We draw on the Continuous Sample of Working Lives (CSWL) to investigate disparities in SE mortality among retired men aged 65 and above over the longest possible period covered by this data source: 2005–2018. We use the initial pension income (PI) level as our single indicator of the SE status of the retired population. Methods: The mortality gradient by income is quantified in two ways: via an indicator referred to as "relative mortality", and by estimating changes in total life expectancy (LE) by PI level at ages 65 and 75 over time. We show that, should the information provided by the relative mortality ratio not be completely clear, a second indicator needs to be introduced to give a broad picture of the true extent of inequality in mortality. Results: The first indicator reveals that, for the period covered and for all age groups, the differences in death rates across PI levels widens over time. At older age groups, these differences across PI levels diminish. The second indicator shows that disparities in LE at ages 65 and 75 between pensioners in the lowest and highest income groups are relatively small, although slightly higher than previously reported for Spain. This gap in LE widens over time, from 1.49 to 2.54 years and from 0.71 to 1.40 years respectively for pensioners aged 65 and 75. These differences are statistically significant. Conclusions: Along with other behavioral and structural aspects, a combination of factors such as the design of the pension system, the universality and quality of the health system, and high levels of family support could explain why LE inequalities for retired Spanish men are relatively small. To establish the reasons for this increased inequality in LE, more research needs to be carried out. An analysis of all Spanish social security records instead of just a sample would provide us with more information. [ABSTRACT FROM AUTHOR]

Background: The security of medical insurance fund is very important to health equity. In China, the expenditure of medical insurance fund has increased sharply year after year, and the balance of local medical insurance fund is difficult to sustain. To realize the equitable distribution of the medical insurance burden, the central government has to continuously increase transfer payments, which causes regional unfairness in the distribution of central financial resources. This paper explores the influence of central transfer payments on the balance of medical insurance fund, influential mechanisms, and the strategic behavior of local governments. Methods: First, we constructed a dynamic game model between central government and local governments and analyzed the mechanism of central transfer payments affecting the balance of local medical insurance fund. Then, based on the provincial panel data of 28 provincial administrative regions in China from 2004 to 2014, an empirical test was made. The spatial regression model was constructed, and the transfer payments obtained by neighboring provinces in the previous year were taken as instrumental variables. Results: Central transfer payments led to strategic behaviors by local governments that resulted in increased local health insurance fund expenditures and lower balance rates. Moreover, the central transfer payments demonstrated "path dependence". Central transfer payments had a significant negative influence on the local NCMS fund balance rate. The local government subsidy and per capita GDP had a significant positive impact on the local NCMS fund balance rate. The obtained transfer payments of local governments had a significant space correlation. This study based on NCMS data remains valid. Conclusions: Central transfer payments induced the strategic behavior of local governments, which neglected to supervise the expenditure of medical insurance fund, reducing the efficiency of medical insurance fund management and use. The financial resources of medical insurance fund are unevenly distributed among provinces. Measures such as strengthening the supervision ability and initiatives of local governments, refining the central transfer payment mechanism, promoting the economic growth of western regions, and increasing rates for individual contributions appropriately can ensure that the medical insurance fund are used well and distributed equitably. [ABSTRACT FROM AUTHOR]

Background: The security of medical insurance fund is very important to health equity. In China, the expenditure of medical insurance fund has increased sharply year after year, and the balance of local medical insurance fund is difficult to sustain. To realize the equitable distribution of the medical insurance burden, the central government has to continuously increase transfer payments, which causes regional unfairness in the distribution of central financial resources. This paper explores the influence of central transfer payments on the balance of medical insurance fund, influential mechanisms, and the strategic behavior of local governments. Methods: First, we constructed a dynamic game model between central government and local governments and analyzed the mechanism of central transfer payments affecting the balance of local medical insurance fund. Then, based on the provincial panel data of 28 provincial administrative regions in China from 2004 to 2014, an empirical test was made. The spatial regression model was constructed, and the transfer payments obtained by neighboring provinces in the previous year were taken as instrumental variables. Results: Central transfer payments led to strategic behaviors by local governments that resulted in increased local health insurance fund expenditures and lower balance rates. Moreover, the central transfer payments demonstrated "path dependence". Central transfer payments had a significant negative influence on the local NCMS fund balance rate. The local government subsidy and per capita GDP had a significant positive impact on the local NCMS fund balance rate. The obtained transfer payments of local governments had a significant space correlation. This study based on NCMS data remains valid. Conclusions: Central transfer payments induced the strategic behavior of local governments, which neglected to supervise the expenditure of medical insurance fund, reducing the efficiency of medical insurance fund management and use. The financial resources of medical insurance fund are unevenly distributed among provinces. Measures such as strengthening the supervision ability and initiatives of local governments, refining the central transfer payment mechanism, promoting the economic growth of western regions, and increasing rates for individual contributions appropriately can ensure that the medical insurance fund are used well and distributed equitably. [ABSTRACT FROM AUTHOR]

