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Background: Removing user fees in primary health care services is one of the most critical policy issues being considered in Africa. User fees were introduced in many African countries during the 1980s and their impacts are well documented. Concerns regarding the negative impacts of user fees have led to a recent shift in health financing debates in Africa. Kenya is one of the countries that have implemented a user fees reduction policy. Like in many other settings, the new policy was evaluated less that one year after implementation, the period when expected positive impacts are likely to be highest. This early evaluation showed that the policy was widely implemented, that levels of utilization increased and that it was popular among patients. Whether or not the positive impacts of user fees removal policies are sustained has hardly been explored. We conducted this study to document the extent to which primary health care facilities in Kenya continue to adhere to a 'new' charging policy 3 years after its implementation. Methods: Data were collected in two districts (Kwale and Makueni). Multiple methods of data collection were applied including a cross-sectional survey (n = 184 households Kwale; 141 Makueni), Focus Group Discussions (n = 12) and patient exit interviews (n = 175 Kwale; 184 Makueni). Results: Approximately one third of the survey respondents could not correctly state the recommended charges for dispensaries, while half did not know what the official charges for health centres were. Adherence to the policy was poor in both districts, but facilities in Makueni were more likely to adhere than those in Kwale. Only 4 facilities in Kwale adhered to the policy compared to 10 in Makueni. Drug shortage, declining revenue, poor policy design and implementation processes were the main reasons given for poor adherence to the policy. Conclusion: We conclude that reducing user fees in primary health care in Kenya is a policy on paper that is yet to be implemented fully. We recommend that caution be taken when deciding on how to reduce or abolish user fees and that all potential consequences are carefully considered. [ABSTRACT FROM AUTHOR]

Background: Around 18% of the population in Chile has disabilities. Evidence shows that this population has greater healthcare needs, yet they face barriers to accessing healthcare due to health system failures. This paper aims to assess the inclusion of people with disabilities in health policy documents and to explore the perceptions of key national stakeholders regarding the policy context, policy processes, and actors involved., Methods: A policy content analysis was conducted of 12 health policy documents using the EquiFrame framework, adapted to assess disability inclusion. Documents were reviewed and rated on their quality of commitment against 21 core concepts of human rights in the framework. Key national stakeholders (n = 15) were interviewed, and data were thematically analysed under the Walt and Gilson Policy Analysis Triangle, using NVivo R1., Results: Core human rights concepts of disability were mentioned at least once in nearly all health policy documents (92%). However, 50% had poor policy commitments for disability. Across policies, Prevention of health conditions was the main human rights concept reflected, while Privacy of information was the least referenced concept. Participants described a fragmented disability movement and health policy, related to a dominant biomedical model of disability. It appeared that disability was not prioritized in the health policy agenda, due to ineffective mainstreaming of disability by the Government and the limited influence and engagement of civil society in policy processes. Moreover, the limited existing policy framework on disability inclusion is not being implemented effectively. This implementation gap was attributed to lack of financing, leadership, and human resources, coupled with low monitoring of disability inclusion., Conclusions: Improvements are needed in both the development and implementation of disability-inclusive health policies in Chile, to support the achievement of the right to healthcare for people with disabilities and ensuring that the health system truly "leaves no one behind"., (© 2024. The Author(s).)

Addressing health inequity is a central component of the Sustainable Development Goals and a priority of the World Health Organization (WHO). WHO supports countries in strengthening their health information systems in order to better collect, analyze and report health inequality data. Improving information and research about health inequality is crucial to identify and address the inequalities that lead to poorer health outcomes. Building analytical capacities of individuals, particularly in low-resource areas, empowers them to build a stronger evidence-base, leading to more informed policy and programme decision-making. However, health inequality analysis requires a unique set of skills and knowledge. This paper describes three resources developed by WHO to support the analysis of inequality data by non-statistical users using Microsoft Excel, a widely used and accessible software programme. The resources include a practical eLearning course, which trains learners in the preparation and reporting of disaggregated data using Excel, an Excel workbook that takes users step-by-step through the calculation of 21 summary measures of health inequality, and a workbook that automatically calculates these measures with the user's disaggregated dataset. The utility of the resources is demonstrated through an empirical example. [ABSTRACT FROM AUTHOR]

Background: Health system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal. Methods: Our analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa's power cube and Long's actor interface analysis. Results: We observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs' and SCHMTs' capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents. Conclusion: Our findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required. [ABSTRACT FROM AUTHOR]

Background: This is the final of 10 papers that describe the implementation of the Expanded Census-Based, Impact-Oriented Approach (CBIO+) by Curamericas/Guatemala in the Cuchumatanes mountains of the Department of Huehuetenango and its effectiveness in improving the health and well-being of women and children in a population of 98,000 in three municipalities. The CBIO+ Approach consists of three components: the CBIO (Census-Based, Impact-Oriented) Approach, the Care Group Approach, and the Community Birthing Center Approach. Methods: Each of the preceding papers was summarized. An assessment was made regarding the degree to which the initial implementation research hypotheses were confirmed. The total field cost per capita for operation of the Project was calculated. An assessment of the cost-effectiveness of the Project was made based on the estimated impact of the Project, the number of lives saved, and the number of disability-adjusted life years averted. Results: The Project attained a number of notable achievements in terms of expanding the coverage of key maternal and child health interventions, improving the nutritional status of children, reducing the mortality of children and mothers, providing quality care for mothers at the Community Birthing Centers (Casas Maternas Rurales) that integrate traditional midwives (comadronas) into the care of women during childbirth at the birthing centers, as well as empowering women and building social capital in the communities. CBIO+ is an effective and affordable approach that is particularly notable for its capacity to engage communities in the process of improving the health of mothers and children. Overall, there is strong and consistent evidence in support of the research hypotheses. The findings did produce evidence of declines in under-5 and maternal mortality, but they were not as robust as had been hoped. Conclusion: CBIO+ is an approach that has been effective in engaging communities in the process of improving the health of their mothers and children and in reducing health inequities in this marginalized, difficult-to-reach population of Indigenous Maya people. The CBIO+ Approach is cost-effective and merits further development and broader application in Guatemala and beyond. [ABSTRACT FROM AUTHOR]

While the health of and healthcare use by migrants has received significant scholarly and policy attention in Australia, current debates highlight that a critical examination of the theoretical underpinnings of these inquiries and responses is needed. We conducted a systematic review and critical interpretive synthesis (CIS) to critically examine how the policy and scholarly literature conceptualises migrants' interactions with and experiences of the Australian health system. Guided by PRISMA, we searched for literature without imposing any limits. We also searched key State and Federal Government websites for relevant policy documents. Our initially broad inclusion criteria became refined as the CIS progressed. We prioritised the likely relevance and theoretical contribution of the papers to our inquiry over methodological quality. The CIS of 104 papers revealed that the Australian scholarly literature and policy documents consistently homogenise and reduce migrants according to an assumed, (1) cultural identity, (2) linguistic affiliation, and/or (3) broad geographic origin. Based on these three critiques and drawing on the theoretical literature, we propose a synthesising argument on how the Australian literature could better conceptualise migrants' experiences of the Australian health system. We contend that both research and policy should explicitly recognise and engage with the multifaceted and shifting ways that migrants define themselves, generally, and during their encounters with destination country health systems. Engagement with this notion is necessary for also understanding how aspects of migrants' identities are dynamically co-constructed during their interactions with the health system. These understandings have implications for improving the design and implementation of policies and programs directed at improving the responsiveness of Australia's health system to the needs and expectations of migrant communities specifically, and destination countries broadly. [ABSTRACT FROM AUTHOR]