Background: Emergency department crowding is an obstacle in the process of obtaining emergency care services, which will lead to the increase of time cost. Most studies focused on the direct access to emergency medical resources, and few studies took the crowding of hospital emergency department as an evaluation index to reflect the convenience of obtaining emergency medical resources. It is a significance for the identification of areas with insufficient access to emergency service resources with this method. Methods: This paper utilizes the improved potential model and the inverted Two-Step Floating Catchment Area method, combined with network map API service data to evaluate response time, delivery time and waiting time (for emergency department crowding) spent in different residential areas of Xi'an City in the process of emergency. Meanwhile, the vulnerable regions of gaining emergency medical resources are identified through the comprehensive analysis of the three stages of emergency. Results: The studies show that the residents in built-up area are more convenient to get ambulance service and arrive at care hospitals than those in suburban areas, but they may face greater hospital crowdedness. Although suburban residents are faced with low hospital crowdedness, they spend more time on getting ambulances and going to care hospitals. The accessibility of emergency medical resources varies greatly among residents in different regions, with 5.38% of the residents were identified in the high-risk area distributing in suburban residential areas in the south of the city center, 21.92% in the medium risk area in the southern mountainous areas and the periphery of the core suburban areas of the city, and 46.11% in the low-risk area which are mainly distributed in built-up areas in gaining emergency medical services. Conclusions: Obviously, getting an ambulance and arriving at the nearest hospital quickly shows that it is conducive to access to emergency resources. However, the impact of hospital emergency crowding can not be ignored, especially in the area surrounded by high-grade hospitals in the central area of the city. In considering the spatial layout of emergency stations and emergency hospitals, the dislocation distribution of hospitals at different levels should be reasonably adjusted to balance the equity of residents in obtaining emergency medical resources. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic inequalities in cardiovascular (CVD) health outcomes are well documented. While Russia has one of the highest levels of CVD mortality in the world, the literature on contemporary socio-economic inequalities in biomarker CVD risk factors is sparse. This paper aims to assess the extent and the direction of SEP inequalities in established physiological CVD risk biomarkers, and to explore the role of lifestyle factors in explaining SEP inequalities in physiological CVD risk biomarkers. Methods: We used cross-sectional data from a general population-based survey of Russians aged 35-69 years living in two cities (n = 4540, Know Your Heart study 2015-18). Logistic models were used to assess the associations between raised physiological risk biomarkers levels (blood pressure levels, cholesterol levels, triglycerides, HbA1C, and C-reactive protein) and socioeconomic position (SEP) (education and household financial constraints) adjusting for age, obesity, smoking, alcohol and health-care seeking behavior. Results: High education was negatively associated with a raised risk of blood pressure (systolic and diastolic) and C-reactive protein for both men and women. High education was positively associated with total cholesterol, with higher HDL levels among women, and with low triglycerides and HbA1c levels among men. For the remaining risk biomarkers, we found little statistical support for SEP inequalities. Adjustment for lifestyle factors, and particularly BMI and waist-hip ratio, led to a reduction in the observed SEP inequalities in raised biomarkers risk levels, especially among women. High financial constraints were weakly associated with high risk biomarkers levels, except for strong evidence for an association with C-reactive protein (men). Conclusions: Notable differences in risk biomarkers inequalities were observed according to the SEP measure employed. Clear educational inequalities in raised physiological risk biomarkers levels, particularly in blood pressure and C-reactive protein were seen in Russia and are partly explained by lifestyle factors, particularly obesity among women. These findings provide evidence-based information on the need for tackling health inequalities in the Russian population, which may help to further contribute to CVD mortality decline. [ABSTRACT FROM AUTHOR]

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

Background: Researching access to health services, and ways to improve equity, frequently requires researchers to recruit people facing social disadvantage. Recruitment can be challenging, and there is limited high quality evidence to guide researchers. This paper describes experiences of recruiting 1068 participants facing social disadvantage for a randomised controlled trial of prescription charges, and provides evidence on the advantages and disadvantages of recruitment methods. Methods: Those living in areas of higher social deprivation, taking medicines for diabetes, taking anti-psychotic medicines, or with COPD were eligible to participate in the study. Several strategies were trialled to meet recruitment targets. We initially attempted to recruit participants in person, and then switched to a phone-based system, eventually utilising a market research company to deal with incoming calls. We used a range of strategies to publicise the study, including pamphlets in pharmacies and medical centres, media (especially local newspapers) and social media. Results: Enrolling people on the phone was cheaper on average than recruiting in person, but as we refined our approach over time, the cost of the latter dropped significantly. In person recruitment had many advantages, such as enhancing our understanding of potential participants' concerns. Forty-nine percent of our participants are Māori, which we attribute to having Māori researchers on the team, recruiting in areas of high Māori population, team members' existing links with Māori health providers, and engaging and working with Māori providers. Conclusions: Recruiting people facing social disadvantage requires careful planning and flexible recruitment strategies. Support from organisations trusted by potential participants is essential. Registration: The Free Meds study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12618001486213). [ABSTRACT FROM AUTHOR]

Background: Most existing research on rural–urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural–urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China. Methods: Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015–2019) and 25,849 live births in City B (2018–2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable. Results: While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively. Conclusions: Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services. [ABSTRACT FROM AUTHOR]

Background: Health outcomes in India are characterized by pervasive inequities due to deeply entrenched socio-economic gradients amongst the population. Therefore, it is imperative to investigate these systematic disparities in health, however, evidence of inequities does not commensurate with its policy objectives in India. Thus, our paper aims to examine the magnitude of and trends in horizontal inequities in self-reported morbidity and untreated morbidity in India over the period of 2004 to 2017–18. Methods: The study used cross-sectional data from nationwide healthcare surveys conducted in 2004, 2014 and 2017–18 encompassing sample size of 3,85,055; 3,35,499 and 5,57,887 individuals respectively. Erreygers concentration indices were employed to discern the magnitude and trend in horizontal inequities in self-reported morbidity and untreated morbidity. Need standardized concentration indices were further used to unravel the inter-regional and intra-regional income related inequities in outcomes of interest. Additionally, regression based decomposition approach was applied to ascertain the contributions of both legitimate and illegitimate factors in the measured inequalities. Results: Estimates were indicative of profound inequities in self-reported morbidity as inequity indices were positive and significant for all study years, connoting better-off reporting more morbidity, given their needs. These inequities however, declined marginally from 2004(HI: 0.049, p< 0.01) to 2017–18(HI: 0.045, P< 0.01). Untreated morbidity exhibited pro-poor inequities with negative concentration indices. Albeit, significant reduction in horizontal inequity was found from 2004(HI= − 0.103, p< 0.01) to 2017–18(HI = − 0.048, p< 0.01) in treatment seeking over the years. The largest contribution of inequality for both outcomes stemmed from illegitimate variables in all the study years. Our findings also elucidated inter-state heterogeneities in inequities with high-income states like Andhra Pradesh, Kerala and West Bengal evincing inequities greater than all India estimates and Northeastern states divulged equity in reporting morbidity. Inequities in untreated morbidity converged for most states except in Punjab, Chhattisgarh and Himachal Pradesh where widening of inequities were observed from 2004 to 2017–18. Conclusions: Pro-rich and pro-poor inequities in reported and untreated morbidities respectively persisted from 2004 to 2017–18 despite reforms in Indian healthcare. Magnitude of these inequities declined marginally over the years. Health policy in India should strive for targeted interventions closing inequity gap. [ABSTRACT FROM AUTHOR]