The unifying theme of the papers in this series is a concern for understanding the everyday practice of governance in low- and middle-income country (LMIC) health systems. Rather than seeing governance as a normative health system goal addressed through the architecture and design of accountability and regulatory frameworks, these papers provide insights into the real-world decision-making of health policy and system actors. Their multiple, routine decisions translate policy intentions into practice -- and are filtered through relationships, underpinned by values and norms, influenced by organizational structures and resources, and embedded in historical and socio-political contexts. These decisions are also political acts -- in that they influence who accesses benefits and whose voices are heard in decision-making, reinforcing or challenging existing institutional exclusion and power inequalities. In other words, the everyday practice of governance has direct impacts on health system equity. The papers in the series address governance through diverse health policy and system issues, consider actors located at multiple levels of the system and draw on multi-disciplinary perspectives. They present detailed examination of experiences in a range of African and Indian settings, led by authors who live and work in these settings. The overall purpose of the papers in this series is thus to provide an empirical and embedded research perspective on governance and equity in health systems. [ABSTRACT FROM AUTHOR]

Background: Persons with albinism face challenges to their wellbeing, safety, and security, ranging from vision impairment and skin cancer to stigma and discrimination. In some regions, they also face human rights atrocities including mutilation and murder. Research on human rights and albinism is a relatively new field that has gained momentum since the United Nations appointment of an Independent Expert on the enjoyment of human rights by persons with albinism. In this paper, we present the results of a mixed methods study undertaken to identify priorities for research, advocacy, and policy on albinism and human rights., Methods: The first component was a synthesis of peer-reviewed and grey literatures at the nexus of albinism, spiritual/cultural beliefs and practices, and human rights. We then conducted a priority-setting survey, informed by Delphi methods, on extant knowledge-practice gaps and research, advocacy, and policy priorities. Inclusion criteria included demonstrated expertise in the field (e.g., peer-reviewed publications, funded research), membership on national or international associations, or advocacy (civil society organizations) of more than 2 years in albinism and human rights. Thereafter, we gathered leading researchers, policy-makers, and civil society stakeholders for a Roundtable to gain consensus on these priorities., Results: Access to skin and vision care, and education were not deemed high priority for research, likely because the evidence supporting the need for these is well established. However, they were priorities for advocacy and policy: what is needed is mobilization of this evidence through advocacy and implementation of such services (policy). Other social determinants of health (rurality, poverty, and gender equality) are present as subtext in the findings, more so than priorities for research, advocacy, or policy, despite their preponderance in the lives of persons with albinism. Research was prioritized on stigma and discrimination; advocacy; and witchcraft, but with some differentiation between Global North and Global South priorities. Priorities for research, advocacy, and policy vary in keeping with the explanatory frameworks at play, including how harmful practices and witchcraft are viewed., Conclusions: The lived experience of albinism is profoundly shaped by the social determinants of health (SDOH). Threats to the security and well-being of persons with albinism should be viewed through a human rights lens that encompasses the explanatory frameworks at play., (© 2023. The Author(s).)

Context: The COVID-19 pandemic has reignited a commitment from the health policy and health services research communities to rebuilding trust in healthcare and created a renewed appetite for measures of trust for system monitoring and evaluation. The aim of the present paper was to develop a multidimensional measure of trust in healthcare that: (1) Is responsive to the conceptual and methodological limitations of existing measures; (2) Can be used to identify systemic explanations for lower levels of trust in equity-deserving populations; (3) Can be used to design and evaluate interventions aiming to (re)build trust. Methods: We conducted a 2021 review of existing measures of trust in healthcare, 72 qualitative interviews (Aug-Dec 2021; oversampling for equity-deserving populations), an expert review consensus process (Oct 2021), and factor analyses and validation testing based on two waves of survey data (Nov 2021, n = 694; Jan-Feb 2022, n = 740 respectively). Findings: We present the Trust in Multidimensional Healthcare Systems Scale (TIMHSS); a 38-item correlated three-factor measure of trust in doctors, policies, and the system. Measurement of invariance tests suggest that the TIMHSS can also be reliably administered to diverse populations. Conclusions: This global measure of trust in healthcare can be used to measure trust over time at a population level, or used within specific subpopulations, to inform interventions to (re)build trust. It can also be used within a clinical setting to provide a stronger evidence base for associations between trust and therapeutic outcomes. [ABSTRACT FROM AUTHOR]

Background and objective: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. Methods: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca–Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. Results: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural–urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. Conclusions: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage. [ABSTRACT FROM AUTHOR]

Background: Gender equality remains an outstanding global priority, more than 25 years after the landmark Beijing Platform for Action. The disconnect between global health policy intentions and implementation is shaped by several conceptual, pragmatic and political factors, both globally and in South Africa. Actor narratives and different framings of gender and gender equality are one part of the contested nature of gender policy processes and their implementation challenges. The main aim of this paper is to foreground the range of policy actors, describe their narratives and different framings of gender, as part exploring the social construction of gender in policy processes, using the Adolescent Youth Health Policy (AYHP) as a case study. Methods: A case study design was undertaken, with conceptual underpinnings combined from gender studies, sociology and health policy analysis. Through purposive sampling, a range of actors were selected, including AYHP authors from government and academia, members of the AYHP Advisory Panel, youth representatives from the National Department of Health Adolescent and Youth Advisory Panel, as well as adolescent and youth health and gender policy actors, in government, academia and civil society. Qualitative data was collected via in-depth, semi-structured interviews with 30 policy actors between 2019 and 2021. Thematic data analysis was used, as well as triangulation across both respondents, and the document analysis of the AYHP. Results: Despite gender power relations and more gender-transformative approaches being discussed during the policy making process, these were not reflected in the final policy. Interviews revealed an interrelated constellation of diverse and juxtaposed actor gender narratives, ranging from framing gender as equating girls and women, gender as inclusion, gender as instrumental, gender as women's rights and empowerment and gender as power relations. Some of these narrative framings were dominant in the policy making process and were consequently included in the final policy document, unlike other narratives. The way gender is framed in policy processes is shaped by actor narratives, and these diverse and contested discursive constructions were shaped by the dynamic interactions with the South Africa context, and processes of the Adolescent Youth Health Policy. These varied actor narratives were further contextualised in terms of reflections of what is needed going forward to advance gender equality in adolescent and youth health policy and programming. This includes prioritising gender and intersectionality on the national agenda, implementing more gender-transformative programmes, as well as having the commitments and capabilities to take the work forward. Conclusions: The constellation of actors' gender narratives reveals overlapping and contested framings of gender and what is required to advance gender equality. Understanding actor narratives in policy processes contributes to bridging the disconnect between policy commitments and reality in advancing the gender equality agenda. [ABSTRACT FROM AUTHOR]

Introduction: International organisations have called to increase young people's involvement in healthcare and health policy development. We currently lack effective methods for facilitating meaningful engagement by young people in health-related decision-making. The purpose of this scoping review is to identify deliberative priority setting methods and explore the effectiveness of these in engaging young people in healthcare and health policy decision-making. Methods: Seven databases were searched systematically, using MeSH and free text terms, for articles published in English before July 2021 that described the use of deliberative priority setting methods for health decision-making with young people. All titles, abstracts and full-text papers were screened by a team of six independent reviewers between them. Data extraction followed the Centre for Reviews and Dissemination guidelines. The results are presented as a narrative synthesis, structured around four components for evaluating deliberative processes: 1) representation and inclusion of diverse participants, 2) the way the process is run including levels and timing of participant engagement, 3) the quality of the information provided to participants and 4) resulting outcomes and decisions. Findings: The search yielded 9 reviews and 21 studies. The more engaging deliberative priority setting tools involved young people-led committees, mixed methods for identifying and prioritising issues and digital data collection and communication tools. Long-term and frequent contact with young people to build trust underpinned the success of some of the tools, as did offering incentives for taking part and skills development using creative methods. The review also suggests that successful priority setting processes with young people involve consideration of power dynamics, since young people's decisions are likely to be made together with family members, health professionals and academics. Discussion: Young people's engagement in decision-making about their health is best achieved through investing time in building strong relationships and ensuring young people are appropriately rewarded for their time and contribution. If young people are to be instrumental in improving their health and architects of their own futures, decision-making processes need to respect young people's autonomy and agency. Our review suggests that methods of power-sharing with young people do exist but that they have yet to be adopted by organisations and global institutions setting global health policy. [ABSTRACT FROM AUTHOR]

While the terms 'sex' and 'gender' represent distinct concepts, their influence may intersect as important determinants of health. Despite their influence in shaping individual health outcomes, there is often inaccuracy and inconsistency in the degree to which sex and gender considerations are integrated in the health policymaking process. This primary aim of this paper is to fill the gap in the current understanding of how sex and gender considerations are integrated in this process. A scoping review methodology was used with the objective of assessing the extent to which sex and gender were considered inclusively and comprehensively in established examples of health policy planning and development. One hundred seventy-five documents from the academic and grey literature were found to meet the inclusion criteria for this scoping review. The authors charted the data from these publications, assessing the ways in which sex and gender were incorporated in their policy development process. Five key findings were ascertained from this review: (1) the terms sex and gender are often used interchangeably; (2) the terms sex and gender are often used with a limited and binary scope; (3) the most inclusive and comprehensive documents included transgender and gender diverse populations; (4) there are significant variations in the degree of inclusivity and comprehensivity of these documents based on geographic distribution; and (5) documents published within the last 5 years were more inclusive than older documents. This paper concludes with an acknowledgment of the limitations of the study design, a summary of the findings, future research directions, and implications for policymakers. [ABSTRACT FROM AUTHOR]

Background: There is a large and growing unmet need for rehabilitation - a diverse category of services that aim to improve functioning across the life course - particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries., Methods: We conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework., Results: The novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries' national government's health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies - particularly from civil conflict - and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility., Conclusions: This framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services., (© 2023. The Author(s).)

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., (© 2023. The Author(s).)

Introduction: Promoting health equity is a key goal of many public health systems. However, little is known about how equity is conceptualized in such systems, particularly as standards of public health practice are established. As part of a larger study examining the renewal of public health in two Canadian provinces, Ontario and British Columbia (BC), we undertook an analysis of relevant public health documents related to equity. The aim of this paper is to discuss how equity is considered within documents that outline standards for public health. Methods: A research team consisting of policymakers and academics identified key documents related to the public health renewal process in each province. The documents were analyzed using constant comparative analysis to identify key themes related to the conceptualization and integration of health equity as part of public health renewal in Ontario and BC. Documents were coded inductively with higher levels of abstraction achieved through multiple readings. Sets of questions were developed to guide the analysis throughout the process. Results: In both sets of provincial documents health inequities were defined in a similar fashion, as the consequence of unfair or unjust structural conditions. Reducing health inequities was an explicit goal of the public health renewal process. In Ontario, addressing "priority populations" was used as a proxy term for health equity and the focus was on existing programs. In BC, the incorporation of an equity lens enhanced the identification of health inequities, with a particular emphasis on the social determinants of health. In both, priority was given to reducing barriers to public health services and to forming partnerships with other sectors to reduce health inequities. Limits to the accountability of public health to reduce health inequities were identified in both provinces. Conclusion: This study contributes to understanding how health equity is conceptualized and incorporated into standards for local public health. As reflected in their policies, both provinces have embraced the importance of reducing health inequities. Both concepualized this process as rooted in structural injustices and the social determinants of health. Differences in the conceptualization of health equity likely reflect contextual influences on the public health renewal processes in each jurisdiction. [ABSTRACT FROM AUTHOR]

Background: Air pollution has been identified as related to the diseases of susceptible population, but the spatial heterogeneity of its economic burden and its determinants are rarely investigated. The issue is of great policy significance, especially after the epidemic of COVID-19, when human are facing the joint crisis of health and environment, and some areas is prone to falling into poverty. Methods: The geographical detector was adopted to study the spatial distribution characteristics of the incidence of catastrophic health expenditure (ICHE) for older adults in 100 rural areas in China at the prefecture-city level. The health factors, sociological factors, policy factors and environmental factors and their interactions are identified. Results: First, most health service factors had strong explanatory power for ICHE whether it interacts with air pollution. Second, 50 single-factor high-risk areas of ICHE were found in the study, but at the same time, there were 21 areas dominated by multiple factors. Conclusion: The different contributions and synergy among the factors constitute the complex mechanism of factors and catastrophic health expenditure. Moreover, during this process, air pollution aggravates the contribution of health service factors toward ICHE. In addition, the leading factors of ICHE are different among regions. At the end, this paper also puts forward some policy suggestions from the perspective of health and environment crisis in the post-COVID-19 world: environmental protection policies should be combined with the prevention of infectious diseases; advanced health investment is the most cost-effective policy for the inverse health sequences of air pollution and infectious diseases such as coronavirus disease 2019 (COVID-19); integrating environmental protection policy into healthy development policy, different regions take targeted measures to cope with the intertwined crisis. [ABSTRACT FROM AUTHOR]

Mental health is impacted by social, economic, and environmental factors, the Social Determinants of Health (SDH). Migrants experiencing precarious living and working conditions may be more at risk of poor mental health than the majority population. This paper aims to evaluate the relationship of educational attainment and other SDH with depressive symptoms among the resident population, including Italians and migrants. This study examined the respondents to the Italian "Progressi delle Aziende Sanitarie per la Salute in Italia" (PASSI) surveillance system, 2014–18. The sample of 144.055 respondents is composed of the resident working adults aged 25–69 with Italian citizenship (n = 136.514) and foreign citizenship (n = 7.491). Findings show that among Italians high level of education appears to be a protective factor for mental health, in accordance with the international evidence (adjPR: tertiary education 0,74 p-value = 0.000). However, among immigrants high level of education is associated with the presence of depressive symptoms (adjPR: tertiary education: 1.61 p-value = 0.006), particularly for men (adjPR: tertiary education: 2.40 p-value = 0.006). The longer the length of stay in Italy for immigrants the higher the risk of depressive symptoms: adjPR for 10+ years: 2.23 p-value = 0.005. The data show that high education could represent a risk factor for mental health of immigrants. Moreover, among migrants there are some significant mental health inequities between male and female related to the duration of stay in Italy, economic activity and educational level. Considering that health is related to the nature of society as well as to access to technical solutions, multicultural societies require culturally oriented interventions for tackling health inequities. This means developing evidence-based policies in order to tackle health inequalities in the population as a whole, including culturally oriented measures in the larger framework of developing diversity sensitive services. [ABSTRACT FROM AUTHOR]