Background: Health outcomes in India are characterized by pervasive inequities due to deeply entrenched socio-economic gradients amongst the population. Therefore, it is imperative to investigate these systematic disparities in health, however, evidence of inequities does not commensurate with its policy objectives in India. Thus, our paper aims to examine the magnitude of and trends in horizontal inequities in self-reported morbidity and untreated morbidity in India over the period of 2004 to 2017–18. Methods: The study used cross-sectional data from nationwide healthcare surveys conducted in 2004, 2014 and 2017–18 encompassing sample size of 3,85,055; 3,35,499 and 5,57,887 individuals respectively. Erreygers concentration indices were employed to discern the magnitude and trend in horizontal inequities in self-reported morbidity and untreated morbidity. Need standardized concentration indices were further used to unravel the inter-regional and intra-regional income related inequities in outcomes of interest. Additionally, regression based decomposition approach was applied to ascertain the contributions of both legitimate and illegitimate factors in the measured inequalities. Results: Estimates were indicative of profound inequities in self-reported morbidity as inequity indices were positive and significant for all study years, connoting better-off reporting more morbidity, given their needs. These inequities however, declined marginally from 2004(HI: 0.049, p< 0.01) to 2017–18(HI: 0.045, P< 0.01). Untreated morbidity exhibited pro-poor inequities with negative concentration indices. Albeit, significant reduction in horizontal inequity was found from 2004(HI= − 0.103, p< 0.01) to 2017–18(HI = − 0.048, p< 0.01) in treatment seeking over the years. The largest contribution of inequality for both outcomes stemmed from illegitimate variables in all the study years. Our findings also elucidated inter-state heterogeneities in inequities with high-income states like Andhra Pradesh, Kerala and West Bengal evincing inequities greater than all India estimates and Northeastern states divulged equity in reporting morbidity. Inequities in untreated morbidity converged for most states except in Punjab, Chhattisgarh and Himachal Pradesh where widening of inequities were observed from 2004 to 2017–18. Conclusions: Pro-rich and pro-poor inequities in reported and untreated morbidities respectively persisted from 2004 to 2017–18 despite reforms in Indian healthcare. Magnitude of these inequities declined marginally over the years. Health policy in India should strive for targeted interventions closing inequity gap. [ABSTRACT FROM AUTHOR]

Background: After achieving universal basic medical insurance coverage, Chinese government put the development of private health insurance (PHI) on its agenda to further strengthen financial risk protection. This paper aims to assess the level of financial protection that PHI provides for its insured households on the basis of resident basic medical insurance (RBMI). Methods: We employed balanced panel data collected between 2015 and 2017 from the China Household Finance Survey (CHFS). Catastrophic health expenditure (CHE) and impoverishment due to health spending were applied to measure the financial protection effects. Random effects panel logistic regression model was performed to identify the factors associated with CHE and impoverishment among households covered by RBMI. In the robustness test, the method of propensity score matching (PSM) was employed to solve the problem of endogeneity. Results: From 2015 to 2017, the CHE incidence increased from 12.96 to 14.68 % for all sampled households, while the impoverishment rate decreased slightly from 5.43 to 5.32 % for all sampled households. In 2015, the CHE incidence and impoverishment rate under RBMI + PHI were 4.53 and 0.72 %, respectively, which were lower than those under RBMI alone. A similar phenomenon was observed in 2017. Regression analysis also showed that the households with RBMI + PHI were significantly less likely to experience CHE (marginal effect: -0.054, 95 %CI: -0.075 to -0.034) and impoverishment (marginal effect: -0.049, 95 %CI: -0.069 to -0.028) compared to those with RBMI alone. The results were still robust after using PSM method to eliminate the effects of self-selection on the estimation results. Conclusions: In the context of universal basic medical insurance coverage, the CHE incidence and impoverishment rate of Chinese households with RBMI were still considerably high in 2015 and 2017. PHI played a positive role in decreasing household financial risk on the basis of RBMI. [ABSTRACT FROM AUTHOR]

Background: In the U.S., strong ethnic/racial, socioeconomic, demographic, and geographic breastfeeding (BF) inequities persist, and African American and Hispanic women are less likely to meet their breastfeeding goals compared to White women. This systematic review (SR) was designed to answer the question: What is the impact of breastfeeding interventions targeting ethnic/racial minority women in the U.S. on improving BF initiation, duration and exclusivity rates? Methods: The SR was conducted following the Institute of Medicine Guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study protocol was developed and registered a priori in PROSPERO (ID#CRD42020177764). The electronical databases searched was MEDLINE All (Ovid). Search strategies were led by the team's expert public health librarian using both controlled vocabulary and free text queries and were tested against a validated set of relevant papers included in existing reviews. The GRADE methodology was used to assess the quality of the studies. Results: We included 60 studies that had randomized (n = 25), observational (n = 24), quasi-experimental (n = 9), or cross-sectional (n = 2) designs. The studies focused on populations that were multi-ethnic/racial (n = 22), only Hispanic (n = 24), only Black (n = 13), and only American Indian (n = 1). The study interventions were classified following the socioecological model: macrosystem/policy level (n = 6); community level (n=51), which included healthcare organizations (n = 34), The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (n = 9), and community organizations/public health institutions (n = 8); and interpersonal level (n = 3). Conclusions: Policy and community level interventions delivered through WIC, healthcare facilities, and community agencies) are likely to improve BF outcomes among women of color. The combination of interventions at different levels of the socioecological model has not been studied among minority women in the U.S. Implementation science research is needed to learn how best to scale up and sustain effective BF interventions, taking into account the needs and wants of minority women. Thus, it is strongly recommended to conduct large scale implementation research studies addressesing how to strengthen the different health and social environments surrounding women of color in the U.S. to improving their BF outcomes. [ABSTRACT FROM AUTHOR]

Background: In low- and middle-income countries (LMICs), low levels of formal maternal educational are positively associated with breastfeeding whereas the reverse is true among women with higher levels of formal education. As such, breastfeeding has helped to reduce health equity gaps between rich and poor children. Our paper examines trends in breastfeeding and formula consumption by maternal educational in LMICs over nearly two decades. Methods: We used 319 nationally representative surveys from 81 countries. We used WHO definitions for breastfeeding indicators and categorized maternal education into three categories: none, primary, and secondary or higher. We grouped countries according to the World Bank income groups and UNICEF regions classifications. The trend analyses were performed through multilevel linear regression to obtain average absolute annual changes in percentage points. Results: Significant increases in prevalence were observed for early initiation and exclusive breastfeeding across all education categories, but more prominently in women with no formal education for early breastfeeding and in higher level educated women for exclusive breastfeeding. Small decreases in prevalence were seen mostly for women with no formal education for continued breastfeeding at 1 and 2 years. Among formula indicators, only formula consumption between 6 and 23 months decreased significantly over the period for women with primary education. Analysis by world regions demonstrated that gains in early and exclusive breastfeeding were almost universally distributed among education categories, except in the Middle East and North Africa where they decreased throughout education categories. Continued breastfeeding at 1 and 2 years increased in South Asia, Latin America and the Caribbean, and Eastern Europe and Central Asia for primary or higher education categories. Declines occurred for the group of no formal education in South Asia and nearly all education categories in the Middle East and North Africa with a decline steeper for continued breastfeeding at 2 years. With a few exceptions, the use of formula is higher among children of women at the highest education level in all regions. Conclusions: Over the course of our study, women with no formal education have worsening breastfeeding indicators compared to women with primary and secondary or higher education. [ABSTRACT FROM AUTHOR]

Background: Health outcomes in India are characterized by pervasive inequities due to deeply entrenched socio-economic gradients amongst the population. Therefore, it is imperative to investigate these systematic disparities in health, however, evidence of inequities does not commensurate with its policy objectives in India. Thus, our paper aims to examine the magnitude of and trends in horizontal inequities in self-reported morbidity and untreated morbidity in India over the period of 2004 to 2017–18. Methods: The study used cross-sectional data from nationwide healthcare surveys conducted in 2004, 2014 and 2017–18 encompassing sample size of 3,85,055; 3,35,499 and 5,57,887 individuals respectively. Erreygers concentration indices were employed to discern the magnitude and trend in horizontal inequities in self-reported morbidity and untreated morbidity. Need standardized concentration indices were further used to unravel the inter-regional and intra-regional income related inequities in outcomes of interest. Additionally, regression based decomposition approach was applied to ascertain the contributions of both legitimate and illegitimate factors in the measured inequalities. Results: Estimates were indicative of profound inequities in self-reported morbidity as inequity indices were positive and significant for all study years, connoting better-off reporting more morbidity, given their needs. These inequities however, declined marginally from 2004(HI: 0.049, p< 0.01) to 2017–18(HI: 0.045, P< 0.01). Untreated morbidity exhibited pro-poor inequities with negative concentration indices. Albeit, significant reduction in horizontal inequity was found from 2004(HI= − 0.103, p< 0.01) to 2017–18(HI = − 0.048, p< 0.01) in treatment seeking over the years. The largest contribution of inequality for both outcomes stemmed from illegitimate variables in all the study years. Our findings also elucidated inter-state heterogeneities in inequities with high-income states like Andhra Pradesh, Kerala and West Bengal evincing inequities greater than all India estimates and Northeastern states divulged equity in reporting morbidity. Inequities in untreated morbidity converged for most states except in Punjab, Chhattisgarh and Himachal Pradesh where widening of inequities were observed from 2004 to 2017–18. Conclusions: Pro-rich and pro-poor inequities in reported and untreated morbidities respectively persisted from 2004 to 2017–18 despite reforms in Indian healthcare. Magnitude of these inequities declined marginally over the years. Health policy in India should strive for targeted interventions closing inequity gap. [ABSTRACT FROM AUTHOR]

Background: China issued strict nationwide guidelines to combat the COVID-19 outbreak in January 2020 and gradually loosened the restrictions on movement in early March. Little is known about how these disease control measures affected the 600 million people who live in rural China. The goal of this paper is to document the quarantine measures implemented in rural China outside the epicenter of Hubei Province and to assess the socioeconomic effect of the measures on rural communities over time. Methods: We conducted three rounds of interviews with informants from 726 villages in seven provinces, accounting for over 25% of China's overall rural population. The survey collected data on rural quarantine implementation; COVID-19 infections and deaths in the survey villages; and effects of the quarantine on employment, income, education, health care, and government policies to address any negative impacts. The empirical findings of the work established that strict quarantine measures were implemented in rural villages throughout China in February. Results: There was little spread of COVID-19 in rural communities: an infection rate of 0.001% and zero deaths reported in our sample. However, there were negative social and economic outcomes, including high rates of unemployment, falling household income, rising prices, and disrupted student learning. Health care was generally accessible, but many delayed their non-COVID-19 health care due to the quarantine measures. Only 20% of villagers received any form of local government aid, and only 11% of villages received financial subsidies. There were no reports of national government aid programs that targeted rural villagers in the sample areas. Conclusions: By examining the economic and social effects of the COVID-19 restrictions in rural communities, this study will help to guide other middle- and low-income countries in their containment and restorative processes. Without consideration for economically vulnerable populations, economic hardships and poverty will likely continue to have a negative impact on the most susceptible communities. [ABSTRACT FROM AUTHOR]