Background: Given the persistence of Indigenous health inequities across national contexts, many countries have adopted strategies to improve the health of Indigenous peoples. Governmental recognition of the unique health needs of Indigenous populations is necessary for the development of targeted programs and policies to achieve universal health coverage. At the same time, the participation of Indigenous peoples in decision-making and program and policy design helps to ensure that barriers to health services are appropriately addressed and promotes the rights of Indigenous peoples to self-determination. Due to similar patterns of Indigenous health and health determinants across borders, there have been calls for greater global collaboration in this field. However, most international studies on Indigenous health policy link Anglo-settler democracies (Canada, Australia, Aotearoa/New Zealand and the United States), despite these countries representing a small fraction of the world's Indigenous people. Aim: This paper examines national-level policy in Australia, Brazil, Chile and New Zealand in relation to governmental recognition of differential Indigenous health needs and engagement with Indigenous peoples in health. The paper aims to examine how Indigenous health needs and engagement are addressed in national policy frameworks within each of the countries in order to contribute to the understanding of how to develop pro-equity policies within national health care systems. Methods: For each country, a review was undertaken of national policies and legislation to support engagement with, and participation of, Indigenous peoples in the identification of their health needs, development of programs and policies to address these needs and which demonstrate governmental recognition of differential Indigenous health needs. Government websites were searched as well as the following databases: Google, OpenGrey, CAB Direct, PubMed, Web of Science and WorldCat. Findings: Each of the four countries have adopted international agreements regarding the engagement of Indigenous peoples in health. However, there is significant variation in the extent to which the principles laid out in these agreements are reflected in national policy, legislation and practice. Brazil and New Zealand both have established national policies to facilitate engagement. In contrast, national policy to enable engagement is relatively lacking in Australia and Chile. Australia, Brazil and New Zealand each have significant initiatives and policy structures in place to address Indigenous health. However, in Brazil this is not necessarily reflected in practice and although New Zealand has national policies these have been recently reported as insufficient and, in fact, may be contributing to health inequity for Māori. In comparison to the other three countries, Chile has relatively few national initiatives or policies in place to support Indigenous engagement or recognise the distinct health needs of Indigenous communities. Conclusions: The adoption of international policy frameworks forms an important step in ensuring that Indigenous peoples are able to participate in the formation and implementation of health policy and programs. However, without the relevant principles being reflected in national legislature, international agreements hold little weight. At the same time, while a national legislative framework facilitates the engagement of Indigenous peoples, such policy may not necessarily translate into practice. Developing multi-level approaches that improve cohesion between international policy, national policy and practice in Indigenous engagement in health is therefore vital. Given that each of the four countries demonstrate strengths and weaknesses across this causal chain, cross-country policy examination provides guidance on strengthening these links. [ABSTRACT FROM AUTHOR]

This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programs – the relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we 'know' as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation. Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented? We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategy – its objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behavior are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies. [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: China now faces an increasingly aging society which may exert economic pressure in the long run. This study illustrates the spatial pattern and evolution of population aging and economic development in China. The coupling coordination degree of population aging and economic development at the national and provincial levels are calculated and demonstrated, and the spatial patterns and characteristics are investigated. Methods: This paper presents a coupling analysis of the elderly population rate (EPR) and per capita Gross Regional Product (GRPpc) in China by using the coupling and coordination model. Further, the spatial pattern and evolution of population aging and economic development are investigated based on the standard deviational ellipse. The collected data is at the level of provincial administrative units in mainland China covering the period 2002 to 2020. Results: The results reveal the spatial difference in the coupling and coordination degree between EPR and GRPpc across provinces. The eastern coastal areas are higher than the central and western regions of China. The orientation and directions of EPR are more than GRPpc, indicating that the polarization in population aging is more severe than economic development. Significant positive correlations between coupling coordination degree and sustainable competitiveness are detected. Conclusions: Policymakers should fully consider regional differences and sustainable development in policy formulation of China. The western and northeastern provinces should be given priority in the regional sustainable development plan. At the same time, the coordination between population aging and economic development also requires to be examined especially. [ABSTRACT FROM AUTHOR]

Background: Since 1968, China has trained about 1.5 million barefoot doctors in a few years' time to provide basic health services to 0.8 billion rural population. China's Ministry of Health stopped using the term of barefoot doctor in 1985, and changed policy to develop village doctors. Since then, village doctors have kept on playing an irreplaceable role in China's rural health, even though the number of village doctors has fluctuated over the years and they face serious challenges. United Nations declared Sustainable Development Goals in 2015 to achieve universal health coverage by 2030. Under this context, development of Community Health workers (CHWs) has become an emerging policy priority in many resource-poor developing countries. China's experiences and lessons learnt in developing and maintaining village doctors may be useful for these developing countries. Methods: This paper aims to synthesis lessons learnt from the Chinese CHW experiences. It summarizes China's experiences in exploring and using strategic partnership between the community and the formal health system to develop CHWs in the two stages, the barefoot doctor stage (1968-1985) and the village doctor stage (1985-now). Chinese and English literature were searched from PubMed, CNKI and Wanfang. The information extracted from the selected articles were synthesized according to the four partnership strategies for communities and health system to support CHW development, namely 1) joint ownership and design of CHW programmes; 2) collaborative supervision and constructive feedback; 3) a balanced package of incentives, both financial and non-financial; and 4) a practical monitoring system incorporating data from the health system and community. Results: The study found that the townships and villages provided an institutional basis for barefoot doctor policy, while the formal health system, including urban hospitals, county health schools, township health centers, and mobile medical teams provided training to the barefoot doctors. But After 1985, the formal health system played a more dominant role in the CHW system including both selection and training of village doctors. China applied various mechanisms to compensate village doctors in different stages. During 1960s and 1970s, the main income source of barefoot doctors was from their villages' collective economy. After 1985 when the rural collective economy collapsed and barefoot doctors were transformed to village doctors, they depended on user fees, especially from drug sale revenues. In the new century, especially after the new round of health system reform in 2009, government subsidy has become an increasing source of village doctors' income. Conclusion: The barefoot doctor policy has played a significant role in providing basic human resources for health and basic health services to rural populations when rural area had great shortages of health resources. The key experiences for this great achievement are the intersection between the community and the formal health system, and sustained and stable financial compensation to the community health workers. [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., (© 2021. The Author(s).)

Background: During the first decade of the current century, Latin American countries have shown high and consistent economic growth rates, increasing per capita GDP and reducing poverty. Social indicators improved in even the poorest and least equitable countries in the region. In terms of health care results, marked advances were made in infant mortality rates. Objective: The aim of this paper is to identify if decreasing poverty rates in Latin America and the Caribbean during the first decade of the century have had an effect on health inequality, specifically by reducing the health care equity gap and, if so, whether that trend and its effects were distributed evenly at the sub-national level. Methods: Basic statistical tools were applied to national and sub-national administrative data for eleven Latin American countries (Argentina, Belize, Bolivia, Brazil, Colombia, Dominican Republic, El Salvador, Mexico, Nicaragua, Peru, and Uruguay) to compare the evolution of a set of social determinants with a classic health care outcome, such infant mortality) during the period 1995–2012. This document proposes a set of indicators to analyze relative evolution of results and convergence to equity, and to discuss general trends in health care reforms across the region. Results: The document shows a correspondence between poverty reduction, and improvement of health care indicators at a regional level, though national differences persist. In some cases, like Brazil and Peru, the reduction in infant mortality rates is coupled with significant movements towards health equity. This trend is different in Bolivia, where the drop in poverty is not followed by better outcomes in poor departments. At the same, results are not necessarily linked to health systems organization and/or specific reforms. For instance, both Brazil and Peru pursue in applying decentralized solutions, although the incentive mechanisms are quite different: the former has a supply side structure at the public provision level while the latter has implemented mixed payment systems. Conclusion: While some of the same instruments and measures of effectiveness in health care reforms appear across the region, specific impact evaluations should be performed. To reduce the equity gap in Latin America requires not only major improvements in social determinants but also the design and implementation of sound institutional policy and more robust regulatory frameworks (institutional determinants) so that more resources yield better practices. [ABSTRACT FROM AUTHOR]

Background: Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers' access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods: We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results: Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models. Conclusion: ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies. [ABSTRACT FROM AUTHOR]

Background: Historically, lesbian, gay, bisexual, transgender and queer (LGBTQ) health research has focused heavily on the risks for poor health outcomes, obscuring the ways in which LGBTQ populations maintain and improve their health across the life course. In this paper we argue that informing culturally competent health policy and systems requires shifting the LGBTQ health research evidence base away from deficit-focused approaches toward strengths-based approaches to understanding and measuring LGBTQ health. Methods: We recently conducted a scoping review with the aim of exploring strengths-based approaches to LGBTQ health research. Our team found that the concept of resilience emerged as a key conceptual framework. This paper discusses a subset of our scoping review findings on the utility of resilience as a conceptual framework in understanding and measuring LGBTQ health. Results: The findings of our scoping review suggest that the ways in which resilience is defined and measured in relation to LGBTQ populations remains contested. Given that LGBTQ populations have unique lived experiences of adversity and discrimination, and may also have unique factors that contribute to their resilience, the utility of heteronormative and cis-normative models of resilience is questionable. Our findings suggest that there is a need to consider further exploration and development of LGBTQ-specific models and measures of resilience that take into account structural, social, and individual determinants of health and incorporate an intersectional lens. Conclusions: While we fully acknowledge that the resilience of LGBTQ populations is central to advancing LGBTQ health, there remains much work to be done before the concept of resilience can be truly useful in measuring LGBTQ health. [ABSTRACT FROM AUTHOR]