Introduction: Although India has made significant progress in institutional delivery after the implementation of the National Rural Health Mission under which the Janani Suraksha Yojana (JSY) is a sub-programme which played a vital role in the increase of institutional delivery in public facilities. Therefore, this paper aims to provide an understanding of the JSY coverage at the district level in India. Further, it tries to carve out the factors responsible for the regional disparity of JSY coverage at district levels. Methods: The study used the National Family Health Survey data, which is a cross-sectional survey conducted in 2015–16, India. The sample size of this study was 148,145 women aged 15–49 years who gave last birth in the institution during 5 years preceding the survey. Bivariate and multivariate regression analysis was used to fulfill the study objectives. Additionally, Moran's I statistics and bivariate Local Indicator for Spatial Association (LISA) maps were used to understand spatial dependence and clustering of JSY coverage. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of JSY utilization. Results: The value of spatial-autocorrelation for JSY was 0.71 which depicts the high dependence of the JSY coverage over districts of India. The overall coverage of JSY in India is 36.4% and it highly varied across different regions, districts, and even socioeconomic groups. The spatial error model depicts that if in a district the women with no schooling status increase by 10% then the benefits of JSY get increased by 2.3%. Similarly, if in a district the women from poor wealth quintile, it increases by 10% the benefits of JSY also increased by 4.6%. However, the coverage of JSY made greater imperative to understand it due to its clustering among districts of specific states only. Conclusion: It is well reflected in the EAGs states in terms of spatial-inequality in service coverage. There is a need to universalize the JSY programme at a very individual level. And, it is required to revisit the policy strategy and the implementation plans at regional or district levels. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) has resulted in an enormous dislocation of society especially in South Africa. The South African government has imposed a number of measures aimed at controlling the pandemic, chief being a nationwide lockdown. This has resulted in income loss for individuals and firms, with vulnerable populations (low earners, those in informal and precarious employment, etc.) more likely to be adversely affected through job losses and the resulting income loss. Income loss will likely result in reduced ability to access healthcare and a nutritious diet, thus adversely affecting health outcomes. Given the foregoing, we hypothesize that the economic dislocation caused by the coronavirus will disproportionately affect the health of the poor. Methods: Using the fifth wave of the National Income Dynamics Study (NIDS) dataset conducted in 2017 and the first wave of the NIDS-Coronavirus Rapid Mobile Survey (NIDS-CRAM) dataset conducted in May/June 2020, this paper estimated income-related health inequalities in South Africa before and during the COVID-19 pandemic. Health was a dichotomized self-assessed health measure, with fair and poor health categorized as "poor" health, while excellent, very good and good health were categorized as "better" health. Household per capita income was used as the ranking variable. Concentration curves and indices were used to depict the income-related health inequalities. Furthermore, we decomposed the COVID-19 era income-related health inequality in order to ascertain the significant predictors of such inequality. Results: The results indicate that poor health was pro-poor in the pre-COVID-19 and COVID-19 periods, with the latter six times the value of the former. Being African (relative to white), per capita household income and household experience of hunger significantly predicted income-related health inequalities in the COVID-19 era (contributing 130%, 46% and 9% respectively to the inequalities), while being in paid employment had a nontrivial but statistically insignificant contribution (13%) to health inequality. Conclusions: Given the significance and magnitude of race, hunger, income and employment in determining socioeconomic inequalities in poor health, addressing racial disparities and hunger, income inequality and unemployment will likely mitigate income-related health inequalities in South Africa during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: In low- and middle-income countries (LMICs), low levels of formal maternal educational are positively associated with breastfeeding whereas the reverse is true among women with higher levels of formal education. As such, breastfeeding has helped to reduce health equity gaps between rich and poor children. Our paper examines trends in breastfeeding and formula consumption by maternal educational in LMICs over nearly two decades. Methods: We used 319 nationally representative surveys from 81 countries. We used WHO definitions for breastfeeding indicators and categorized maternal education into three categories: none, primary, and secondary or higher. We grouped countries according to the World Bank income groups and UNICEF regions classifications. The trend analyses were performed through multilevel linear regression to obtain average absolute annual changes in percentage points. Results: Significant increases in prevalence were observed for early initiation and exclusive breastfeeding across all education categories, but more prominently in women with no formal education for early breastfeeding and in higher level educated women for exclusive breastfeeding. Small decreases in prevalence were seen mostly for women with no formal education for continued breastfeeding at 1 and 2 years. Among formula indicators, only formula consumption between 6 and 23 months decreased significantly over the period for women with primary education. Analysis by world regions demonstrated that gains in early and exclusive breastfeeding were almost universally distributed among education categories, except in the Middle East and North Africa where they decreased throughout education categories. Continued breastfeeding at 1 and 2 years increased in South Asia, Latin America and the Caribbean, and Eastern Europe and Central Asia for primary or higher education categories. Declines occurred for the group of no formal education in South Asia and nearly all education categories in the Middle East and North Africa with a decline steeper for continued breastfeeding at 2 years. With a few exceptions, the use of formula is higher among children of women at the highest education level in all regions. Conclusions: Over the course of our study, women with no formal education have worsening breastfeeding indicators compared to women with primary and secondary or higher education. [ABSTRACT FROM AUTHOR]

Background: Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels. Methods: The current analysis selected 4 indicators from the WASH Benefits trial— presence of water and soap in household handwashing stations, observed mother's hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline. Results: For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (− 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, − 25% (− 35, − 15) Q2: − 34% (− 44, − 23%)] than the wealthiest household [Q5 DID: − 1% (− 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1–4 DID: 50–54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%). Conclusion: By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program. Trial registration: WASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095. Date of registration: April 30, 2012 'Retrospectively registered'. [ABSTRACT FROM AUTHOR]

Introduction: This paper aimed at estimating the resources required to implement a community Score Card by a typical rural district health team in Uganda, as a mechanism for fostering accountability, utilization and quality of maternal and child healthcare service. Methods: This costing analysis was done from the payer's perspective using the ingredients approach over five quarterly rounds of scoring between 2017 and 2018. Expenditure data was obtained from project records, entered and analyzed in Microsoft excel. Two scale-up scenarios, scenario one (considered cost inputs by the MakSPH research teams) and scenario two (considering cost inputs based on contextual knowledge from district implementing teams), were simulated to better understand the cost implications of integrating the Community Score Card (CSC) into a district health system. Results: The total and average cost of implementing CSC for five quarterly rounds over a period of 18 months were USD 59,962 and USD 11,992 per round of scoring, respectively. Considering the six sub-counties (including one Town Council) in Kibuku district that were included in this analysis, the average cost of implementating the CSC in each sub-county was USD 1998 per scoring round. Scaling-up of the intervention across the entire district (included 22 sub-counties) under the first scenario would cost a total of USD 19,003 per scoring round. Under the second scaleup scenario, the cost would be lower at USD 7116. The total annual cost of scaling CSC in the entire district would be USD 76,012 under scenario one compared to USD 28,465 under scenario two. The main cost drivers identified were transportation costs, coordination and supervision costs, and technical support to supplement local implementers. Conclusion: Our analysis suggests that it is financially feasible to implement and scale-up the CSC initiative, as an accountability tool for enhancing service delivery. However, the CSC design and approach needs to be embedded within local systems and implemented in collaboration with existing stakeholders so as to optimise costs. A comprehensive economic analysis of the costs associated with transportation, involvement of the district teams in coordination, supervision as well as provision of technical support is necessary to determine the cost-effectiveness of the CSC approach. [ABSTRACT FROM AUTHOR]

Background: The National Health Mission (NHM), the largest ever publicly funded health programme worldwide, used over half of the national health budget in India and primarily aimed to improve maternal and child health in the country. Though large scale public health investment has improved the health care utilization and health outcomes across states and socio-economic groups in India, little is known on the equity concern of NHM. In this context, this paper examines the utilization pattern and net benefit of public subsidy for institutional delivery by the level of care in India. Methods: Data from the most recent round of the National Family Health Survey (NFHS 4), conducted during 2015–16, was used in the study. A total of 148,645 last birth delivered in a health centre during the 5 years preceding the survey were used for the analyses. Out-of-pocket (OOP) payment on delivery care was taken as the dependent variable and was analysed by primary care and secondary level of care. Benefits Incidence Analysis (BIA), descriptive statistics, concentration index (CI), and concentration curve (CC) were used to do the analysis. Results: Institutional delivery from the public health centres in India is pro-poor and has a strong economic gradient. However, about 28% mothers from richest wealth quintile did not pay for delivery in public health centres compared to 16% among the poorest wealth quintile. Benefit incidence analyses suggests a pro-poor distribution of institutional delivery both at primary and secondary level of care. In 2015–16, at the primary level, about 32.29% of subsidies were used by the poorest, 27.22% by poorer, 20.39% by middle, 13.36% by richer and 6.73% by the richest wealth quintile. The pattern at the secondary level was similar, though the magnitude was lower. The concentration index of institutional delivery in public health centres was − 0.161 [95% CI, − 0.158, − 0.165] compared to 0.296 [95% CI, 0.289, 0.303] from private health centres. Conclusion: Provision and use of public subsidy for institutional delivery in public health centres is pro-poor in India. Improving the quality of service in primary health centres is recommended to increase utilisation and reduce OOP payment for health care in India. [ABSTRACT FROM AUTHOR]

Background: The Arab ethnic minority makes up 21% of Israel's population, yet comprised just 8.8% of confirmed cases and 3.6% of deaths from COVID-19, despite their higher risk profile and greater burden of underlying illness. This paper presents differences in patterns of morbidity and mortality from COVID-19 in the Arab, ultra-Orthodox and overall populations in Israel, and suggests possible reasons for the low rates of infection in the Arab population. Methods: Data were obtained from the Israeli Ministry of Health's (MOH) open COVID-19 database, which includes information on 1270 localities and is updated daily. The database contains the number of COVID-19 diagnostic tests performed, the number of confirmed cases and deaths in Israel. Results: In the first 4 months of Israel's COVID-19 outbreak, just 2060 cases were confirmed in the Arab population, comprising 8.8% of the 23,345 confirmed cases, or 2.38 times less than would be expected relative to the population size. In contrast, the ultra-Orthodox made up 30.1% of confirmed cases yet just 10.1% of the population. Confirmed case rate per 100,000 was twice as high in the general Jewish population compared to the Arab population. The Arab mortality rate was 0.57 per 100,000, compared to 3.37 in the overall population, and to 7.26 in the ultra-Orthodox community. We discuss possible reasons for this low morbidity and mortality including less use of nursing homes, and effective leadership which led to early closure of mosques and high adherence to social distancing measures, even during the month of Ramadan. Conclusions: Despite a disproportionate burden of underlying illness, the Arab population did not fulfil initial predictions during the first wave of the COVID-19 outbreak and maintained low numbers of infections and deaths. This contrasts with reports of increased mortality in ethnic minorities and economically disadvantaged populations in other countries, and with high rates of infection in the ultra-Orthodox sector in Israel. Effective leadership and cooperation between individuals and institutions, particularly engagement of community and religious leaders, can reduce a group's vulnerability and build resilience in an emergency situation such as the current pandemic. [ABSTRACT FROM AUTHOR]