Background: Spurred by the WHO's endorsement of universal health coverage as a goal of all health systems, many countries are undertaking health financing reforms. The nature of these reforms, and the policy processes by which they are achieved, will depend on context-specific factors, including the history of reform efforts and the political imperatives driving reforms. South Africa's pursuit of universal health coverage through a National Health Insurance is the latest in a nearly 100-year history of health system reform efforts shaped by social and political realities. Methods: We conducted an interdisciplinary, retrospective literature review to explore how these reform efforts have unfolded, and been shaped by the contextual realities of the moment. We began the review by identifying peer-reviewed literature on health system reform in South Africa, and iteratively expanded the search through author tracking, citation tracking and purposeful searches for material on particular events or processes referenced in the initial body of evidence. Data was extracted and organised chronologically into nine periods. Results: The analysis suggests that in South Africa politics; the power of the private sector; competing policy priorities and budgetary constraints; and ideas, values and ideologies have been particularly important in constraining, and sometimes spurring, health system reform efforts. Political transitions and pressures - including the introduction of apartheid in 1948, anti-apartheid opposition, the transition to democracy, and corruption and governance failures - have alternately created political imperatives for reform, and constrained reform efforts. In addition, the country's political history has given rise to dominant ideas, values and ideologies that imbue health system reform with a particular social meaning. While these ideas and values increase opposition and complicate reform efforts, they also help to expose the inequities of the current system as problematic and re-emphasise the need for reform. Conclusion: Ultimately, this analysis demonstrates the context-specific nature of health system reform processes and the influence of history on what sorts of reforms are politically feasible and socially acceptable, even in the context of a global push for universal health coverage. [ABSTRACT FROM AUTHOR]

Introduction: Reduction in health inequalities and providing universal access to health care have been identified as two important global milestones by the World Health Organization for countries to achieve by 2030. Therefore, recognizing the magnitude of oral health inequalities in India has become a pressing priority to improve access to dental care within the country. This scoping review was conducted with the aim of reviewing, collating and analysing the current knowledge base on oral health inequalities in India. Methodology: The scoping review followed Arksey and O'Malley's approach, and reporting was performed in accordance with the PRISMA-ScR guidelines. A systematic search was conducted on Scopus, PubMed, Web of Science, and EMBASE to identify literature addressing one or more dimensions of oral health inequalities in India, published in English between January 2002 and April 2022. The data were charted, and qualitative analysis was performed to derive themes, highlighting the key concepts emerging from this review. Results: In accordance with the eligibility criteria, a total of 71 articles retrieved through database search and backward citation search were included in this scoping review. The major themes ranged from individual to diverse sociodemographic factors acting as barriers to and facilitators of access to dental care. Deficiencies in human resources for oral health, along with a wide diversity in dental service provision and dental education were other major themes contributing to inequality. Subsequently, this has resulted in recommendations on restructuring the dental workforce and their development and modifications in oral health care policies and practices. The qualitative synthesis demonstrates the intertwined nature of the multiple factors that influence the goal of achieving an affordable, accessible, extensive and inclusive oral healthcare system in India. Conclusions: This comprehensive review provides a broad perspective on oral health inequalities in India, providing valuable insights for both researchers and policymakers in this area and guiding their efforts towards achieving universal oral health coverage in the Indian context. [ABSTRACT FROM AUTHOR]

This paper focuses on the particular challenges in cancer prevention and control (CPC) in low- and middle-income countries (LMICs). In particular, this paper extrapolates challenges and opportunities in Armenia, which has the 2nd highest rate of cancer-related deaths in the world, the 11th highest smoking prevalence among men globally, and an evolving health system infrastructure for non-communicable disease (NCD) prevention and control, including CPC. Despite significant progress in enhancing research capacity in Armenia over the past decade, additional efforts are needed, particularly in CPC-related research. Key opportunities are to advance tobacco control and utilization of mHealth. Public health training programs remain insufficient in the area of CPC, and in-country research expertise regarding CPC and related areas (e.g., tobacco control, mHealth, policy) is limited, particularly given the need to address the diverse and complex determinants of onset, prevention, and management of cancer. Moreover, critical gaps in research dissemination and knowledge translation from evidence to policy and practice continue to exist. Thus, public health infrastructure must be enhanced, in-country CPC leaders across various relevant disciplines must be further developed and supported, and medical and public health training must more fully integrate CPC and research dissemination and translation to inform policy and practice.

Background: The process of medical tariffs setting in Iran remains to be a contentious issue and is heavily criticized by many stakeholders. This paper explores the experience of setting health care services tariffs in the Iranian health care system over the last five decades., Methods: We analyzed data collected through literature review and reviews of the official documents developed at the various levels of the Iranian health system using inductive and deductive content analysis. Twenty-two face-to-face semi-structured interviews supplemented the analysis. Data were analysed and interpreted using 'policy triangle' and 'garbage can' models., Results: Our comprehensive review of changes in the medical tariff setting provides valuable lessons for major stakeholders. Most changes were implemented in a sporadic, inadequate, and a non-evidence-based manner. Disparities in tariffs between public and private sectors continue to exist. Lack of clarity in tariffs setting mechanisms and its process makes negotiations between various stakeholders difficult and can potentially become a source of a corrupt income. Such clarity can be achieved by using fair and technically sound tariffs. Technical aspects of tariff setting should be separated from the political negotiations over the overall payment to the medical professionals. Transparency regarding a conflict of interest and establishing punitive measures against those violating the rules could help improving trust in the doctor-patient relationship., Conclusion: Use of evidence-informed models and methods in medical tariff setting could help to strike the right balance in the process of health care services provision to address health system objectives. A sensitive application of policy models can offer significant insights into the nature of medical tariff setting and highlight existing constraints and opportunities. This study generates lessons learned in tariffs setting, particularly for low- and middle-income countries.

This editorial provides an overview of a thematic series that brings attention to the persistently deficient and unequal access to sexual and reproductive health services for young women in sub-Saharan Africa. It represents an effort to analyze the multifaceted relationship between laws, policies and access to services in Ethiopia, Zambia and Tanzania. Using a comparative perspective and qualitative research methodology, the papers presented in this issue explore legal, political and social factors and circumstances that condition access to sexual and reproductive health services within and across the three countries. Through these examples we show the often inconsistent and even paradoxical relationship between the formal law and practices on the ground. Particular emphasis is placed on safe abortion services as an intensely politicized issue in global sexual and reproductive health. In addition to the presentation of the individual papers, this editorial comments on the global politics of abortion which represents a critical context for the regional and local developments in sexual and reproductive health policy and care provision in general, and for the contentious issue of abortion in particular.