Background: Over the last decade, the expenditure on public medical and health has increased greatly in China, however, problems as low efficiency and unfairness still exist. How to accurately describe the effectiveness of existing medical and health resources in combination with regional heterogeneity is of great significance to China's medical and health reform. Methods: Based on provincial panel data for the period of 2005 to 2017, combining expected output and unexpected output, this paper constructs a super-efficiency three-stage SBM-DEA model, to measure and analyze the spatial-temporal heterogeneity characteristics and influencing factors of public medical and health efficiency (PMHE). Results: (1) After the impacts of random error and external environmental factors are removed, the mean value of overall PMHE is 0.9274, failing to reach DEA efficiency, and PMHE shows a fluctuated downward trend. (2) The adjusted PMHE level shows a prominent spatial imbalance at the stage 3. The average efficiency level is ranked by the East > the West > the Central > the Northeast. (3) The increases of GDP per capita and population density are beneficial to the improvement of PMHE, while income level and education level are disadvantageous to PMHE, and last, the urbanization level, an uncertain effect. (4) There is no σ convergence of the PMHE in the East, the Central and the West, that is, the internal differences may gradually expand in the future, while the Northeast shows a significant σ convergence trending of PMHE. (5) The state's allocation of medical and health resources has undergone major changes during "The Twelfth Five-Year Plan". Conclusion: This study innovatively incorporates undesired outputs of health care into the efficiency evaluation framework by constructing the main efficiency evaluation indicators. The results of the robust evaluation conclude that China's existing investment in medical and health resources is generally not effective. Therefore, although China's health care reform has made certain achievement, it is still necessary to expand the investment in health care resources. [ABSTRACT FROM AUTHOR]

Background: Lesbian, gay and bisexual (LGB) people often face individual- and system-level barriers in health care. However, LGB people's experiences of health care in non-European and non-American settings have been scarcely studied. In China, while it has been estimated that there are at least 70 million gender and sexual minorities, there has been no larger-scale study on LGB people's experiences of health care beyond a focus on gay men and HIV. This study is the first larger-scale quantitative study to investigate LGB people's experiences of health care in China, where non-heterosexuality is officially silenced and the needs of non-heterosexual people are largely ignored by service providers. Methods: An online survey was designed in joint partnership by academic, community groups and the United Nations Development Programme. Targeted and snowball sampling was adopted for participant recruitment. Such unique cross-sectoral partnership made this research possible in the authoritarian state of China where data collection on LGB people is extremely rare. For the analysis in this paper, a sample of 15,611 Chinese LGB people were included. Frequency and descriptive statistics were conducted to describe the LGB respondents' demographic characteristics and their experiences in health care settings. Chi-square tests were conducted to test how experiences vary across LGB people with different demographic characteristics. Results: More than three quarters of the respondents said they would be willing to disclose to their medical care providers their sexual orientation if asked. However, only 5.7% of the respondents said that medical care providers ever asked them about their sexual orientation. About 8.0% of the LGB people surveyed reported having experienced negative treatment in medical care settings. Six percent (5.7%) of the Chinese LGB people said in accessing mental health care services, they were recommended, coaxed into, or provided conversion therapy for sexual orientation, gender identity or gender expression. Conclusions: There is a strong need to enhance LGB cultural competence among health care providers. Policymakers in China should also formulate laws, policies, regulations, clearly articulated codes of conduct, and transparent procedures and practices to ensure non-discrimination of LGB people in the health care system, with a particular focus on banning conversion therapy. [ABSTRACT FROM AUTHOR]

Background: The recent economic crisis has been a major shock not only to the economic sector, but also to the rest of society. Our main objective in this paper is to show the impact of the economic crisis on convergence, i.e. the reduction or equalising of disparities, among the EU-27 countries in terms of health. The aim is to observe whether the economic crisis (from 2008 onwards) has in fact had an effect on health inequalities within the EU. Methods: We estimate convergence by specifying a dynamic panel model with random-effects (time, regions and countries). We are particularly interested in σ-convergence. As dependent variables, we use life expectancy, total mortality and (cause-specific) mortality in the regions of the EU-27 countries over the period 1995-2011. Results: The results of the analysis show that, in terms of health, there has been a catching-up process among the EU regions. However, we find no reduction, on average, in dispersion levels as the σ-convergence shows. The main finding of this paper has been the sharp increase in disparities in 2010 for all health outcomes (albeit less abrupt for cancer mortality). Conclusion: This increase in disparities in 2010 coincides with the austerity measures implemented in the EU countries. Our main conclusion is that these austerity measures have had an impact on socioeconomic inequalities. [ABSTRACT FROM AUTHOR]

Background: Over the past few decades Egypt has attempted to limit and control female genital mutilation (FGM). However, these efforts have not succeeded in curbing the practice, which maintains wide popular support and is firmly embedded in local traditions and structures. An attitudinal change is therefore a prerequisite for any successful campaign against FGM. This paper charts the evolution of beliefs that the practice of FGM in Egypt should be stopped. Method: This paper examines trends in opposition to FGM among ever-married women in Egypt between 1995 and 2014, using six waves of the Egypt Demographic and Health Surveys. Results: The results show that the percentage of ever-married women who think the practice of FGM should be stopped rose from 13.9 % in 1995 to 31.3 % in 2014. The central question here is whether this trend exists because new cohorts of young married women are more modern and more opposed to the practice, or because opposition to FGM has spread through multiple segments of society. Our results show that back in 1995 opposition to FGM was concentrated in two groups: non-circumcised women, and wealthy, highly educated urban women. Between 1995 and 2014 opposition to FGM increased considerably among other groups of women. Conclusion: Our results show that the observed increases in opposition to FGM are not caused by younger cohorts of married women who oppose FGM, nor by the expansion of the groups most likely to oppose FGM. Rather, the results imply that the belief that FGM should be stopped spread to all walks of life, although poorly educated rural women remain least likely to oppose FGM. [ABSTRACT FROM AUTHOR]