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: Implementation Research (IR) in and around health systems comes with unique challenges for researchers including implementation, multi-layer governance, and ethical issues. Partnerships between researchers, implementers, policy makers and community members are central to IR and come with additional challenges. In this paper, we elaborate on the challenges faced by frontline field researchers, drawing from experience with an IR study on Village Health Sanitation and Nutrition Committees (VHSNCs). Methods: The IR on VHSNC took place in one state/province in India over an 18-month research period. The IR study had twin components; intervention and in-depth research. The intervention sought to strengthen the VHSNC functioning, and concurrently the research arm sought to understand the contextual factors, pathways and mechanism affecting VHSNC functions. Frontline researchers were employed for data collection and a research assistant was living in the study sites. The frontline research assistant experienced a range of challenges, while collecting data from the study sites, which were documented as field memos and analysed using inductive content analysis approach. Results: Due to the relational nature of IR, the challenges coalesced around two sets of relationships (a) between the community and frontline researchers and (b) between implementers and frontline researchers. In the community, the frontline researcher was viewed as the supervisor of the intervention and was perceived by the community to have power to bring about beneficial changes with public services and facilities. Implementers expected help from the frontline researcher in problem-solving in VHSNCs, and feedback on community mobilization to improve their approaches. A concerted effort was undertaken by the whole research team to clarify and dispel concerns among the community and implementers through careful and constant communication. The strategies employed were both managerial, relational and reflexive in nature. Conclusion: Frontline researchers through their experiences shape the research process and its outcome and they play a central role in the research. It demonstrates that frontline researcher resilience is very crucial when conducting health policy and systems research. [ABSTRACT FROM AUTHOR]

Background: Equity and justice in healthcare payment form an integral part of health policy and planning. In the majority of low and middle-income countries (LMICs), healthcare inequalities are further aggravated by Out of Pocket Expenditure (OOPE). This paper examines the pattern of health equity and regional disparities in healthcare spending among Indian states by applying Andersen's behavioural model of healthcare utilization. Methods: The present study uses data from the 66th quinquennial round of Consumer Expenditure Survey, of the National Sample Survey Organization (NSSO), conducted in 2009-10 by Ministry of Statistics and Programme Implementation (MoSPI), Government of India (GoI). To measure equity and regional disparities in healthcare expenditure, states have been categorized under three heads on the basis of monthly OOPE i.e., Category A (OOPE > =INR 100); Category B (OOPE between INR 50 to 99) and Category C (OOPE < INR 50). Multiple Generalised Linear Regression Model (GLRM) has been employed to explore the effect of various socio-economic covariates on the level of OOPE. Results: The gap in the ratio of average healthcare spending between the poorest and richest households was maximum in Category A states Category B (richest/poorest = 14.60), followed by (richest/poorest 11.70) and Category C (richest/poorest 11.40). Results also indicate geographical concentration of lower level healthcare spending among Indian states (e.g., Odisha, Chhattisgarh and all the north-eastern states). Results from the multivariate analysis suggest that people residing in urban areas, having higher economic status, belonging to non-Muslim communities, non-Scheduled Tribes (STs), and non-poor households spend more on healthcare than their counterparts. Conclusions: In spite of various efforts by the government to reduce the burden of healthcare spending, widespread inequalities in healthcare expenditure are prevalent. Households with high healthcare needs (SCs/STs, and the poor) are in a more disadvantaged position in terms of spending on health care. It has also been observed that spending on healthcare was comparatively lower among backward or isolated states. No doubt, the overall social security measures should be enhanced, but at the same time, looking at the regional differences, more priority should be assigned to the disadvantaged states to reduce the burden of OOPE. It is proposed that there is need to increase government spending, especially for the disadvantaged states and population, to minimise the burden of OOPE. [ABSTRACT FROM AUTHOR]

Introduction: Non communicable diseases are the biggest cause of death worldwide. Beside mortality, these diseases also cause high rates of morbidity and disability. Their high prevalence is generally associated to multi-morbidity. Because they need costly prolonged treatment and care, non communicable diseases have social and economical consequences that affect individuals, households and the whole society. They raise the equity problem between and within countries. Methods and limitations: This annotated bibliography is a systematic review on multimorbidy of non communicable diseases and health equity in WHO Eastern Mediterranean countries. Medline/PubMed, EMBASE and other sources were used to get peer reviewed papers dealing with the review theme. The words/strings used for search and inclusion criteria were: multimorbidity, comorbidity, equity, non communicable diseases, chronic diseases, WHO Eastern Mediterranean and Arab countries. Bibliography with annotations: According to the inclusion criteria, 26 papers were included in the present review. Generally, lack or paucity of publications was encountered in themes like headache, cancer and respiratory diseases. Of the 26 contributions selected, twelve dealt with comorbidity of depression and mental disorders with other chronic diseases. Another set of 11 publications was devoted to multimorbidity of diabetes, cardiovascular diseases (CVDs), hypertension, metabolic syndrome and obesity. Considering association of multimorbidity and social determinants, this review shows that female gender, low income, low level of education, old age and unemployed/retired are the most exposed to multimorbidity. It should also be stressed that, geographically, no contribution was issued from North African countries. Non communicable diseases are one of the biggest challenges facing health decision makers in WHO Eastern Mediterranean countries where the multidimensional transition is boosting increases in multimorbidity of depression and mental diseases, cardiovascular diseases, diabetes, cancer and respiratory diseases among the whole population but with the highest burden among the least disadvantaged individuals or subpopulations. Health ministries in WHO Eastern Mediterranean countries should pay a particular attention to the association between equity and multimorbidity and opt for cost effective strategies based on early diagnosis and sensitisation for healthy diet, physical activity, no smoking and no alcohol. [ABSTRACT FROM AUTHOR]

Introduction: At the turn of the century, when the Millennium Development Goals placed maternal mortality reduction high on the global agenda, Ethiopia relaxed its restrictive abortion law to expand grounds on which a woman could legally obtain an abortion. This radical policy shift took place within a context of predominant anti-abortion public opinion shaped by strong religious convictions. Drawing upon Walt and Gilson's policy analysis framework, this paper explores the tension between public policy and religious dogma for the strategies chosen by the Ethiopian Ministry of Health and its partners implementing the new policy, and for access to safe abortion services., Methods: The study employed a qualitative research methodology. It targeted organizations that are key stakeholders in the field of reproductive health. These included policy makers and policy implementers like ministries, UN agencies and international and national NGOs as well as religious organizations as key opinion leaders. The data collection took place in Addis Ababa between 2016 and 2018. A total of 26 interviews were conducted, transcribed, and analyzed using the principles of qualitative content analysis., Results: Our analysis showed that the implementing organizations adopted a strategy of silence not to provoke anti-abortion sentiments and politicization of the abortion issue which was seen as a threat to the revised law and policy. This strategy has facilitated a rollout of services and has improved access to safe abortion care. Nevertheless informants were concerned that the silence strategy has prevented dissemination of knowledge about the revised law to the general public, to health workers and to the police. In turn this has caused confusion about eligibility to legal and safe abortion procedures., Conclusions: While silence as a strategy works to protect the law enhancing the health and survival of young women, it may at the same time prevent the law from being fully effective. As a long term strategy, silence fails to expand awareness and access to safe abortion services, and may not sufficiently serve to fulfill the potential of the law to prevent abortion related maternal deaths.

Background: Unsafe abortion continues to be a major hazard for maternal health in Sub-Saharan Africa, where abortion remains highly controversial and access to safe abortion services is unequally distributed. Although national abortion laws are central in indicating women's potential for accessing safe abortion services, the character of an abortion law may alone say little about national discursive abortion landscapes and access scenarios. The article calls for the study and problematization of the relationship between legal abortion frameworks on the one hand, and discourses surrounding abortion on the other, in an attempt to move closer to an understanding of the complexity of factors that influence knowledge about and access to safer abortion services. With the restrictive abortion law in Tanzania as a starting point, the paper explores the ways in which the major global abortion discourses manifest themselves in the country and indicate potential implications of a hybrid abortion regime., Methods: The study combined a review of major legal and policy documents on abortion, a review of publications on abortion in Tanzanian newspapers between 2000 and 2015 (300 articles), and 23 semi-structured qualitative interviews with representatives from central institutions and organizations engaged in policy- or practical work related to reproductive health., Results: Tanzania's abortion law is highly restrictive, but the discursive abortion landscape is diverse and is made manifest through legal- and policy documents and legal- and policy related disputes. The discourses were characterized by diverse frames of reference based in religion, public health and in human rights-based values, and as such reflect the major global discourses. Fairclough's concepts interdiscursivity and recontextualization were drawn upon to develop an understanding of how the concepts health, rights and life emerge across the discourses, but are employed in contrasting lines of argumentation in struggles for hegemony and legitimacy., Discussion and Conclusions: The paper demonstrates that a hybrid discursive regime relating to abortion characterizes the legally restrictive abortion context of Tanzania. We argue that such a complex discursive landscape, which cuts across the restrictive - liberal divide, generates an environment that seems to open avenues for enhanced access to abortion related knowledge and services.

Introduction: Unsafe abortion is a major contributor to the continued high global maternal mortality and morbidity rates. Legal abortion frameworks and access to sexuality education and contraception have been pointed out as vital to reduce unsafe abortion rates. This paper explores the relationship between abortion law, policy and women's access to safe abortion services within the different legal and political contexts of Ethiopia, Tanzania and Zambia. The research is inspired by recent calls for contextualized policy research., Methods: The research was based in Addis Ababa (Ethiopa), Dar es Salaam (Tanzania) and Lusaka (Zambia) and had a qualitative exploratory research design. The project involved studying the three countries' abortion laws and policies. It moreover targeted formal organizations as implementers of policy as well as stakeholders in support of, or in opposition to the existing abortion laws. Semi-structured interviews were carried out with study participants (79) differently situated vis-à-vis abortion, exploring their views on abortion-related legal- and policy frames and their perceived implications for access., Results: The abortion laws have been classified as 'liberal' in Zambia, 'semi-liberal' in Ethiopia and 'restrictive' in Tanzania, but what we encountered in the three study contexts was a seeming paradoxical relationship between national abortion laws, abortion policy and women's actual access to safe abortion services. The study findings moreover reveal that the texts that make up the three national abortion laws are highly ambiguous. The on-paper liberal Zambian and semi-liberal Ethiopian laws in no way ensure access, while the strict Tanzanian law is hardly sufficient to prevent young women from seeking and obtaining abortion. In line with Walt and Gilson's call to move beyond a narrow focus on the content of policy, our study demonstrates that the connection between law, health policy and access to health services is complex and critically dependent on the socio-economic and political context of implementation., Conclusions: Legal frameworks are vital instruments for securing the right to health, but broad contextualized studies rather than classifications of law along a liberal-restrictive continuum are demanded in order to enhance existing knowledge on access to safe abortion services in a given context.

Introduction: The Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds, but access to safe abortion services is limited and this constitutes a considerable problem for rights to sexual and reproductive health. The case of Zambia provides an opportunity to explore the relationship between a legal framework that permits abortion on diverse grounds, the moral and political disputes around abortion and access to sexual and reproductive health services., Methods: This paper draws upon eleven months of ethnographic fieldwork in Zambia. The fieldwork included 28 open-ended interviews with key stakeholders as well as the collection of archival material related to the origins of Zambia's legal framework for abortion. The archival material and the interview data were analyzed thematically, using theoretical perspectives on discourse and the anthropology of policies., Results: The study findings show that the Zambian case is not easily placed into standard categories of liberal or restrictive abortion laws. The archival material reveals that restrictive elements were in focus when the Zambian Termination of Pregnancy Act was passed (1972). The restrictive aspects of the law were emphasized further when Zambia was later declared as a Christian nation. Some of these restrictive elements are still readily recognized in today's abortion debate. Currently there are multiple opinions on whether Zambian abortion policy is liberal, restrictive or neither. The law emerges as ambiguous, and this ambiguity is actively used by both those working to increase access to safe and legal abortion services, and those who work to limit such access. Coupled with a lack of knowledge about the law, its ambiguity may work to reduce access to safe abortion services on the grounds permitted by the law., Conclusions: We argue that the Zambian Termination of Pregnancy Act is ambiguous and leaves much room for interpretation. This paper challenges the notion that the Zambian abortion law is liberal and opens up for further discussion on the relationship between how a law is described and perceived by the public, and the rights to health and services ensured by it.

Retrenchment of government services has occurred across a wide range of sectors and regions. Care services, in particular, have been clawed away in the wake of fiscal policies of cost containment and neoliberal policies centred on individual responsibility and market autonomy. Such policies have included the deinstitutionalisation of care from hospitals and clinics, and early discharge from hospital, both of which are predicated on the notion that care can be provided informally within families and communities. In this paper we examine the post-birth "care crisis" that new mothers face in one region of Canada. Method: The data are drawn from a larger study of social determinants of pregnant and new mothers' health in Victoria, Canada. Mixed methods interviews were conducted among a purposive sample of women at three points in time. This paper reports data on sample characteristics, length of stay in hospital and health service gaps. This data is contextualised via a more in-depth analysis of qualitative responses from Wave 2 (4-6 weeks postpartum). Results: Out results show a significant portion of participants desired services that were not publically available to them during the post-birth period. Among those who reported a gap in care, the two most common barriers were: cost and unavailability of home care supports. Participants' open-ended responses revealed many positive features of the public health care system but also gaps in services, and economic barriers to receiving the care they wanted. The implications of these findings are discussed in relation to recent neoliberal reforms. Discussion & conclusions: While Canada may be praised for its public provision of maternity care, mothers' reports of gaps in care during the early postpartum period and increasing use of private doulas is a worrying trend. To the extent that individual mothers or families rely on the market for care provision, issues of equity and quality of care are pivotal. This paper concludes with suggestions for further research on the impact of recent changes in post-birth care on new fathers and on inequities in pre and post-birth care in less-resourced regions of the world. [ABSTRACT FROM AUTHOR]

Objectives: The function of pooling and the ways that countries organize this is critical for countries' progress towards universal health coverage, but its potential as a policy instrument has not received much attention. We provide a simple classification of country pooling arrangements and discuss the specific ways that fragmentation manifests in each and the typical challenges with respect to universal health coverage objectives associated. This can help countries assess their pooling setup and contribute to identifying policy options to address fragmentation or mitigate its consequences. Methods: The paper is based on a review of published and grey literature in PubMed, Google and Google Scholar and our information gathered from our professional work in countries on health financing policies. We examined the nature and structure of pooling in more than 100 countries across all income groups to develop the classification. Findings: We propose eight broad types of pooling arrangements: (1.) a single pool; (2.) territorially distinct pools; (3.) territorially overlapping pools in terms of service and population coverage; (4.) different pools for different socio-economic groups with population segmentation; (5.) different pools for different population groups, with explicit coverage for all; (6.) multiple competing pools with risk adjustment across the pools; and in combination with types (1.)-(6.), (7.) fragmented systems with voluntary health insurance, duplicating publicly financed coverage; and (8.) complementary or supplementary voluntary health insurance. However, we recognize that any classification is a simplification of reality and does not substitute for a country-specific analysis of pooling arrangements. Conclusion: Pooling arrangements set the potential for redistributive health spending. The extent to which the potential redistributive and efficiency gains established by a particular pooling arrangement are realized in practice depends on its interaction and alignment with the other health financing functions of revenue raising and purchasing, including the links between pools and the service benefits and populations they cover. [ABSTRACT FROM AUTHOR]