Background: Equity is the core of primary care. The issue of equity in health has become urgent, and China has attached increasing attention to it. With rapid economic development and great changes in medical insurance policy, the pattern of equity in health has changed tremendously. The reform of healthcare in Zhejiang Province is at the forefront in China, and studies on Zhejiang Province are of great significance to the entire country. This paper aimed to measure health equity from the perspectives of health needs and health-seeking behavior and to provide suggestions for the next policy formulations, with respect to timeliness. Methods: The investigator's household survey was conducted in August 2016. A sample of 1000 households, which included 2807 individuals in Zhejiang, China, was obtained with the multi-stage stratified cluster sampling method. Descriptive analysis and chi-square tests were adopted in the analysis. The value of the concentration index was used to measure the equity. Results: This study found that the poor have more urgent health needs and poorer health situations than the rich. Through studies on health-seeking behavior, the utilization of outpatient services was almost equitable, while the utilization of hospitalization showed a pro-rich inequity (i.e., the rich use more services). Individuals with employerbased medical insurance used more outpatient services than those with rural and urban medical insurance. More people in the poorer income groups did not use inpatient services due to financial difficulties. Conclusions: Absolute medical prices and medical insurance may explain the equity in the utilization of outpatient services and the inequity in the utilization of hospitalization. In view of the pro-rich inequity of hospitalization, more financial protection should be provided for the poor. [ABSTRACT FROM AUTHOR]

Background: In a context of population ageing, it is a priority for planning and prevention to understand the socioeconomic (SE) patterning of functional limitations and its consequences on healthcare needs. This paper aims at measuring the gender and SE inequalities in functional limitations and their age of onset among the Southern European elderly; then, we evaluate how functional status is linked to formal and informal care use. Methods: We used Portuguese, Italian and Spanish data from the Survey of Health, Ageing and Retirement in Europe (SHARE) of 2011 (n = 9233). We constructed a summary functional limitation score as the sum of two variables: i) Activities of Daily Living (ADL) and ii) Instrumental Activities of Daily Living (IADL). We modelled the functional limitation as a function of age, gender, education, subjective poverty, employment and marital status using multinomial logit models. We then estimated how functional limitation affected informal and formal care demand using negative binomial and logistic models. Results: Women were 2.3 percentage points (pp) more likely to experience severe functional limitation than men, and overcame a 10% probability threshold of suffering from severe limitation around 5 years earlier. Subjective poverty was associated with a 3.1 pp. higher probability of severe functional limitation. Having a university degree reduced the probability of severe functional limitation by 3.5 pp. as compared to none educational level. Discrepancies were wider for the oldest old: women aged 65-79 years old were 3.3 pp. more likely to suffer severe limitations, the excess risk increasing to 15.5 pp. among those older than 80. Similarly, educational inequalities in functional limitation were wider at older ages. Being severely limited was related with a 32.1 pp. higher probability of receiving any informal care, as compared to those moderately limited. Finally, those severely limited had on average 3.2 hospitalization days and 4.6 doctor consultations more, per year, than those without limitations. Conclusion: Functional limitations are unequally distributed, hitting women and the worse-off earlier and more severely, with consequences on care needs. Considering the burden on healthcare systems and families, public health policies should seek to reduce current inequalities in functional limitations. [ABSTRACT FROM AUTHOR]

Background: This paper uses the concepts of organisational culture and organisational trust to explore the Implementation of equity-oriented policies -- the Uniform Patient Fee Schedule (UPFS) and Patients' Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems' people-centeredness and "software". Methods: The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. Results: Regarding the UPFS, the hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals' PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Conclusions: Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation "hardware" such as putting in place necessary staff and resources, it emphasises "software" implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers' status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected. [ABSTRACT FROM AUTHOR]

Background: The objective of this paper is to analyse whether the recent recession has altered health care utilisation patterns of different income groups in Spain. Methods: Based on information concerning individuals 'income and health care use, along with health need indicators and demographic characteristics (provided by the Spanish National Health Surveys from 2006/07 and 2011/12), econometric models are estimated in two parts (mixed logistic regressions and truncated negative binominal regressions) for each of the public health services studied (family doctor appointments, appointments with specialists, hospitalisations, emergencies and prescription drug use). Results: The results show that the principle of universal access to public health provision does not in fact prevent a financial crisis from affecting certain income groups more than others in their utilisation of public health services. Conclusions: Specifically, in relative terms the recession has been more detrimental to low-income groups in the cases of specialist appointments and hospitalisations, whereas it has worked to their advantage in the cases of emergency services and family doctor appointments. [ABSTRACT FROM AUTHOR]

Background: There is limited evidence on how health care inputs are distributed from the sub-national level down to health facilities and their potential influence on promoting health equity. To address this gap, this paper assesses equity in the distribution of health care inputs across public primary health facilities at the district level in Tanzania. Methods: This is a quantitative assessment of equity in the distribution of health care inputs (staff, drugs, medical supplies and equipment) from district to facility level. The study was carried out in three districts (Kinondoni, Singida Rural and Manyoni district) in Tanzania. These districts were selected because they were implementing primary care reforms. We administered 729 exit surveys with patients seeking out-patient care; and health facility surveys at 69 facilities in early 2014. A total of seventeen indices of input availability were constructed with the collected data. The distribution of inputs was considered in relation to (i) the wealth of patients accessing the facilities, which was taken as a proxy for the wealth of the population in the catchment area; and (ii) facility distance from the district headquarters. We assessed equity in the distribution of inputs through the use of equity ratios, concentration indices and curves. Results: We found a significant pro-rich distribution of clinical staff and nurses per 1000 population. Facilities with the poorest patients (most remote facilities) have fewer staff per 1000 population than those with the least poor patients (least remote facilities): 0.6 staff per 1000 among the poorest, compared to 0.9 among the least poor; 0.7 staff per 1000 among the most remote facilities compared to 0.9 among the least remote. The negative concentration index for support staff suggests a pro-poor distribution of this cadre but the 45 degree dominated the concentration curve. The distribution of vaccines, antibiotics, anti-diarrhoeal, anti-malarials and medical supplies was approximately proportional (non dominance), whereas the distribution of oxytocics, anti-retroviral therapy (ART) and anti-hypertensive drugs was pro-rich, with the 45 degree line dominating the concentration curve for ART. Conclusion: This study has shown there are inequities in the distribution of health care inputs across public primary care facilities. This highlights the need to ensure a better coordinated and equitable distribution of inputs through regular monitoring of the availability of health care inputs and strengthening of reporting systems. [ABSTRACT FROM AUTHOR]