Background: The cost of cancer drugs presents a significant challenge to accessibility of treatment worldwide. Projections indicate that by 2040, two-thirds of cancer cases will occur in low- and middle- income countries. Paradoxically, despite this impending burden, LMICs command less than 5% share of global resources for treating cancer. Morocco, like many LMICs, faces significant obstacles in providing innovative cancer treatments to its population. Aim: Firstly, we aimed to conduct an original research investigating the availability and affordability of innovative cancer drugs in Morocco. Secondly, we sought to review the broader market dynamics, pricing, and reimbursement policies in the country. Methods: For the first objective, we identified a preliminary list of medicines approved for oncological indications in the Moroccan market based on resources from ANAM (National Agency for Health Insurance), pharmacy regulators, and online resources that compile information on approved medicines. For the second objective, we exhaustively reviewed the regulatory documents, legal texts and grey literature reports. All the informations were examined by pharma delegates and local experts. Results: As of January 2024, Morocco has 39 innovative anticancer medicines with market authorization. 30% of these drugs were approved after 2020. The majority of approved drugs were for breast, lung, colorectal, and prostate cancer. The period between FDA approval and entry into the Moroccan market ranges from 2 to 7 years, with a median of 3 years for breast cancer drugs and 7 years for more expensive drugs like Olaparib and Osimertinib. 22 out of the 39 drugs are not reimbursed, with an average reimbursement time of 4 years. Compared to prices in France, the most notable pricing disparities concern immunotherapy agents, priced 600 to 900 euros lower in France, while drugs like Pazopanib and Erlotinib cost 50% less in Morocco. Conclusion: Our study reveals significant disparities in the availability and affordability of innovative cancer drugs in Morocco. Regulatory hurdles, importation challenges, and pricing strategies contribute to this inequitable landscape. Addressing systemic barriers, fostering collaborations between stakeholders, and adopting a value-based pricing approach are imperative steps toward ensuring equitable access to high-quality interventions for patients, regardless of their geographical location. [ABSTRACT FROM AUTHOR]

Health inequalities continue to exacerbate in the European Region, this underlines the need to strengthen the equity impact of public health policies. Nurses and midwives, professional groups that account for 61.8% of the practicing health professionals, work at the point of care, interdisciplinary and see the effects of health inequalities in their everyday work supporting communities and the environment where they are born, live, work and age. The government chief nursing and midwifery officer (GCNMOs) influence, provide policy advice and lead health systems planning and delivery of services. Further to this, it is increasingly being document that they participate in public health policy and inspire others to commit to the implementation of a new vision to strengthen equity impact on population health outcomes. In 2023, a series of discussions with GCNMOs, multidisciplinary researchers and experts, representing 35 of 53 countries in the WHO European Region explored the implications as to how GCNMOs can contribute to addressing the social determinants of health inequalities. Based on this dialogue, we provide a proposal of public health actions for health equity that will benefit from GCNMOs in delivering co-benefits for better health and inclusive growth. These actions can include equity-responsive health systems and health promotion, universal social protection, secure employment and healthy working conditions, environmental protection, education, decent housing, or urban planning among others. Unless governments facilitate the process where GCNMOs have clear mandates, sufficient authority, recognition, and support to engage in policy advocacy, governments will miss out on building fairer and healthier societies that are truly intersectoral and collaborative. [ABSTRACT FROM AUTHOR]

There are increased sector-wide efforts within health and social care systems to engage those with lived experience in service design, delivery, and monitoring – aiming to secure more equitable health outcomes. However, critical knowledge gaps persist around how national whole-system engagement strategies can account for the challenges experienced by populations that encounter exclusion within complex multi-layered systems. This includes a failure to delineate shared challenges across groups, and to develop transferable cross-group frameworks to assist sector-wide change. There is, therefore, a danger that those groups already least heard will be collectively left behind. With a view to informing a more inclusive engagement strategy in Ireland, this national study aims to investigate multi-level (policy and strategic, operational, on-the-ground services, individual) shared challenges impacting engagement for five populations who have been identified as underserved groups in a complex health and social care system, including: (1) those who misuse drugs and alcohol, (2) those who are experiencing homelessness, (3) those experiencing mental health, (4) migrants and those of minority ethnicies, and (5) Irish Travellers. Adopting a mixed-methods approach which draws on an evidence-informed multistakeholder perspective, this study employs data from: focus groups and life-course interviews with lived-experience populations (n=136), five focus groups (n=39) and a national on-line survey (n=320) with population-specific services providers; and national-level stakeholder interviews (n=9). Two cross-group participatory consultative forums with lived-experience and provider participants (n=28) were used to co-produce priority action areas based on study findings. This article presents findings on shared challenges in engaging these groups around leadership and commitment, implementation and action, population capacities, trust, and representation, stigma, and discrimination. Derived from these challenges, six development areas are presented to advance an inclusive equitable engagement approach in Ireland. These comprise: 1) balancing top-down prioritisation, and bottom-up direction; 2) sustaining multi-level, multi-form implementation; 3) measuring effectiveness and action; 4) embedding inclusive equitable engagement; 5) trust as a prerequisite, and outcome; and 6) an equalising, agency empowering agenda. [ABSTRACT FROM AUTHOR]

Background: Access of all people to the healthcare they need, without financial hardship is the goal of Universal Health Coverage (UHC). As UHC initiatives expand, assessing the needs of vulnerable populations can reveal gaps in the system which may be covered by relevant policies. In this study we (i) identify the met and unmet primary healthcare needs of the poorest population of Khyber Pakhtunkhwa province (KP), Pakistan, and (ii) explore why the gaps exist. Methods: We used Leveque's Framework of Patient-centred Access to Healthcare to examine unmet primary healthcare (PHC) needs and their underlying causes for the poorest population in four districts of Khyber Pakhtunkhwa province, Pakistan. Using a triangulation mixed methods design, we analysed data from a quantitative household survey of744 households, 17 focus group discussions with household members and, 11 interviews with healthcare providers. Results: Our results show that indicate that despite service utilization, PHC needs were not met, primarily due to prohibitively high costs at each stage of access. Furthermore, gaps in outreach and information (approachability), and varying availability of medicines and diagnostics at facilities (appropriateness) the supply side as well as difficulties in navigating the system (inability to perceive) and adhering to prescriptions (inability to engage) on the demand side, also led to unmet PHC needs. Going beyond utilization, our findings highlight that engagement with care is an important determinant of met needs for vulnerable populations. Conclusion: Social health protection policies can contribute to advancing UHC for primary care. However, in our setting, enhancing communication and outreach, addressing gender and age disparities, and improving quality of care and health infrastructure are necessary to fully meet the needs of the poorest populations. Highlights: • The primary health needs of the poorest population of Khyber Pakhtunkhwa remain largely unmet or are met with difficulties, across the care-seeking pathway. • Major contributors to unmet primary healthcare needs in the study area are: low outreach, crowded facilities and, varying availability of medicines and diagnostics at facilities on the supply side, and difficulties in navigating care and inability to afford prescribed care on the demand side. • Social Health Protection is a crucial tool for advancing Universal Health Coverage and improving primary healthcare, however these needs cannot be met without quality service provision and outreach from facilities. • Levesque's framework of access to care (2013) can be effectively employed to identify broad-based unmet needs and assess gaps in primary healthcare systems. [ABSTRACT FROM AUTHOR]

Background: Governments increasingly recognize the need to engage non-state providers (NSPs) in health systems in order to move successfully towards Universal Health Coverage (UHC). One common approach to engaging NSPs is to contract-out the delivery of primary health care services. Research on contracting arrangements has typically focused on their impact on health service delivery; less is known about the actual processes underlying the development and implementation of interventions and the contextual factors that influence these. This paper reports on the design and implementation of service agreements (SAs) between local governments and NSPs for the provision of primary health care services in Tanzania. It examines the actors, policy process, context and policy content that influenced how the SAs were designed and implemented., Methods: We used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. All interviews were audiotaped, transcribed and translated into English. Data were managed in NVivo (version 10.0) and analyzed thematically., Results: The institutional frameworks shaping the engagement of the government with NSPs are rooted in Tanzania's long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage NSP facilities. Development partners provided significant technical and financial support, signaling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with NSPs, financing the contracts remained largely dependent on donor funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements., Conclusions: Tanzania's central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with NSPs for primary health care services. Furthermore, forums for continuous dialogue between the government and contracted NSPs should be fostered in order to clarify the expectations of all parties and resolve any misunderstandings.